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Stroke Prevention Drugs May Reduce Dementia Risk
Patients with atrial fibrillation could reduce the risk of dementia by taking stroke prevention medications, according to recommendations published online ahead of print March 18 in EP Europace and presented at the conference. The international consensus document was also published in Heart Rhythm, the official journal of the Heart Rhythm Society (HRS), and Journal of Arrhythmia, the official journal of the Japanese Heart Rhythm Society (JHRS) and the Asia Pacific Heart Rhythm Society (APHRS).
The expert consensus statement on arrhythmias and cognitive function was developed by the European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC); HRS; APHRS; and the Latin American Heart Rhythm Society (LAHRS).
Arrhythmias, as well as some procedures undertaken to treat them, can increase the risk of cognitive decline and dementia. The international consensus document was written for doctors specializing in arrhythmias and aims to raise awareness of the risks of cognitive impairment and dementia and of methods to reduce them.
Atrial fibrillation is associated with a higher risk for cognitive impairment and dementia, even in the absence of apparent stroke, according to the document. This increased risk may arise because atrial fibrillation is linked with a more than twofold risk of silent strokes. The accumulation of silent strokes and the associated brain injuries over time may contribute to cognitive impairment.
Stroke prevention with oral anticoagulant drugs is the main priority in the management of patients with atrial fibrillation. Oral anticoagulation may reduce the risk of dementia, according to the consensus document.
Adopting a healthy lifestyle also may reduce the risk of cognitive decline in patients with atrial fibrillation. This lifestyle includes not smoking and preventing or controlling hypertension, obesity, diabetes, and sleep apnea.
The document also reviews the association between other arrhythmias and cognitive dysfunction, including postcardiac arrest, in patients with cardiac implantable devices such as implantable cardioverter defibrillators and pacemakers, and ablation procedures.
Treatment of atrial fibrillation with catheter ablation can itself lead to silent strokes and cognitive impairment. To reduce this risk, physicians should follow recommendations for performing ablation and for the management of patients before and after the procedure, according to the document.
Physicians may suspect cognitive impairment if a patient’s appearance or behavior changes (eg, if appointments are missed). Family members should be asked for collateral information. If suspicions are confirmed, the consensus document recommends tools to conduct an objective assessment of cognitive function.
The paper highlights gaps in knowledge and areas for further research. These gaps include, for instance, how to identify patients with atrial fibrillation at increased risk of cognitive impairment and dementia, the effect of rhythm control on cognitive function, and the impact of cardiac resynchronization therapy on cognitive function.
EHRA Updates Guide on NOACs
A new version of the European Heart Rhythm Association (EHRA) Practical Guide on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation was published online ahead of print March 19 in European Heart Journal and presented at the meeting.
“European Society of Cardiology guidelines state that NOACs should be preferred over vitamin K antagonists, such as warfarin, for stroke prevention in patients with atrial fibrillation, except those with a mechanical heart valve or rheumatic mitral valve stenosis, and their use in clinical practice is increasing,” said Jan Steffel, MD, Head of the Department of Cardiology at University Heart Center Zurich.
The guide gives advice about how to use NOACs in specific clinical situations. While companies provide a Summary of Product Characteristics for a drug, there are legal restrictions on the content, and the information is often not detailed enough for doctors.
The 2018 edition of the guide has several new chapters. One outlines how to use NOACs in particular groups of patients, including those with very low body weight, the very obese, athletes, frail patients for whom there is concern about bleeding, and patients with cognitive impairment who may forget to take their pills.
Another new chapter briefly summarizes the correct dosing of NOACs in conditions other than atrial fibrillation, such as prevention of deep venous thrombosis, treatment of venous thromboembolism, and treatment of ischemic heart disease. The dosing for each condition is different, which underscores the need for clarity.
Updated advice is given on the combined use of antiplatelets and NOACs in patients with coronary artery disease, particularly those with an acute coronary syndrome or patients scheduled for percutaneous coronary intervention with stenting.
The guide also offers scientific evidence about the use of anticoagulants around cardioversion. The authors give detailed advice about what to do in patients on long-term NOAC treatment who need cardioversion versus patients newly diagnosed with atrial fibrillation and started on a NOAC before cardioversion.
Since the previous edition of the guide was published, the first NOAC reversal agent has received market approval. The authors provide advice about using idarucizumab, which reverses the anticoagulant effect of dabigatran, when there is acute bleeding, when urgent surgery is required, or when the patient has a stroke. Guidance is also included on andexanet alfa, another reversal agent expected to receive market approval, with the caveat that the instructions on the label should be followed.
Unlike warfarin, NOACs do not require monitoring of plasma levels followed by dose adjustments. The guide describes rare scenarios in which physicians might want to know the NOAC plasma level. One scenario concerns patients undergoing major surgery in whom it is unclear, for example because of other drugs or renal dysfunction, whether the usual practice of stopping the NOAC 48 hours in advance is sufficient. The plasma level of the NOAC could be measured just before surgery to confirm that the anticoagulant effect has waned.
The chapter on drug–drug interactions has been expanded with information about anticancer and antiepileptic drugs. “While this is mostly based on potential pharmacokinetic interactions and case reports, it is the first of its kind. This is likely to be adapted and become more complete over the years as our experience increases at this new frontier,” said Dr. Steffel.
Apixaban Is Safe During Catheter Ablation
Apixaban and warfarin are equally safe during catheter ablation of atrial fibrillation, according to results of the AXAFA-AFNET 5 trial. The drugs have similar rates of stroke and bleeding, and an improvement in cognitive function was shown for the first time.
Nearly one-third of all strokes are caused by atrial fibrillation. Oral anticoagulation is the cornerstone of stroke prevention in patients with atrial fibrillation. European Society of Cardiology (ESC) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) in preference over vitamin K antagonists (VKAs) such as warfarin, except in patients with a mechanical heart valve or rheumatic mitral valve stenosis. Unlike VKAs, NOACs do not require frequent monitoring and dose adjustment, and NOACs reduce long-term rates of stroke and death, compared with VKAs.
Catheter ablation is used in patients with atrial fibrillation to restore and maintain the heart’s normal rhythm, but the procedure entails risks of stroke, bleeding, acute brain lesions, and cognitive impairment. ESC guidelines recommend that patients continue taking their prescribed NOAC or VKA during the procedure. The results of this study confirm that the NOAC apixaban is as safe as a VKA in this situation.
The AXAFA-AFNET 5 trial was the first randomized trial to examine whether continuous apixaban was a safe alternative to a VKA during catheter ablation of atrial fibrillation. In all, 633 patients with atrial fibrillation and additional stroke risk factors scheduled to undergo atrial fibrillation ablation in Europe and the United States were randomized to receive either continuous apixaban or the locally used VKA (ie, warfarin, phenprocoumon, acenocoumarol, or fluindione).
The primary outcome was a composite of all-cause death, stroke, and major bleeding up to three months after ablation. It occurred in 22 patients randomized to apixaban and 23 randomized to VKA. “The results show that apixaban is a safe alternative to warfarin during catheter ablation of atrial fibrillation in patients at risk of stroke,” said Professor Paulus Kirchhof, MD, Chair in Cardiovascular Medicine at the University of Birmingham in the United Kingdom.
The researchers assessed cognitive function at the beginning and end of the trial and found that it improved equally in both treatment groups. “This is the first randomized trial to show that cognitive function is improving after atrial fibrillation ablation,” said Professor Kirchhof. “It is possible that this is due to continuous anticoagulation, although we did not test this specifically.” An MRI substudy in 335 patients showed a similar rate of silent strokes in the apixaban (27%) and VKA (25%) groups.
Patients in the trial were four years older than participants of previous studies with the NOACs rivaroxaban and dabigatran, said Professor Kirchhof. Local investigators chose the VKA and catheter ablation procedure, which led to the use of various drugs and techniques. “These characteristics of the trial mean that the results apply to older patients and in different clinical settings,” said Professor Kirchhof.
European Society of Cardiology Publishes Guidelines on Syncope
European Society of Cardiology guidelines on syncope were presented at the conference and published online ahead of print March 19 in the European Heart Journal.
Syncope is a transient loss of consciousness caused by reduced blood flow to the brain. Approximately 50% of people have one syncopal event during their lifetime. The most common type is vasovagal syncope, commonly known as fainting, triggered by fear, seeing blood, or prolonged standing, for example.
The challenge for doctors is to identify the minority of patients whose syncope is caused by a potentially deadly heart problem. The guidelines recommend a new algorithm for emergency departments to stratify patients and discharge those at low risk. Patients at intermediate or high risk should receive diagnostic tests in the emergency department or an outpatient syncope clinic.
“The new pathway avoids costly hospitalizations while ensuring the patient is properly diagnosed and treated,” said Professor Michele Brignole, MD, a cardiologist at Ospedali del Tigullio in Lavagna, Italy.
Most syncope does not increase the risk of death, but it can cause injury due to falls or be dangerous in certain occupations, such as airline pilots. The guidelines provide recommendations on how to prevent syncope, which include keeping hydrated; avoiding hot, crowded environments; tensing the muscles; and lying down. The document gives advice on driving for patients with syncope, although the risk of accidents is low.
The document emphasizes the value of video recording in the hospital or at home to improve diagnosis. It recommends that friends and relatives use their smartphones to film the attack and recovery. Clinical clues, such as the duration of the loss of consciousness, whether the patient’s eyes are open or closed, and jerky movements, can distinguish between syncope, epilepsy, and other conditions.
Another diagnostic tool is the implantable loop recorder, a small device inserted underneath the skin of the chest that records the heart’s electrical signals. The guidelines recommend extending its use for diagnosis in patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk of sudden cardiac death.
The guidelines include an addendum with practical instructions for doctors about how to perform and interpret diagnostic tests.
“The Task Force that prepared the guidelines was truly multidisciplinary,” said Professor Brignole. “A minority of cardiologists was joined by experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing.”
Drinking Alcohol Makes the Heart Race
The more alcohol one drinks, the higher one’s heart rate gets, according to research. Binge drinking has been linked with atrial fibrillation, a phenomenon called “the holiday heart syndrome.” The connection was initially based on small studies and anecdotal evidence from the late 1970s.
The Munich Beer Related Electro-cardiogram Workup (Munich BREW) study was conducted by researchers from the LMU University Hospital Munich Department of Cardiology and supported by the German Cardiovascular Research Centre and the European Commission. It was the first assessment of the acute effects of alcohol on ECG readings. The study included more than 3,000 people attending the 2015 Munich Oktoberfest.ECG readings were taken, and breath alcohol concentrations were measured. Age, sex, heart disease, heart medications, and smoking status were recorded. Participants were, on average, 35 years old, and 30% were women.
The average breath alcohol concentration was 0.85 g/kg. Increasing breath alcohol concentration was significantly associated with sinus tachycardia of more than 100 bpm in 25.9% of the cohort.
The current analysis of the MunichBREW study looked in more detail at the quantitative ECG measurements in 3,012 participants. The researchers investigated the association between blood alcohol concentration and the ECG parameters of excitation (ie, heart rate), conduction (ie, PR interval and QRS complex), and repolarization (ie, QT interval).
Increased heart rate was associated with higher breath alcohol concentration, confirming the initial results of the MunichBREW study. The association was linear, with no threshold. Alcohol consumption had no effect on the other three parameters.
“The more alcohol you drink, the higher your heart rate gets,” said Stefan Brunner, MD, a cardiologist at the University Hospital Munich, one of the lead authors.
The researchers are currently investigating whether the increase in heart rate with alcohol consumption could lead to heart rhythm disorders in the longer term.
Stroke Prevention Drugs May Reduce Dementia Risk
Patients with atrial fibrillation could reduce the risk of dementia by taking stroke prevention medications, according to recommendations published online ahead of print March 18 in EP Europace and presented at the conference. The international consensus document was also published in Heart Rhythm, the official journal of the Heart Rhythm Society (HRS), and Journal of Arrhythmia, the official journal of the Japanese Heart Rhythm Society (JHRS) and the Asia Pacific Heart Rhythm Society (APHRS).
The expert consensus statement on arrhythmias and cognitive function was developed by the European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC); HRS; APHRS; and the Latin American Heart Rhythm Society (LAHRS).
Arrhythmias, as well as some procedures undertaken to treat them, can increase the risk of cognitive decline and dementia. The international consensus document was written for doctors specializing in arrhythmias and aims to raise awareness of the risks of cognitive impairment and dementia and of methods to reduce them.
Atrial fibrillation is associated with a higher risk for cognitive impairment and dementia, even in the absence of apparent stroke, according to the document. This increased risk may arise because atrial fibrillation is linked with a more than twofold risk of silent strokes. The accumulation of silent strokes and the associated brain injuries over time may contribute to cognitive impairment.
Stroke prevention with oral anticoagulant drugs is the main priority in the management of patients with atrial fibrillation. Oral anticoagulation may reduce the risk of dementia, according to the consensus document.
Adopting a healthy lifestyle also may reduce the risk of cognitive decline in patients with atrial fibrillation. This lifestyle includes not smoking and preventing or controlling hypertension, obesity, diabetes, and sleep apnea.
The document also reviews the association between other arrhythmias and cognitive dysfunction, including postcardiac arrest, in patients with cardiac implantable devices such as implantable cardioverter defibrillators and pacemakers, and ablation procedures.
Treatment of atrial fibrillation with catheter ablation can itself lead to silent strokes and cognitive impairment. To reduce this risk, physicians should follow recommendations for performing ablation and for the management of patients before and after the procedure, according to the document.
Physicians may suspect cognitive impairment if a patient’s appearance or behavior changes (eg, if appointments are missed). Family members should be asked for collateral information. If suspicions are confirmed, the consensus document recommends tools to conduct an objective assessment of cognitive function.
The paper highlights gaps in knowledge and areas for further research. These gaps include, for instance, how to identify patients with atrial fibrillation at increased risk of cognitive impairment and dementia, the effect of rhythm control on cognitive function, and the impact of cardiac resynchronization therapy on cognitive function.
EHRA Updates Guide on NOACs
A new version of the European Heart Rhythm Association (EHRA) Practical Guide on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation was published online ahead of print March 19 in European Heart Journal and presented at the meeting.
“European Society of Cardiology guidelines state that NOACs should be preferred over vitamin K antagonists, such as warfarin, for stroke prevention in patients with atrial fibrillation, except those with a mechanical heart valve or rheumatic mitral valve stenosis, and their use in clinical practice is increasing,” said Jan Steffel, MD, Head of the Department of Cardiology at University Heart Center Zurich.
The guide gives advice about how to use NOACs in specific clinical situations. While companies provide a Summary of Product Characteristics for a drug, there are legal restrictions on the content, and the information is often not detailed enough for doctors.
The 2018 edition of the guide has several new chapters. One outlines how to use NOACs in particular groups of patients, including those with very low body weight, the very obese, athletes, frail patients for whom there is concern about bleeding, and patients with cognitive impairment who may forget to take their pills.
Another new chapter briefly summarizes the correct dosing of NOACs in conditions other than atrial fibrillation, such as prevention of deep venous thrombosis, treatment of venous thromboembolism, and treatment of ischemic heart disease. The dosing for each condition is different, which underscores the need for clarity.
Updated advice is given on the combined use of antiplatelets and NOACs in patients with coronary artery disease, particularly those with an acute coronary syndrome or patients scheduled for percutaneous coronary intervention with stenting.
The guide also offers scientific evidence about the use of anticoagulants around cardioversion. The authors give detailed advice about what to do in patients on long-term NOAC treatment who need cardioversion versus patients newly diagnosed with atrial fibrillation and started on a NOAC before cardioversion.
Since the previous edition of the guide was published, the first NOAC reversal agent has received market approval. The authors provide advice about using idarucizumab, which reverses the anticoagulant effect of dabigatran, when there is acute bleeding, when urgent surgery is required, or when the patient has a stroke. Guidance is also included on andexanet alfa, another reversal agent expected to receive market approval, with the caveat that the instructions on the label should be followed.
Unlike warfarin, NOACs do not require monitoring of plasma levels followed by dose adjustments. The guide describes rare scenarios in which physicians might want to know the NOAC plasma level. One scenario concerns patients undergoing major surgery in whom it is unclear, for example because of other drugs or renal dysfunction, whether the usual practice of stopping the NOAC 48 hours in advance is sufficient. The plasma level of the NOAC could be measured just before surgery to confirm that the anticoagulant effect has waned.
The chapter on drug–drug interactions has been expanded with information about anticancer and antiepileptic drugs. “While this is mostly based on potential pharmacokinetic interactions and case reports, it is the first of its kind. This is likely to be adapted and become more complete over the years as our experience increases at this new frontier,” said Dr. Steffel.
Apixaban Is Safe During Catheter Ablation
Apixaban and warfarin are equally safe during catheter ablation of atrial fibrillation, according to results of the AXAFA-AFNET 5 trial. The drugs have similar rates of stroke and bleeding, and an improvement in cognitive function was shown for the first time.
Nearly one-third of all strokes are caused by atrial fibrillation. Oral anticoagulation is the cornerstone of stroke prevention in patients with atrial fibrillation. European Society of Cardiology (ESC) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) in preference over vitamin K antagonists (VKAs) such as warfarin, except in patients with a mechanical heart valve or rheumatic mitral valve stenosis. Unlike VKAs, NOACs do not require frequent monitoring and dose adjustment, and NOACs reduce long-term rates of stroke and death, compared with VKAs.
Catheter ablation is used in patients with atrial fibrillation to restore and maintain the heart’s normal rhythm, but the procedure entails risks of stroke, bleeding, acute brain lesions, and cognitive impairment. ESC guidelines recommend that patients continue taking their prescribed NOAC or VKA during the procedure. The results of this study confirm that the NOAC apixaban is as safe as a VKA in this situation.
The AXAFA-AFNET 5 trial was the first randomized trial to examine whether continuous apixaban was a safe alternative to a VKA during catheter ablation of atrial fibrillation. In all, 633 patients with atrial fibrillation and additional stroke risk factors scheduled to undergo atrial fibrillation ablation in Europe and the United States were randomized to receive either continuous apixaban or the locally used VKA (ie, warfarin, phenprocoumon, acenocoumarol, or fluindione).
The primary outcome was a composite of all-cause death, stroke, and major bleeding up to three months after ablation. It occurred in 22 patients randomized to apixaban and 23 randomized to VKA. “The results show that apixaban is a safe alternative to warfarin during catheter ablation of atrial fibrillation in patients at risk of stroke,” said Professor Paulus Kirchhof, MD, Chair in Cardiovascular Medicine at the University of Birmingham in the United Kingdom.
The researchers assessed cognitive function at the beginning and end of the trial and found that it improved equally in both treatment groups. “This is the first randomized trial to show that cognitive function is improving after atrial fibrillation ablation,” said Professor Kirchhof. “It is possible that this is due to continuous anticoagulation, although we did not test this specifically.” An MRI substudy in 335 patients showed a similar rate of silent strokes in the apixaban (27%) and VKA (25%) groups.
Patients in the trial were four years older than participants of previous studies with the NOACs rivaroxaban and dabigatran, said Professor Kirchhof. Local investigators chose the VKA and catheter ablation procedure, which led to the use of various drugs and techniques. “These characteristics of the trial mean that the results apply to older patients and in different clinical settings,” said Professor Kirchhof.
European Society of Cardiology Publishes Guidelines on Syncope
European Society of Cardiology guidelines on syncope were presented at the conference and published online ahead of print March 19 in the European Heart Journal.
Syncope is a transient loss of consciousness caused by reduced blood flow to the brain. Approximately 50% of people have one syncopal event during their lifetime. The most common type is vasovagal syncope, commonly known as fainting, triggered by fear, seeing blood, or prolonged standing, for example.
The challenge for doctors is to identify the minority of patients whose syncope is caused by a potentially deadly heart problem. The guidelines recommend a new algorithm for emergency departments to stratify patients and discharge those at low risk. Patients at intermediate or high risk should receive diagnostic tests in the emergency department or an outpatient syncope clinic.
“The new pathway avoids costly hospitalizations while ensuring the patient is properly diagnosed and treated,” said Professor Michele Brignole, MD, a cardiologist at Ospedali del Tigullio in Lavagna, Italy.
Most syncope does not increase the risk of death, but it can cause injury due to falls or be dangerous in certain occupations, such as airline pilots. The guidelines provide recommendations on how to prevent syncope, which include keeping hydrated; avoiding hot, crowded environments; tensing the muscles; and lying down. The document gives advice on driving for patients with syncope, although the risk of accidents is low.
The document emphasizes the value of video recording in the hospital or at home to improve diagnosis. It recommends that friends and relatives use their smartphones to film the attack and recovery. Clinical clues, such as the duration of the loss of consciousness, whether the patient’s eyes are open or closed, and jerky movements, can distinguish between syncope, epilepsy, and other conditions.
Another diagnostic tool is the implantable loop recorder, a small device inserted underneath the skin of the chest that records the heart’s electrical signals. The guidelines recommend extending its use for diagnosis in patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk of sudden cardiac death.
The guidelines include an addendum with practical instructions for doctors about how to perform and interpret diagnostic tests.
“The Task Force that prepared the guidelines was truly multidisciplinary,” said Professor Brignole. “A minority of cardiologists was joined by experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing.”
Drinking Alcohol Makes the Heart Race
The more alcohol one drinks, the higher one’s heart rate gets, according to research. Binge drinking has been linked with atrial fibrillation, a phenomenon called “the holiday heart syndrome.” The connection was initially based on small studies and anecdotal evidence from the late 1970s.
The Munich Beer Related Electro-cardiogram Workup (Munich BREW) study was conducted by researchers from the LMU University Hospital Munich Department of Cardiology and supported by the German Cardiovascular Research Centre and the European Commission. It was the first assessment of the acute effects of alcohol on ECG readings. The study included more than 3,000 people attending the 2015 Munich Oktoberfest.ECG readings were taken, and breath alcohol concentrations were measured. Age, sex, heart disease, heart medications, and smoking status were recorded. Participants were, on average, 35 years old, and 30% were women.
The average breath alcohol concentration was 0.85 g/kg. Increasing breath alcohol concentration was significantly associated with sinus tachycardia of more than 100 bpm in 25.9% of the cohort.
The current analysis of the MunichBREW study looked in more detail at the quantitative ECG measurements in 3,012 participants. The researchers investigated the association between blood alcohol concentration and the ECG parameters of excitation (ie, heart rate), conduction (ie, PR interval and QRS complex), and repolarization (ie, QT interval).
Increased heart rate was associated with higher breath alcohol concentration, confirming the initial results of the MunichBREW study. The association was linear, with no threshold. Alcohol consumption had no effect on the other three parameters.
“The more alcohol you drink, the higher your heart rate gets,” said Stefan Brunner, MD, a cardiologist at the University Hospital Munich, one of the lead authors.
The researchers are currently investigating whether the increase in heart rate with alcohol consumption could lead to heart rhythm disorders in the longer term.
Stroke Prevention Drugs May Reduce Dementia Risk
Patients with atrial fibrillation could reduce the risk of dementia by taking stroke prevention medications, according to recommendations published online ahead of print March 18 in EP Europace and presented at the conference. The international consensus document was also published in Heart Rhythm, the official journal of the Heart Rhythm Society (HRS), and Journal of Arrhythmia, the official journal of the Japanese Heart Rhythm Society (JHRS) and the Asia Pacific Heart Rhythm Society (APHRS).
The expert consensus statement on arrhythmias and cognitive function was developed by the European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC); HRS; APHRS; and the Latin American Heart Rhythm Society (LAHRS).
Arrhythmias, as well as some procedures undertaken to treat them, can increase the risk of cognitive decline and dementia. The international consensus document was written for doctors specializing in arrhythmias and aims to raise awareness of the risks of cognitive impairment and dementia and of methods to reduce them.
Atrial fibrillation is associated with a higher risk for cognitive impairment and dementia, even in the absence of apparent stroke, according to the document. This increased risk may arise because atrial fibrillation is linked with a more than twofold risk of silent strokes. The accumulation of silent strokes and the associated brain injuries over time may contribute to cognitive impairment.
Stroke prevention with oral anticoagulant drugs is the main priority in the management of patients with atrial fibrillation. Oral anticoagulation may reduce the risk of dementia, according to the consensus document.
Adopting a healthy lifestyle also may reduce the risk of cognitive decline in patients with atrial fibrillation. This lifestyle includes not smoking and preventing or controlling hypertension, obesity, diabetes, and sleep apnea.
The document also reviews the association between other arrhythmias and cognitive dysfunction, including postcardiac arrest, in patients with cardiac implantable devices such as implantable cardioverter defibrillators and pacemakers, and ablation procedures.
Treatment of atrial fibrillation with catheter ablation can itself lead to silent strokes and cognitive impairment. To reduce this risk, physicians should follow recommendations for performing ablation and for the management of patients before and after the procedure, according to the document.
Physicians may suspect cognitive impairment if a patient’s appearance or behavior changes (eg, if appointments are missed). Family members should be asked for collateral information. If suspicions are confirmed, the consensus document recommends tools to conduct an objective assessment of cognitive function.
The paper highlights gaps in knowledge and areas for further research. These gaps include, for instance, how to identify patients with atrial fibrillation at increased risk of cognitive impairment and dementia, the effect of rhythm control on cognitive function, and the impact of cardiac resynchronization therapy on cognitive function.
EHRA Updates Guide on NOACs
A new version of the European Heart Rhythm Association (EHRA) Practical Guide on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation was published online ahead of print March 19 in European Heart Journal and presented at the meeting.
“European Society of Cardiology guidelines state that NOACs should be preferred over vitamin K antagonists, such as warfarin, for stroke prevention in patients with atrial fibrillation, except those with a mechanical heart valve or rheumatic mitral valve stenosis, and their use in clinical practice is increasing,” said Jan Steffel, MD, Head of the Department of Cardiology at University Heart Center Zurich.
The guide gives advice about how to use NOACs in specific clinical situations. While companies provide a Summary of Product Characteristics for a drug, there are legal restrictions on the content, and the information is often not detailed enough for doctors.
The 2018 edition of the guide has several new chapters. One outlines how to use NOACs in particular groups of patients, including those with very low body weight, the very obese, athletes, frail patients for whom there is concern about bleeding, and patients with cognitive impairment who may forget to take their pills.
Another new chapter briefly summarizes the correct dosing of NOACs in conditions other than atrial fibrillation, such as prevention of deep venous thrombosis, treatment of venous thromboembolism, and treatment of ischemic heart disease. The dosing for each condition is different, which underscores the need for clarity.
Updated advice is given on the combined use of antiplatelets and NOACs in patients with coronary artery disease, particularly those with an acute coronary syndrome or patients scheduled for percutaneous coronary intervention with stenting.
The guide also offers scientific evidence about the use of anticoagulants around cardioversion. The authors give detailed advice about what to do in patients on long-term NOAC treatment who need cardioversion versus patients newly diagnosed with atrial fibrillation and started on a NOAC before cardioversion.
Since the previous edition of the guide was published, the first NOAC reversal agent has received market approval. The authors provide advice about using idarucizumab, which reverses the anticoagulant effect of dabigatran, when there is acute bleeding, when urgent surgery is required, or when the patient has a stroke. Guidance is also included on andexanet alfa, another reversal agent expected to receive market approval, with the caveat that the instructions on the label should be followed.
Unlike warfarin, NOACs do not require monitoring of plasma levels followed by dose adjustments. The guide describes rare scenarios in which physicians might want to know the NOAC plasma level. One scenario concerns patients undergoing major surgery in whom it is unclear, for example because of other drugs or renal dysfunction, whether the usual practice of stopping the NOAC 48 hours in advance is sufficient. The plasma level of the NOAC could be measured just before surgery to confirm that the anticoagulant effect has waned.
The chapter on drug–drug interactions has been expanded with information about anticancer and antiepileptic drugs. “While this is mostly based on potential pharmacokinetic interactions and case reports, it is the first of its kind. This is likely to be adapted and become more complete over the years as our experience increases at this new frontier,” said Dr. Steffel.
Apixaban Is Safe During Catheter Ablation
Apixaban and warfarin are equally safe during catheter ablation of atrial fibrillation, according to results of the AXAFA-AFNET 5 trial. The drugs have similar rates of stroke and bleeding, and an improvement in cognitive function was shown for the first time.
Nearly one-third of all strokes are caused by atrial fibrillation. Oral anticoagulation is the cornerstone of stroke prevention in patients with atrial fibrillation. European Society of Cardiology (ESC) guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) in preference over vitamin K antagonists (VKAs) such as warfarin, except in patients with a mechanical heart valve or rheumatic mitral valve stenosis. Unlike VKAs, NOACs do not require frequent monitoring and dose adjustment, and NOACs reduce long-term rates of stroke and death, compared with VKAs.
Catheter ablation is used in patients with atrial fibrillation to restore and maintain the heart’s normal rhythm, but the procedure entails risks of stroke, bleeding, acute brain lesions, and cognitive impairment. ESC guidelines recommend that patients continue taking their prescribed NOAC or VKA during the procedure. The results of this study confirm that the NOAC apixaban is as safe as a VKA in this situation.
The AXAFA-AFNET 5 trial was the first randomized trial to examine whether continuous apixaban was a safe alternative to a VKA during catheter ablation of atrial fibrillation. In all, 633 patients with atrial fibrillation and additional stroke risk factors scheduled to undergo atrial fibrillation ablation in Europe and the United States were randomized to receive either continuous apixaban or the locally used VKA (ie, warfarin, phenprocoumon, acenocoumarol, or fluindione).
The primary outcome was a composite of all-cause death, stroke, and major bleeding up to three months after ablation. It occurred in 22 patients randomized to apixaban and 23 randomized to VKA. “The results show that apixaban is a safe alternative to warfarin during catheter ablation of atrial fibrillation in patients at risk of stroke,” said Professor Paulus Kirchhof, MD, Chair in Cardiovascular Medicine at the University of Birmingham in the United Kingdom.
The researchers assessed cognitive function at the beginning and end of the trial and found that it improved equally in both treatment groups. “This is the first randomized trial to show that cognitive function is improving after atrial fibrillation ablation,” said Professor Kirchhof. “It is possible that this is due to continuous anticoagulation, although we did not test this specifically.” An MRI substudy in 335 patients showed a similar rate of silent strokes in the apixaban (27%) and VKA (25%) groups.
Patients in the trial were four years older than participants of previous studies with the NOACs rivaroxaban and dabigatran, said Professor Kirchhof. Local investigators chose the VKA and catheter ablation procedure, which led to the use of various drugs and techniques. “These characteristics of the trial mean that the results apply to older patients and in different clinical settings,” said Professor Kirchhof.
European Society of Cardiology Publishes Guidelines on Syncope
European Society of Cardiology guidelines on syncope were presented at the conference and published online ahead of print March 19 in the European Heart Journal.
Syncope is a transient loss of consciousness caused by reduced blood flow to the brain. Approximately 50% of people have one syncopal event during their lifetime. The most common type is vasovagal syncope, commonly known as fainting, triggered by fear, seeing blood, or prolonged standing, for example.
The challenge for doctors is to identify the minority of patients whose syncope is caused by a potentially deadly heart problem. The guidelines recommend a new algorithm for emergency departments to stratify patients and discharge those at low risk. Patients at intermediate or high risk should receive diagnostic tests in the emergency department or an outpatient syncope clinic.
“The new pathway avoids costly hospitalizations while ensuring the patient is properly diagnosed and treated,” said Professor Michele Brignole, MD, a cardiologist at Ospedali del Tigullio in Lavagna, Italy.
Most syncope does not increase the risk of death, but it can cause injury due to falls or be dangerous in certain occupations, such as airline pilots. The guidelines provide recommendations on how to prevent syncope, which include keeping hydrated; avoiding hot, crowded environments; tensing the muscles; and lying down. The document gives advice on driving for patients with syncope, although the risk of accidents is low.
The document emphasizes the value of video recording in the hospital or at home to improve diagnosis. It recommends that friends and relatives use their smartphones to film the attack and recovery. Clinical clues, such as the duration of the loss of consciousness, whether the patient’s eyes are open or closed, and jerky movements, can distinguish between syncope, epilepsy, and other conditions.
Another diagnostic tool is the implantable loop recorder, a small device inserted underneath the skin of the chest that records the heart’s electrical signals. The guidelines recommend extending its use for diagnosis in patients with unexplained falls, suspected epilepsy, or recurrent episodes of unexplained syncope and a low risk of sudden cardiac death.
The guidelines include an addendum with practical instructions for doctors about how to perform and interpret diagnostic tests.
“The Task Force that prepared the guidelines was truly multidisciplinary,” said Professor Brignole. “A minority of cardiologists was joined by experts in emergency medicine, internal medicine and physiology, neurology and autonomic diseases, geriatric medicine, and nursing.”
Drinking Alcohol Makes the Heart Race
The more alcohol one drinks, the higher one’s heart rate gets, according to research. Binge drinking has been linked with atrial fibrillation, a phenomenon called “the holiday heart syndrome.” The connection was initially based on small studies and anecdotal evidence from the late 1970s.
The Munich Beer Related Electro-cardiogram Workup (Munich BREW) study was conducted by researchers from the LMU University Hospital Munich Department of Cardiology and supported by the German Cardiovascular Research Centre and the European Commission. It was the first assessment of the acute effects of alcohol on ECG readings. The study included more than 3,000 people attending the 2015 Munich Oktoberfest.ECG readings were taken, and breath alcohol concentrations were measured. Age, sex, heart disease, heart medications, and smoking status were recorded. Participants were, on average, 35 years old, and 30% were women.
The average breath alcohol concentration was 0.85 g/kg. Increasing breath alcohol concentration was significantly associated with sinus tachycardia of more than 100 bpm in 25.9% of the cohort.
The current analysis of the MunichBREW study looked in more detail at the quantitative ECG measurements in 3,012 participants. The researchers investigated the association between blood alcohol concentration and the ECG parameters of excitation (ie, heart rate), conduction (ie, PR interval and QRS complex), and repolarization (ie, QT interval).
Increased heart rate was associated with higher breath alcohol concentration, confirming the initial results of the MunichBREW study. The association was linear, with no threshold. Alcohol consumption had no effect on the other three parameters.
“The more alcohol you drink, the higher your heart rate gets,” said Stefan Brunner, MD, a cardiologist at the University Hospital Munich, one of the lead authors.
The researchers are currently investigating whether the increase in heart rate with alcohol consumption could lead to heart rhythm disorders in the longer term.
