Falsche Diagnose Vorhofflimmern

Bogun F et al.: Misdiagnosis of atrial fibrillation and its clinical consequences. Am J Med. 117 (2004):636-42.
DOI: 10.1016/j.amjmed.2004.06.024

Bei 382 (35 %) von 1085 Patienten mit vermeintlichem Vorhofflimmern (VHF) lt. Computeralgorithmus war die Diagnose falsch. Bei 92 Patienten (24 %) wurde die falsche Diagnose nicht vom Arzt korrigiert. Dies führte zu inadäquater Therapie (inkl. antiarrhythmischer Medikation und Antikoagulation) bei 39 Patienten (10 %) und unnötigen weiteren Tests bei 90 Patienten (24 %). Bei 43 Patienten (11 %) wurde die falsche Abschlussdiagnose „paroxysmales VHF“ gestellt.

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Schlaganfallrisiko in Abhängigkeit von der VHF-Dauer

Botto GL et al.: Presence and Duration of Atrial Fibrillation Detected by Continuous Monitoring: Crucial Implications for the Risk of Thromboembolic Events. J Cardiovasc Electrophysiol 20 (2009): 241‐248
https://doi.org/10.1111/j.1540-8167.2008.01320.x

AF and the Risk of Thromboembolic Events. Introduction: Asymptomatic atrial fibrillation (AF) can expose patients to the risk of stroke. The primary objective of this study was to assess the incidence of thromboembolic events in relationship with CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke, or transient ischemic attack) score and AF presence/duration. The secondary objective was to compare intermittent versus continuous monitoring strategies.

Methods and Results: Data from patients with an implanted pacemaker and a history of AF were analyzed. Thromboembolic risk was quantified through CHADS2 score. Three AF groups were considered: patients with <5‐minutes AF on 1 day (AF‐free); patients with >5‐minutes AF on 1 day but <24 hours (AF‐5 minutes); patients with AF episodes >24 hours (AF‐24 hours). Monitoring strategies involving 24‐hour Holter, 1‐week Holter, and 30‐day Holter were simulated. Data from 568 patients continuously monitored for 1 year were analyzed: 171 (30%) had CHADS2 score = 0; 269 (47%) had CHADS2 score = 1; 111 (20%) had CHADS2 score = 2; and 17 (3%) had CHADS2 score ≥ 3. During follow‐up, 14 patients (2.5%) had an ischemic thromboembolic event. AF‐24 hours patients numbered 223 (39.2%); AF‐5 minutes, 179 (31.5%); and AF‐free, 29.2%. By combining AF presence/duration with CHADS2 score, two subpopulations with markedly different risks of events (0.8% vs 5%, P = 0.035) were identified, the former corresponding to AF‐free with CHADS2≤2, or AF‐5 minutes with CHADS2≤1, or AF‐24 hours with CHADS2= 0. The mean sensitivity in detecting an AF episode lasting >5 minutes was 44.4%, 50.4%, and 65.1% for 24‐hour Holter, 1‐week Holter, and 1‐month Holter monitoring, respectively.

Conclusion: In patients with recurrent AF episodes, risk stratification for thromboembolic events can be improved by combining CHADS2 score with AF presence/duration.

Schlaganfallrisiko bei paroxysmalem Vorhofflimmern

Hohnloser SH et al.: Incidence of Stroke in Paroxysmal Versus Sustained Atrial Fibrillation in Patients Taking Oral Anticoagulation or Combined Antiplatelet Therapy: An ACTIVE W Substudy. JACC 50 (2007): 2156-2161
https://doi.org/10.1016/j.jacc.2007.07.076

Objectives
Our goal was to determine the risk of stroke or non-cerebral embolism associated with paroxysmal compared with sustained atrial fibrillation (AF).

Background
The risk of stroke and non-cerebral embolism and the efficacy of oral anticoagulation (OAC) in paroxysmal AF as compared with sustained AF are not precisely known.

Methods
The ACTIVE W (Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events) was a trial comparing OAC to combined antiplatelet therapy with aspirin and clopidogrel for prevention of vascular events in 6,706 AF patients. The incidence of thromboembolic events and major bleeds were compared in patients with paroxysmal AF (n = 1,202) and persistent or permanent AF (n = 5,495).

Results
Patients with paroxysmal AF were younger, had a shorter AF history, more hypertension, and less valvular disease, heart failure, and diabetes mellitus than patients with sustained AF. At baseline, patients with paroxysmal AF had a CHADS2(cardiac failure, hypertension, age, diabetes, stroke [doubled]) risk score of 1.79 ± 1.03 compared with 2.04 ± 1.12 in patients with sustained AF (p < 0.00001). The annualized risk of stroke or non-central nervous system (CNS) systemic embolism was 2.0 in paroxysmal AF compared with 2.2 in sustained AF (relative risk 0.87, 95% confidence interval [CI] 0.59 to 1.30, p = 0.496). After adjusting for confounding baseline variables, the relative risk was 0.94 (95% CI 0.63 to 1.40, p = 0.755). The incidence of stroke and non-CNS embolism was lower for patients treated with OAC irrespective of type of AF. There were more bleedings of any type in patients receiving clopidogrel plus aspirin, irrespective of the type of AF. Conclusions Patients with paroxysmal AF treated with aspirin plus clopidogrel or OAC have a similar risk for thromboembolic events than patients with sustained AF. This risk can be significantly lowered with OAC. (The ACTIVE W trial; http://www.clinicaltrials.gov/ct/show/NCT00243178; NCT00243178)

Herzexperten liken Wearables

Grätzel P: Herzexperten liken Wearables. Cardio News 23 01/02.2020


Meldung über die im Januar 2020 bei der CES (Consumer Electronics Show) 2020 Las Vegas vorgestellte „Guidance for Wearable Health Solutions“ der Heart Rhythm Society (HRS) und der Consumer Technology Association (CTA). Pressemeldung und Download (PDF 5.2 Mb) der Guidance hier.

Mit dem Papier macht die HRS deutlich, dass sie dem Trend zu Wearables prinzipiell viel Positives abgewinnen kann

Das Positionspapier hebt auch hervor, dass (US-) Ärzte der tragbaren Sensorik generell sehr aufgeschlossen gegenüber ständen. 62 % seien überzeugt, dass diese die Versorgungsqualität der eigenen Patienten verbessern könne.

Antikoagulation bei „Device-detected“ VHF

Perino AC et al.: Practice Variation in Anticoagulation Prescription and Outcomes After Device- Detected Atrial Fibrillation
Insights From the Veterans Health Administration. Circulation (2019) 139:2502–2512. DOI: 10.1161/CIRCULATIONAHA.118.038988
Bei paroxysmalem Vorhofflimmern (VHF) wird das Schlaganfallrisiko nur bei Patienten mit hoher Last an VHF (hier als kumulative Zeit mit VHF an mindestens einem Tag innerhalb von 90 Tagen Überwachungszeit) durch OAK signifikant vermindert (Spalte re.: Hazard Ratio mit 95 %-Konfidenzintervall bei multivariater Regressionsanalyse):
VHF-LastAnteil in Studie (%)Anteil mit OAK (%)Relatives Schlaganfall-Risiko durch OAK (Hazard Ratio)
>6 Min45130.62 (0.26-1.43) p = 0.29
>1 Std39160.79 (0.35-1.77) p = 0.57
>6 Std3220.60.52 (0.22-1.25) p = 0.14
>24 Std2427.40.28 (0.10-0.81) p = 0.02

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