Revista Espanola de Cardiologia Suplementos最新文献

This article provides an update on the nonpharmacological treatment of atrial fibrillation. First, the current status of ablation, including indications, techniques and outcomes, is reviewed. Second, the indications for electrical cardioversion, the precautions that have to be taken and the outcomes achievable are summarized. In addition, there is a discussion of the role of pacemakers for heart rate control in two groups of patients with atrial fibrillation: those with permanent atrial fibrillation and those in whom pharmacological control is difficult, such as patients with paroxysmal atrial fibrillation or bradycardia– tachycardia syndrome. Finally, an overview is presented of the devices currently used for left atrial appendage closure in patients with a high thromboembolic risk and a contraindication to oral anticoagulants.

In Spain, new oral anticoagulants are used in fewer than 20% of patients with nonvalvular atrial fibrillation. This is lower than the rate observed in comparable countries and lower than that expected given current official recommendations and given the number of patients known to lie outside the therapeutic range while taking vitamin-K antagonists. This article provides an overview of the possible causes of the apparently low use of new oral anticoagulants in Spain. A number of distinct barriers have been documented that affect individuals involved in treatment decision-making (i.e. patients and health-care professionals and payers). The most relevant explanatory factors appear to be resistance to change by patients and health-care professionals, prescription being restricted to particular specialists, and the variation in policies affecting access to drugs between different Spanish autonomous regions. The causative factor that appears to best explain differing access to new oral anticoagulants in the Spanish National Health System is the impact of these drugs on the health budget. In particular, difficulties have been created by the absence of a coherent common management framework that takes responsibility for both the decision to fund an innovative treatment and the budgetary implications of its use. The effectiveness of a particular type of therapy does not imply that it will be “possible” to fund it at any given time, given that it is always legitimate to limit its use if decision-making is transparent and based on clear criteria. However, keeping alive, mostly nonexistent, technical uncertainties does not help solve the problem and casts doubt on the credibility of the evaluation process.

Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In Spain, the latest data suggest that the prevalence in people aged over 40 years could be greater than 4%. Both the prevalence and incidence of atrial fibrillation have increased substantially over time. Possible reasons for this rise are the aging of the population, an increase in the number of cardiovascular risk factors and better cardiovascular disease survival. In addition, the increased availability of improved diagnostic tools for detecting atrial fibrillation could have contributed. This article provides a review of the evidence available on the epidemiology of atrial fibrillation in Spain and other western countries.

The pharmacological treatment of atrial fibrillation is based on two fundamental approaches: stroke prevention using oral anticoagulants and control of the arrhythmia itself, primarily by heart rate or rhythm control. This review provides an overview of the main characteristics of each of the principal anticoagulants, from classical vitamin-K antagonists to the most recent direct anticoagulants. In addition, the different treatments used to control the heart rate are discussed, as are the various antiarrhythmic drugs used both to induce reversion to normal sinus rhythm and to maintain a normal rhythm once it has been achieved.

Edoxaban is a direct inhibitor of factor Xa that has been evaluated for the prevention of cerebral and systemic thromboembolic events in patients with nonvalvular atrial fibrillation. A comprehensive program of phase-II studies has demonstrated that administration of a dose of 30 or 60 mg once a day rather than twice daily is associated with fewer hemorrhagic events than warfarin. The dose should be lower in certain conditions (e.g. patients with moderate renal impairment or a body weight ≤60 kg and those taking P-glycoprotein inhibitors) in order to reduce the risk of hemorrhagic complications.

Despite being the most common sustained cardiac arrhythmia and despite having been first described over 100 years ago, atrial fibrillation is, like ventricular fibrillation, virtually the only arrhythmia whose mechanism is still unknown. This lack of knowledge has profound clinical implications and is not just of academic interest. Firstly, lack of knowledge means that the diagnosis of atrial fibrillation is still based on ECG findings, which can often give rise to doubts about the diagnosis, with both surface ECGs and intracardiac electrophysiological studies. Moreover, lack of knowledge about the underlying mechanism also hampers the development of both better-targeted pharmacological and invasive therapies and preventive measures that can avert, or at least delay, the onset of atrial fibrillation. This article provides a review of the most widely accepted theories about the mechanism underlying this arrhythmia, such as the multiple coexisting functional re-entry circuits theory and the mother rotor theory. In addition, the article examines factors that could influence the condition, such as atrial remodeling, atrial fibrosis and scarring, and the critical atrial mass, and considers the role of the pulmonary veins and the evidence supporting a link with re-entry. Diagnostic criteria for this arrhythmia, its classification and recommended diagnostic investigations are also discussed.

This article provides a brief comparison of the different clinical practice guidelines available on the treatment of atrial fibrillation, with an emphasis on the guidelines of the European Society of Cardiology and the American College of Cardiology/American Heart Association. Points of agreement, and areas of where there are discrepancies, between the guidelines are identified, particularly with reference to strategies for preventing thromboembolic complications. In addition, some features of the new European Society of Cardiology guideline are discussed.

Atrial fibrillation, one of the most common cardiac arrhythmias, usually appears in clinical conditions that either cause atrial dilation, increase interatrial pressure or affect the atrial walls. Such conditions can occur with some inflammatory processes. This article provides a review of the principal factors associated with an increased risk of atrial fibrillation – factors that are closely linked to current strategies for preventing the arrhythmia.

Atrial fibrillation is the most common arrhythmia seen in clinical practice. Its prevalence has increased substantially in developed countries because of population aging. Atrial fibrillation is the primary cause of cardioembolic stroke and oral anticoagulant therapy can considerably reduce its risk. Moreover, the number of patients with a cardiac implantable electronic device is increasing. Since these devices have the ability to detect heart rhythm alterations and to store electrograms, they are highly effective tools for detecting atrial high rate episodes, which in most patients usually correspond to episodes of atrial fibrillation or, to a lesser extent, to atrial flutter or tachycardia. Numerous studies have shown that episodes of subclinical atrial fibrillation are associated with an increased risk of thromboembolic events, although it has not been possible to demonstrate a temporal relationship between the two. To date, the efficacy of oral anticoagulants in patients with subclinical atrial fibrillation has been assessed in only one clinical trial, with negative results. Therefore, and until more information is available, the clinical decision on whether to start oral anticoagulant therapy in patients with subclinical atrial fibrillation is not straightforward and, at present, such treatment is not supported by solid clinical evidence.