Mending the rhythm does not improve prognosis in patients with persistent atrial fibrillation: a subanalysis of the RACE study. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Randomized Trial of Warfarin, Aspirin, and Clopidogrel in Patients With Chronic Heart Failure: The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial Management of Newly Detected Atrial Fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. Morbidity and mortality in 229 elderly patients with nonrheumatic atrial fibrillation. A five-year follow-up. Apixaban versus Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intraCerebral HaEmorrhage in patients with Atrial Fibrillation (APACHE-AF): study protocol for a randomised controlled trial Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: Executive summary Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Effects of coadministration of aspirin or clopidogrel on exercise testing in patients with heart failure receiving angiotensin-converting enzyme inhibitors. The Warfarin/Aspirin Study in Heart failure (WASH): a randomized trial comparing antithrombotic strategies for patients with heart failure. Incidence of Thromboembolic Events in Congestive Heart Failure Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. Rhythm control versus rate control for atrial fibrillation and heart failure. Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data From the Warfarin Versus Aspirin in Reduced Ejection Fraction Trial Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study). Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis. Dofetilide in patients with congestive heart failure and left ventricular dysfunction: safety aspects and effect on atrial fibrillation. The Danish Investigators of Arrhythmia and Mortality on Dofetilide (DIAMOND) Study Group. Maintenance of sinus rhythm and survival in patients with heart failure and atrial fibrillation. Should digoxin be proscribed in elderly subjects in sinus rhythm free from heart failure? A population-based study. Clinical course of recent-onset atrial fibrillation treated with oral propafenone. Atrial fibrillation and risk of clinical events in chronic heart failure with and without left ventricular systolic dysfunction: results from the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) program.
AIMS To compare outcome of AF patients with effective rhythm control with patients treated with rate control .  METHODS AND RESULTS Out of the 266 AF patients r and omized to rhythm control in the RACE study , 49 patients turned to long-term sinus rhythm and were continuously treated with oral anticoagulation . The incidence of the primary endpoint in these patients was compared to that in 178 patients out of the initial 256 rate-control patients of RACE who were in AF and using oral anticoagulation continuously . Baseline characteristics of both groups were not different . After a mean follow-up of 2.3+/-0.6 years , the primary endpoint ( a composite of cardiovascular mortality , heart failure , thrombo-embolic complications ( TECs ) , bleeding , serious adverse effects of antiarrhythmic drugs and pacemaker implants ) was 22.4 % in the rhythm-control group vs. 15.2 % in the rate-control group . Multivariable regression analysis indicated coronary artery disease , heart failure , and digitalis as independent risk indicators of cardiovascular morbidity and mortality . Chronic sinus rhythm did not matter . CONCLUSION Among patients who remained on warfarin  , those who mostly were maintained in sinus rhythm under a rhythm-control strategy did not have a superior prognosis compared to those who remained in AF under a rate-control strategy ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on Background — Chronic heart failure remains a major cause of mortality and morbidity . The role of antithrombotic therapy in patients with chronic heart failure has long been debated . The objective of this study was to determine the optimal antithrombotic agent for heart failure patients with reduced ejection fractions who are in sinus rhythm . Methods and Results — This prospect i ve , r and omized clinical trial of open-label warfarin ( target international normalized ratio of 2.5 to 3.0 ) and double-blind treatment with either aspirin ( 162 mg once daily ) or clopidogrel ( 75 mg once daily ) had a 30-month enrollment period and a minimum of 12 months of treatment . We enrolled 1587 men and women ≥18 years of age with symptomatic heart failure for at least 3 months who were in sinus rhythm and had left ventricular ejection fraction of ≤35 % . The primary outcome was the time to first occurrence of death , nonfatal myocardial infa rct ion , or nonfatal stroke . For the primary composite end point , the hazard ratios were as follows : for warfarin versus aspirin , 0.98 ( 95 % CI , 0.86 to 1.12 ; P=0.77 ) ; for clopidogrel versus aspirin , 1.08 ( 95 % CI , 0.83 to 1.40 ; P=0.57 ) ; and for warfarin versus clopidogrel , 0.89 ( 95 % CI , 0.68 to 1.16 ; P=0.39 ) . Warfarin was associated with fewer nonfatal strokes than aspirin or clopidogrel  . Hospitalization for worsening heart failure occurred in 116 ( 22.2 % ) , 97 ( 18.5 % ) , and 89 ( 16.5 % ) patients treated with aspirin , clopidogrel , and warfarin , respectively ( P=0.02 for warfarin versus aspirin ) . Conclusion — The primary outcome measure and the mortality data do not support the primary hypotheses that warfarin is superior to aspirin and that clopidogrel is superior to aspirin 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 Maintenance of sinus rhythm is the main therapeutic goal in patients with atrial fibrillation . However , recurrences of atrial fibrillation and side effects of antiarrhythmic drugs offset the benefits of sinus rhythm . We hypothesized that ventricular rate control is not inferior to the maintenance of sinus rhythm for the treatment of atrial fibrillation . METHODS We r and omly assigned 522 patients who had persistent atrial fibrillation after a previous electrical cardioversion to receive treatment aim ed at rate control or rhythm control . Patients in the rate-control group received oral anticoagulant drugs and rate-slowing medication . Patients in the rhythm-control group underwent serial cardioversions and received antiarrhythmic drugs and oral anticoagulant drugs . The end point was a composite of death from cardiovascular causes , heart failure , thromboembolic complications , bleeding , implantation of a pacemaker , and severe adverse effects of drugs . RESULTS After a mean ( + /-SD ) of 2.3+/-0.6 years , 39 percent of the 266 patients in the rhythm-control group had sinus rhythm , as compared with 10 percent of the 256 patients in the rate-control group . The primary end point occurred in 44 patients ( 17.2 percent ) in the rate-control group and in 60 ( 22.6 percent ) in the rhythm-control group . The 90 percent ( two-sided ) upper boundary of the absolute difference in the primary end point was 0.4 percent ( the prespecified criterion for noninferiority was 10 percent or less ) . The distribution of the various components of the primary end point was similar in the rate-control and rhythm-control groups . CONCLUSIONS Rate control is not inferior to rhythm control for the prevention of death and morbidity from cardiovascular causes and may be appropriate therapy in patients with a recurrence of persistent atrial fibrillation after electrical cardioversion BACKGROUND In the elderly the impact of atrial fibrillation on mortality and morbidity is substantial . Oral anticoagulant therapy reduces the risk of stroke by 70 % ; nevertheless , it remains largely underused . We evaluated , in a community prospect i ve study , the factors associated with embolic events and death and the feasibility of oral anticoagulant therapy managed by general practitioners . METHODS We enrolled at the Trieste Cardiovascular Center 229 patients aged > or = 65 years with non-rheumatic atrial fibrillation . At baseline , each patient underwent a transesophageal echocardiography and received instructions about oral anticoagulation . Patients were regularly followed by their general practitioner and finally evaluated at the Center . RESULTS At baseline , the mean age was 73 years , 14 % of patients were free of heart disease , 27 % had had a previous embolic event , and 33 % had an atrial thrombus . After a 5-year follow-up , 85 % of the patients had been admitted to hospital , 17 % had suffered an embolic event , and 35 % were dead . Diabetes and the presence of a low flow in the left atrial appendage were predictive of embolic events . Heart failure , spontaneous echocontrast and aortic plaques were predictive of death . Anticoagulant therapy increased from 14 to 34 % but the incidence of major bleeding did not change . The patients on anticoagulant therapy at follow-up constituted the group with the worst cardiovascular profile and embolic rate , but had a lower death rate ( 19 % ) compared with those on antiplatelet therapy ( 32 % ) and with those without antithrombotic therapy ( 67 % ) . The hospitalization rates were respectively 78 , 83 and 100 % . CONCLUSIONS In a group of elderly patients followed by their general practitioner with the support of a specialized cardiologic unit , oral anticoagulant therapy was well tolerated and associated with a significant decrease in mortality and hospitalization Background There is a marked lack of evidence on the optimal prevention of ischaemic stroke and other thromboembolic events in patients with non-valvular atrial fibrillation and a recent intracerebral haemorrhage during treatment with oral anticoagulation .  These patients are currently treated with oral anticoagulants , antiplatelet drugs , or no antithrombotic treatment , depending on personal and institutional preferences . Compared with warfarin , the direct oral anticoagulant apixaban reduces the risk of stroke or systemic embolism , intracranial haemorrhage , and case fatality in patients with atrial fibrillation . Compared with aspirin , apixaban reduces the risk of stroke or systemic embolism in patients with atrial fibrillation , and has a similar risk of intracerebral haemorrhage . Novel oral anticoagulants have not been evaluated in patients with atrial fibrillation and a recent intracerebral haemorrhage . To inform a phase III trial , the phase II Apixaban versus Antiplatelet drugs or no antithrombotic drugs after anticoagulation-associated intraCerebral HaEmorrhage in patients with Atrial Fibrillation ( APACHE-AF ) trial aims to obtain estimates of the rates of vascular death or non-fatal stroke in patients with atrial fibrillation and a recent anticoagulation-associated intracerebral haemorrhage treated with apixaban and in those in whom oral anticoagulation is avoided . Methods / Design APACHE-AF is a phase II , multicentre , open-label , parallel-group , r and omised clinical trial with masked outcome assessment . One hundred adults with a history of atrial fibrillation and a recent intracerebral haemorrhage during treatment with anticoagulation in whom clinical equipoise exists on the optimal stroke prevention strategy will be enrolled in 14 hospitals in The Netherl and s . These patients will be r and omly assigned in a 1:1 ratio to either apixaban or to avoiding oral anticoagulation . Patients in the control group may be treated with antiplatelet drugs at the discretion of the treating physician . The primary outcome is the composite of vascular death or non-fatal stroke during follow-up . We aim to include 100 patients in 2.5 years . All patients will be followed-up for the duration of the study , but at least for 1 year . Recruitment commenced in September 2014 and is ongoing . This trial is funded by the Dutch Heart Foundation ( 2012 T077 ) and ZonMW (015008048).Trial registration NTR4526 ( 16 April 2014 ) In 2013 , the European Heart Rhythm Association ( EHRA ) published a Practical Guide on the use of non-VKA oral anticoagulants ( NOACs ) in patients with atrial fibrillation ( AF ) ( Heidbuchel H , Verhamme P , Alings M , Antz M , Hacke W , Oldgren J , Sinnaeve P , Camm AJ , Kirchhof P , European Heart Rhythm A. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation . Europace 2013;15:625 - 651 ; Heidbuchel H , Verhamme P , Alings M , Antz M , Hacke W , Oldgren J , Sinnaeve P , Camm AJ , Kirchhof P. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation : executive summary . Eur Heart J 2013;34:2094 - 2106 ) . The document received widespread interest , not only from cardiologists but also from neurologists , geriatricians , and general practitioners , as became evident from the distribution of > 350 000 copies of its pocket version ( the EHRA Key Message Booklet ) world-wide . Since 2013 , numerous new studies have appeared on different aspects of NOAC therapy in AF patients . Therefore , EHRA up date d the Practical Guide , including new information but also providing balanced guiding in the many areas where prospect i ve data are still lacking . The outline of the original guide that addressed 15 clinical scenarios has been preserved , but all chapters have been rewritten . Main changes in the Up date comprise a discussion on the definition of ' non-valvular AF ' and eligibility for NOAC therapy , inclusion of finalized information on the recently approved edoxaban , tailored dosing information dependent on concomitant drugs , and /or clinical characteristics , an exp and ed chapter on neurologic scenarios ( ischaemic stroke or intracranial haemorrhage under NOAC ) , an up date d anticoagulation card and more specifics on start-up and follow-up issues . There are also many new flow charts , like on appropriate switching between anticoagulants ( VKA to NOAC or vice versa ) , default scenarios for acute management of coronary interventions , step-down schemes for long-term combined antiplatelet-anticoagulant management in coronary heart disease , management of bleeding , and cardioversion under NOAC therapy . The Up date d Guide is available in full in EP Europace ( Heidbuchel H , Verhamme P , Alings M , Antz M , Diener HC , Hacke W , Oldgren J , Sinnaeve P , Camm AJ , Kirchhof P , Advisors . Up date d European Heart Rhythm Association Practical Guide on the use of  non-vitamin K antagonist anticoagulants  in patients with non-valvular atrial fibrillation . Europace 2015;17:1467 - 1507 ) , while additional re sources can be found at the related ESC/EHRA website ( www.NOACforAF.eu ) 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 Stroke and systemic thromboembolism are serious problems for patients with atrial fibrillation ( AF ) , but their incidence can be substantially reduced by appropriate anticoagulation . Bleeding is the major complication of anticoagulant treatment , and the relative risks for bleeding vs stroke must be considered when starting anticoagulation . METHODS The AFFIRM trial included patients with AF and at least one risk factor for stroke , r and omly assigning them to either a rate-control or rhythm-control strategy . All patients were initially treated with warfarin . The incidence of protocol -defined major and minor bleeding was documented during follow-up . Variables associated with bleeding were determined using a Cox proportional hazards model , using baseline and time-dependent covariates . RESULTS The 4060 patients in the AFFIRM trial were followed for an average of 3.5 years . Major bleeding occurred in 260 patients , an annual incidence of approximately 2 % per year , with no significant difference between the rate-control and rhythm-control groups . Increased age , heart failure , hepatic or renal disease , diabetes , first AF episode , warfarin use , and aspirin use were significantly associated with major bleeding . Minor bleeding was common in both treatment arms , with 738 patients reporting this problem in one or more visits . CONCLUSIONS Bleeding is a significant problem that complicates management of patients with AF . Risk factors for bleeding can be identified , and knowledge of these risk factors can be used to plan therapy Angiotensin-converting enzyme ( ACE ) inhibitors are effective drugs that have been shown to lower morbidity and mortality in patients with heart failure who have left ventricular systolic dysfunction . 1–3 Patients with congestive heart failure ( CHF ) often have indications for using both ACE inhibitors and antiplatelet agents . Various clinical trials have suggested that an adverse interaction exists from the combined use of aspirin and an ACE inhibitor in patients with CHF , but few studies have measured this effect directly . 3–12 The most compelling evidence of a potential adverse interaction between ACE inhibitors and aspirin stems from the Studies Of Left Ventricular Dysfunction ( SOLVD ) 1,10 and Cooperative New Sc and inavian Enalapril Survival Study II ( CONSENSUS II ) 11 trials . In SOLVD , although enalapril and aspirin when used alone were associated with lower mortality rates , retrospective analysis revealed that the addition of enalapril did not reduce mortality in patients already taking aspirin , and conversely , neither did the addition of aspirin in patients receiving enalapril . In a post hoc analysis of CONSENSUS II , aspirin and enalapril , when utilized alone , were associated with lower mortality rates . However , the relative risk of death at the end of the study was 1.23 ( 95 % confi dence interval [ CI ] 0.99 to 1.53 ) for patients taking aspirin and enalapril , and 0.86 ( 95 % CI 0.63 to 1.16 ) for patients taking enalapril without aspirin ( p 0.047 ) . Guazzi et al , 7 in a small prospect i ve study , measured maximal exercise oxygen uptake ( VO2max ) in patients with CHF , and demonstrated an adverse effect when ACE inhibitors were combined with aspirin , but not with ACE inhibitors alone . Therefore , we hypothesized that exercise duration and VO2max would not be attenuated by clopidogrel compared with aspirin in patients with CHF who are taking ACE inhibitors .  This study was approved by the institutional review board and all participants gave written consent before starting the study . We consecutively enrolled 18 patients with chronic stable CHF at our institution . Patient selection was made through chart review and phone interview of those patients who were likely to meet entry criteria . Inclusion criteria included patients between ages 19 and 80 years who were in stable New York Heart Association class II or III CHF due to ischemic or idiopathic dilated cardiomyopathy , with a documented left ventricular ejection fraction of 40 % within the past year . Patients had to be in sinus rhythm and on maintainance moderate-to-high dose ACE inhibitor therapy for 3 months . Exclusion criteria included a history of chronic lung disease , severe valvular heart disease , moderate-to-severe pulmonary hypertension , or a myocardial infa rct ion or cerebrovascular accident within the preceding 3 months . Patients with chronic stable angina or any other vascular , musculoskeletal , or metabolic condition precluding exercise testing were also excluded .  Antiplatelet therapy other than aspirin or clopidogrel within 4 weeks of the study or warfarin anticoagulation was not allowed . Exercise testing was performed using BACKGROUND Heart failure is commonly associated with vascular disease and a high rate of athero-thrombotic events , but the risks and benefits of antithrombotic therapy are unknown . METHODS The current study was an open-label , r and omized , controlled trial comparing no antithrombotic therapy , aspirin ( 300 mg/day ) , and warfarin ( target international normalized ratio 2.5 ) in patients with heart failure and left ventricular systolic dysfunction requiring diuretic therapy . The primary objective was to demonstrate the feasibility and inform the design of a larger outcome study . The primary clinical outcome was death , nonfatal myocardial infa rct ion , or nonfatal stroke . RESULTS Two hundred seventy-nine patients were r and omized and 627 patient-years exposure were accumulated over a mean follow-up time of 27 + /- 1 months . Twenty-six ( 26 % ) , 29 ( 32 % ) , and 23 ( 26 % ) patients r and omized to no antithrombotic treatment , aspirin , and warfarin , respectively , reached the primary outcome ( ns ) . There were trends to a worse outcome among those r and omized to aspirin for a number of secondary outcomes . Significantly ( P = .044 ) more patients r and omized to aspirin were hospitalized for cardiovascular reasons , especially worsening heart failure . CONCLUSIONS The Warfarin/Aspirin Study in Heart failure ( WASH ) provides no evidence that aspirin is effective or safe in patients with heart failure . The benefits of warfarin for patients with heart failure in sinus rhythm have not been established . Antithrombotic therapy in patients with heart failure is not evidence based but commonly contributes to polypharmacy Background The incidence of thromboembolism and the benefit of anticoagulation in congestive heart failure are controversial . Methods and Results The data base provided by the Veterans Affairs Vasodilator-Heart Failure Trials ( V-HeFT I and II ) was examined retrospectively to address these issues . In V-HeFT I , 642 men with heart failure were followed an average of 2.28 years , providing 1,464 patient-years of follow-up . In V-HeFT II , 804 men were followed an average of 2.56 years , with 2,061 patient-years of follow-up . Mean left ventricular ejection fraction was 30%o in V-HeFT I and 29 % in V-HeFT II . Functional capacity was at the interface of classes II and III with a peak exercise oxygen consumption of 14.7 mL. kg -1 . min-1 in V-HeFT I and 13.7 mL- kg-1 min-1 in V-HeFT II . Warfarin and antiplatelet agents were administered at the discretion of individual investigators . The incidence of all thromboembolic events during 1,068 patient-years without warfarin in V-HeFIT I was 2.7/100 patient-years and during 1,188 patient-years in V-HeFT II was 2.1/100 patient-years and was not reduced in patients treated with warfarin . Patients experiencing events had a lower peak exercise oxygen consumption ( P<0.03 in V-HeFT I and P<0.001 in V-HeFT II ) and a lower mean ejection fraction ( P=0.10 in V-HeFT I and P=0.07 in V-HeFT II ) . Atrial fibrillation was not associated with an increased risk of thromboembolic events . Conclusions The incidence of thromboembolism and stroke in class II or III congestive heart failure is not high and may not be significantly reduced with warfarin treatment . Routine use of anticoagulants in patients with heart failure may not be justified BACKGROUND Atrial fibrillation  ( AF ) may occur without symptoms . Little is known about demographic features and prognostic information in patients with asymptomatic AF . METHODS In the AFFIRM study , 4060 patients were r and omized to either rhythm or rate control . At baseline , patients were identified as asymptomatic if they answered " no " to a 15-item question naire related to cardiac symptoms during AF in the 6 months before study entry . RESULTS There were 481 ( 12 % ) asymptomatic patients at baseline . Compared with symptomatic patients , asymptomatic patients were more often men and had a lower incidence of coronary artery disease and congestive heart failure , but had more cerebrovascular events . Asymptomatic patients had a longer duration of AF , a lower maximum heart rate , and better left ventricular function . They received fewer cardiac medications and fewer therapies to maintain sinus rhythm . At 5 years , there was a trend for better survival in asymptomatic patients ( 81 % vs 77 % , P = .058 ) , and they were more likely to be free from disabling stroke or anoxic encephalopathy , major bleeding , and cardiac arrest ( 79 % vs 67 % , P = .024 ) . However , mortality and major events were similar after correction for baseline differences . CONCLUSIONS Patients with asymptomatic AF have less serious heart disease but more cerebrovascular disease . Asymptomatic patients receive different therapies than symptomatic patients . However , the absence of symptoms and the differences in treatment does not confer a more favorable prognosis when differences in baseline clinical parameters are considered . Anticoagulation should be considered in these patients BACKGROUND It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure . This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome . However , the benefits and risks of this approach have not been adequately studied . METHODS We conducted a multicenter , r and omized trial comparing the maintenance of sinus rhythm ( rhythm control ) with control of the ventricular rate ( rate control ) in patients with a left ventricular ejection fraction of 35 % or less , symptoms of congestive heart failure , and a history of atrial fibrillation . The primary outcome was the time to death from cardiovascular causes . RESULTS A total of 1376 patients were enrolled ( 682 in the rhythm-control group and 694 in the rate-control group ) and were followed for a mean of 37 months . Of these patients , 182 ( 27 % ) in the rhythm-control group died from cardiovascular causes , as compared with 175 ( 25 % ) in the rate-control group ( hazard ratio in the rhythm-control group , 1.06 ; 95 % confidence interval , 0.86 to 1.30 ; P=0.59 by the log-rank test ) . Secondary outcomes were similar in the two groups , including death from any cause ( 32 % in the rhythm-control group and 33 % in the rate-control group ) , stroke ( 3 % and 4 % , respectively ) , worsening heart failure ( 28 % and 31 % ) , and the composite of death from cardiovascular causes , stroke , or worsening heart failure ( 43 % and 46 % ) . There were also no significant differences favoring either strategy in any predefined subgroup . CONCLUSIONS In patients with atrial fibrillation and congestive heart failure , a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes , as compared with a rate-control strategy . ( Clinical Trials.gov number , NCT00597077 . Background and Purpose — In heart failure ( HF ) , left ventricular ejection fraction ( LVEF ) is inversely associated with mortality and cardiovascular outcomes . Its relationship with stroke is controversial , as is the effect of antithrombotic treatment . We studied the relationship of LVEF with stroke and cardiovascular events in patients with HF and the effect of different antithrombotic treatments . Methods — In the Warfarin Versus Aspirin in Reduced Ejection Fraction ( WARCEF ) trial , 2305 patients with systolic HF ( LVEF⩽35 % ) and sinus rhythm were r and omized to warfarin or aspirin and followed for 3.5±1.8 years . Although no differences between treatments were observed on primary outcome ( death , stroke , or intracerebral hemorrhage ) , warfarin decreased the stroke risk . The present report compares the incidence of stroke and cardiovascular events across different LVEF and treatment subgroups . Results — Baseline LVEF was inversely and linearly associated with primary outcome , mortality and its components ( sudden and cardiovascular death ) , and HF hospitalization , but not myocardial infa rct ion . A relationship with stroke was only observed for LVEF of < 15 % ( incidence rates : 2.04 versus 0.95/100 patient-years ; P=0.009 ) , which more than doubled the adjusted stroke risk ( adjusted hazard ratio , 2.125 ; 95 % CI , 1.182–3.818 ; P=0.012 ) . In warfarin-treated patients , each 5 % LVEF decrement significantly increased the stroke risk ( adjusted hazard ratio , 1.346 ; 95 % CI , 1.044–1.737 ; P=0.022 ; P value for interaction=0.04 ) . Conclusions — In patients with systolic HF and sinus rhythm , LVEF is inversely associated with death and its components , whereas an association with stroke exists for very low LVEF values . An interaction with warfarin treatment on stroke risk may exist . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00041938 BACKGROUND In patients with congestive heart failure ( CHF ) , clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality . Nevertheless so far , there is no published controlled study of long-term antithrombotic therapy in patients with CHF . The aim of this work was to identify the relationship between cardiovascular drug use , especially antithrombotic therapy , and survival of CHF patients in current clinical practice , using an observational , population -based data base . METHODS The EPICAL study ( Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine ) has identified prospect ively all patients with severe CHF in the community of Lorraine . Inclusion criteria were age 20 - 80 years in 1994 , at least one hospitalisation for cardiac decompensation , NYHA III/IV HF , ventricular ejection fraction < or = 30 % or cardiothoracic index > or = 60 % and arterial hypotension or peripheral and /or pulmonary oedema . A total of 417 consecutive patients surviving at hospital discharge were included in the data base . The average follow-up period was 5 years . Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival .  Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors . RESULTS Duration of disease > 1 year , renal failure , serum sodium > or = 138 mmol/l , old age , serious comorbidity , previous decompensation , high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years . Oral anticoagulants , aspirin , lipid lowering drugs and beta-blockers use were associated with better survival . There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival . CONCLUSION Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF . These results together with other previously published circumstantial evidence urge for a prospect i ve , controlled and r and omised trial specifically design ed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure BACKGROUND Atrial fibrillation ( AF ) is a major risk factor ( RF ) for ischemic stroke . Its prevalence and prognostic impact in patients with atherothrombosis are unclear . METHODS Risk factors , drug usage , and 1-year cardiovascular ( CV ) outcomes ( CV death , myocardial infa rct ion [ MI ] , and stroke ) were compared in  AF and non-AF patients from the REduction of Atherothrombosis for Continued Health ( REACH ) Registry , an international , prospect i ve cohort of 68,236 stable out patients with established atherothrombosis or > or=3 atherothrombotic RFs . RESULTS Atrial fibrillation and 1-year follow-up data are available for 63,589 patients . The prevalence of AF was , 12.5 % , 13.7 % , 11.5 % , and 6.2 % among coronary artery disease , CV disease , peripheral artery disease , and RF-only patients , respectively . Of the 6,814 patients with AF , 6.7 % experienced CV death , nonfatal MI , or nonfatal stroke within a year . The annual incidence of nonfatal stroke ( 2.4 % vs 1.6 % , P<.0001 ) and unstable angina ( 6.0 % vs 4.0 % , P<.00001 ) was higher , and CV death was more than double ( 3.2 % vs 1.4 % , P<.0001 ) , in AF versus non-AF patients . In these patients with or at high risk of atherothrombosis , most patients with AF received antiplatelet agents , but only 53.1 % were treated with oral anticoagulants . Even with high CHADS2 ( congestive heart failure , hypertension , aging , diabetes mellitus , and stroke ) scores , anticoagulant use did not exceed ( 59 % ) . The rate of bleeding requiring hospitalization was higher in AF versus non-AF patients ( 1.5 % vs 0.8 % , P<.0001 ) , possibly related to the more frequent use of anticoagulants ( 53.1 % vs 7.1 % ) . CONCLUSIONS Atrial fibrillation is common in patients with atherothrombosis , associated with more frequent fatal and nonfatal CV outcomes , and underuse of oral anticoagulants INTRODUCTION . Atrial fibrillation is a frequent cause of worsening of symptoms in patients with congestive heart failure . The drugs currently available for maintenance of sinus rhythm all have major side effects . METHODS . In 34 Danish coronary care units , 1518 patients with congestive heart failure and reduced left ventricular systolic function were r and omized to receive either placebo or a new class III antiarrhythmic drug , dofetilide . The dose of dofetilide was adjusted according to the presence of atrial fibrillation , the length of the QT interval , and renal function . Patients were continuously monitored electrocardiographically for the first 3 days of the study . The primary end point was all-cause mortality and follow-up was for at least 1 year . RESULTS . In the dofetilide/placebo groups , 311/317 patients  died ( 41%/42 % ) . The hazard ratio for dofetilide treatment was 0.95 ( 95 % confidence interval , 0.81 - 1.11 ) . Treatment with dofetilide reduced worsening of heart failure significantly ( hazard ratio , 0.75 ; 0.63 - 0.89 ) . After 1 year , 61 % of patients with atrial fibrillation at the start of the study had converted to sinus rhythm on dofetilide , vs. 33 % in the placebo group . After conversion to sinus rhythm , 78%/43 % of patients in the dofetilide/placebo groups remained in sinus rhythm for at least 1 year . There were 25 instances ( 3 % ) of torsade de pointes ventricular tachycardia in the dofetilide group and none in the placebo group . CONCLUSION . In patients with congestive heart failure , dofetilide can effectively convert atrial fibrillation to sinus rhythm and maintain sinus rhythm after conversion . Hospitalization for congestive heart failure is reduced . Dofetilide does not affect mortality . (c)2001 by CHF , OBJECTIVES The goal of this study was to evaluate the relationship between the presence of sinus rhythm and outcomes in patients with a history of congestive heart failure ( CHF ) and atrial fibrillation ( AF ) . BACKGROUND The value of sinus rhythm maintenance in patients with AF and heart failure ( HF ) is uncertain . METHODS A total of 1,376 patients with AF , ejection fraction < or = 35 % , and heart failure symptoms were r and omized to a rhythm- or rate-control strategy .  Detailed efficacy analyses were used to evaluate the independent effects of treatment strategy and the presence of sinus rhythm on cardiovascular outcomes . RESULTS Overall , 445 ( 32 % ) patients died and 402 ( 29 % ) experienced worsening HF . The rhythm-control strategy was not predictive of cardiovascular mortality ( hazard ratio [ HR ] : 0.90 , 95 % confidence interval [ CI ] : 0.70 to 1.16 ; p = 0.41 ) , all-cause death ( HR : 0.86 , 95 % CI : 0.69 to 1.08 ; p = 0.19 ) , or worsening HF ( HR : 0.86 , 95 % CI : 0.68 to 1.10 ; p = 0.23 ) . In analyses devised to isolate the effect of underlying rhythm , sinus rhythm was not associated with cardiovascular mortality [ HR : 1.22 , 95 % CI : 0.80 to 1.87 ; p = 0.35 ) , total mortality [ HR : 1.11 , 95 % CI : 0.78 to 1.58 ; p = 0.57 ) , or worsening HF [ HR : 0.62 , 95 % CI : 0.37 to 1.02 ; p = 0.059 ) . CONCLUSIONS A rhythm-control strategy or the presence of sinus rhythm are not associated with better outcomes in patients with AF and CHF Increased mortality in digoxin-treated subjects has been demonstrated in patients with recent myocardial infa rct ion . Those with congestive heart failure ( CHF ) due to causes other than myocardial infa rct ion seem to be free from this effect . No information is currently available concerning mortality in elderly people who are frequently prescribed digitalis even in the absence of CHF . The aim of this study was to investigate whether subjects improperly receiving digoxin were worse off than those not receiving this drug . This analysis is a part of CASTEL , a population -based prospect i ve study that has enrolled a cohort of 2,254 subjects aged > or = 65 years . CHF was diagnosed in 187 subjects and atrial fibrillation ( AF ) in 90 . The remaining 1,977 were free from CHF and in sinus rhythm , but 447 were treated with digitalis .  Cumulative mortality and morbid events by digitalis treatment were calculated in all these categories . Among subjects free from CHF and AF ( improper use ) , all-cause and cardiovascular mortality was significantly higher among those taking digitalis than in those who did not . Non-fatal events including CHF were also more apparent in the former than in the latter . Cox analysis confirmed digitalis as a predictor of mortality in these subjects . No effect of digitalis on survival was found in patients with CHF or AF ( proper use ) . In elderly subjects without atrial fibrillation or CHF , the use of digitalis worsens morbidity and mortality Atrial fibrillation ( AF ) is one of the most common cardiac arrhythmias in the adult population .  Propafenone is a class 1c antiarrhythmic agent that has an electrophysiologic profile suggesting that it might be potentially effective in recent-onset AF . The present study was undertaken , therefore , to examine the time course as well as the frequency of successful conversion in patients with recent-onset AF treated with propafenone administered orally . Fifty patients with recent-onset AF were recruited into 2 groups : 25 patients were given propafenone , 150 mg every 4 h , and 25 patients served as a control group and received verapamil ( a drug known to slow the ventricular response but not to restore sinus rhythm ) 40 mg , every 4 h and up to 48 h or until conversion to sinus rhythm occurred . Of the 50 patients , 2 refused to continue the study and another 2 were excluded because of left heart failure . Conversion to sinus rhythm occurred in 21 of 24 patients ( 87 percent ) in the propafenone group as compared with 9 of 22 ( 41 percent ) in the verapamil group ( p < 0.001 ) . In 10 patients in the propafenone group , conversion occurred within 12 h , within 24 h in another 9 patients , and between 24 and 48 h in the remaining 2 patients . There was no correlation between the duration of AF prior to entry into the study and the subsequent incidence of and time to conversion with propafenone . With respect to cause of AF , all groups showed a high incidence of conversion . Two patients developed heart failure during treatment and one patient ( in the verapamil group ) developed embolic stroke while still having atrial fibrillation . We conclude that in patients with AF , the prognosis for conversion to sinus rhythm within 48 h , with propafenone , is excellent ( 87 percent ) and safe OBJECTIVES We assessed the risk of adverse cardiovascular ( CV ) outcomes associated with atrial fibrillation ( AF ) in the C and esartan in Heart failure- Assessment of Reduction in Mortality and morbidity ( CHARM ) program , which enrolled patients with chronic heart failure ( CHF ) and a broad range of ejection fractions ( EFs ) . BACKGROUND Atrial fibrillation is associated with an increased risk of adverse CV outcomes in patients with CHF and reduced EF . The risk of AF in patients with CHF and preserved left ventricular ejection fraction ( PEF ) is unknown . METHODS A total of 7,599 patients with symptomatic CHF were r and omized to c and esartan or placebo . Patients were divided by baseline EF ( < or = 40 % or > 40 % ) in low or preserved EF groups . Major outcomes were cardiovascular death or hospitalization for worsening heart failure , and all-cause mortality . Median follow-up was 37.7 months . RESULTS A total of 670 ( 17 % ) patients in the low EF group and 478 ( 19 % ) in the PEF group had AF at baseline . Atrial fibrillation predicted a high risk of cardiovascular morbidity and mortality regardless of baseline EF . Patients with AF and low EF had the highest absolute risk for adverse CV outcomes . However , AF was associated with greater relative increased risk of the major outcomes in patients with PEF than in patients with low EF : hazard ratio 1.72 ( 95 % confidence interval [ CI ] 1.45 to 2.06 ) versus 1.29 ( 95 % CI 1.14 to 1.46 ) , respectively . The same was true for the risk of all-cause mortality . C and esartan was associated with similar treatment effects regardless of baseline rhythm . CONCLUSIONS Atrial fibrillation is associated with an increased risk of CV outcomes in patients with CHF and either reduced EF or PEF . C and esartan improved outcomes similarly regardless of baseline rhythm
At present , there are no data on the role of oral anticoagulation versus antiplatelet agents in heart failure with preserved ejection fraction with sinus rhythm .
Also , there were no data from RCTs on the utility of non-vitamin K antagonist oral anticoagulants compared to antiplatelet agents in heart failure with sinus rhythm
BACKGROUND Morbidity in patients with chronic heart failure is high , and this predisposes them to thrombotic complications , including stroke and thromboembolism , which in turn contribute to high mortality .
Oral anticoagulants ( e.g. warfarin ) and antiplatelet agents ( e.g. aspirin ) are the principle oral antithrombotic agents .
Many heart failure patients with sinus rhythm take aspirin because coronary artery disease is the leading cause of heart failure .
Oral anticoagulants have become a st and ard in the management of heart failure with atrial fibrillation .
However , a question remains regarding the appropriateness of oral anticoagulants in heart failure with sinus rhythm .
This up date of a review previously published in 2012 aims to address this question .
OBJECTIVES To assess the effects of oral anticoagulant therapy versus antiplatelet agents for all-cause mortality , non-fatal cardiovascular events and risk of major bleeding in adults with heart failure ( either with reduced or preserved ejection fraction ) who are in sinus rhythm .