Archive for the ‘atrial fibrillation’ Category

AF Screening

Freedman et al present a white paper from the AF-SCREEN International Collaborative. This important paper collates evidence for AF screening and provides insights into the risk of asymptomatic atrial fibrillation and the temporal relationship between AF and ischemic stroke.



Alcohol and Atrial Fibrillation

Voskoboinik et al review the relationship between alcohol and atrial fibrillation. This is an interesting and useful paper.


AHA 2016: Initial Look

Journal Club 22 October 2014


Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial Fibrillation Findings From the TREAT-AF Study





Despite endorsement of digoxin in clinical practice guidelines, there exist limited data on its safety in
atrial fibrillation/flutter (AF).


The goal of this study was to evaluate the association of digoxin with mortality in AF.
METHODS Using complete data of the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF)
study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed,
nonvalvular AF seen within 90 days in an outpatient setting between VA fiscal years 2004 and 2008. We used multivariate
and propensity-matched Cox proportional hazards to evaluate the association of digoxin use with death. Residual
confounding was assessed by sensitivity analysis.


Of 122,465 patients with 353,168 person-years of follow-up (age 72.1 10.3 years, 98.4% male), 28,679
(23.4%) patients received digoxin. Cumulative mortality rates were higher for digoxin-treated patients than for untreated
patients (95 vs. 67 per 1,000 person-years; p < 0.001). Digoxin use was independently associated with mortality after
multivariate adjustment (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.23 to 1.29, p < 0.001) and propensity
matching (HR: 1.21, 95% CI: 1.17 to 1.25, p < 0.001), even after adjustment for drug adherence. The risk of death was not
modified by age, sex, heart failure, kidney function, or concomitant use of beta-blockers, amiodarone, or warfarin.


Digoxin was associated with increased risk of death in patients with newly diagnosed AF, independent
of drug adherence, kidney function, cardiovascular comorbidities, and concomitant therapies. These findings challenge
current cardiovascular society recommendations on use of digoxin in AF.

Supplementary Material

AFFIRM study
AFFIRM subset
AFFIRM subset editorial

Journal Club 23 April 2014


A Randomized Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Heart Failure





This study sought to compare catheter ablation with rate control for persistent atrial fibrillation (AF) in heart fail- ure (HF).
Background The optimal therapy for AF in HF is unclear. Drug-based rhythm control has not proved clinically beneficial. Cath-
eter ablation improves cardiac function in patients with HF, but impact on physiological performance has not been formally evaluated in a randomized trial.


In a randomized, open-label, blinded-endpoint clinical trial, adults with symptomatic HF, radionuclide left ventric- ular ejection fraction (EF) Յ35%, and persistent AF were assigned to undergo catheter ablation or rate control. Primary outcome was 12-month change in peak oxygen consumption. Secondary endpoints were quality of life, B-type natriuretic peptide, 6-min walk distance, and EF. Results were analyzed by intention-to-treat.


Fifty-two patients (age 63 Ϯ 9 years, EF 24 Ϯ 8%) were randomized, 26 each to ablation and rate control. At 12 months, 88% of ablation patients maintained sinus rhythm (single-procedure success 68%). Under rate control, rate criteria were achieved in 96%. The primary endpoint, peak oxygen consumption, significantly increased in the ablation arm compared with rate control (difference ϩ3.07 ml/kg/min, 95% confidence interval: 0.56 to 5.59, p ϭ 0.018). The change was not evident at 3 months (ϩ0.79 ml/kg/min, 95% confidence interval: Ϫ1.01 to 2.60, p ϭ 0.38). Ablation improved Minnesota score (p ϭ 0.019) and B-type natriuretic peptide (p ϭ 0.045) and showed nonsignificant trends toward improved 6-min walk distance (p ϭ 0.095) and EF (p ϭ 0.055).


This first randomized trial of ablation versus rate control to focus on objective exercise performance in AF and HF
shows significant benefit from ablation, a strategy that also improves symptoms and neurohormonal status. The ef- fects develop over 12 months, consistent with progressive amelioration of the HF syndrome.

Supplementary Material

The editorial is here.

European Practical Guide to New Oral Anticoagulants for Nonvalvular Atrial Fibrillation

The full European Society of Cardiology practical guideline for use of new (novel) oral anticoagulants in nonvalvular atrial fibrillation is available here.

Journal Club 5 December 2012


Increased mortality among patients takingm digoxin-analysis from the AFFIRM study





Digoxin is frequently used for rate control of atrial fibrillation (AF). It has, however, been associated with increased
mortality. It remains unclear whether digoxin itself is responsible for the increased mortality (toxic drug effect) or
whether it is prescribed to sicker patients with inherently higher mortality due to comorbidities. The goal of our
study was to determine the relationship between digoxin and mortality in patients with AF.

Methods and results

The association between digoxin and mortality was assessed in patients enrolled in the AF Follow-Up Investigation of
Rhythm Management (AFFIRM) trial using multivariate Cox proportional hazards models. Analyses were conducted
in all patients and in subsets according to the presence or absence of heart failure (HF), as defined by a history of HF
and/or an ejection fraction ,40%. Digoxin was associated with an increase in all-cause mortality [estimated hazard
ratio (EHR) 1.41, 95% confidence interval (CI) 1.19–1.67, P , 0.001], cardiovascular mortality (EHR 1.35, 95% CI
1.06–1.71, P ¼ 0.016), and arrhythmic mortality (EHR 1.61, 95% CI 1.12–2.30, P ¼ 0.009). The all-cause mortality
was increased with digoxin in patients without or with HF (EHR 1.37, 95% CI 1.05–1.79, P ¼ 0.019 and EHR
1.41, 95% CI 1.09–1.84, P ¼ 0.010, respectively). There was no significant digoxin–gender interaction for all-cause
(P ¼ 0.70) or cardiovascular (P ¼ 0.95) mortality.


Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical
characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into
question the widespread use of digoxin in patients with AF.