Enalapril Decreases the Incidence of Atrial Fibrillation in Patients With Left Ventricular Dysfunction Insight From the Studies Of Left Ventricular Dysfunction (SOLVD) Trials Importance of rate control or rate regulation for improving exercise capacity and quality of life in patients with permanent atrial fibrillation and normal left ventricular function: a randomised controlled study Cardiac rate normalization in chronic atrial fibrillation: comparison of long-term efficacy of treatment with amiodarone versus AV node ablation and permanent His-bundle pacing. Probing oral anticoagulation in patients with atrial high rate episodes: Rationale and design of the Non–vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes (NOAH–AFNET 6) trial Clinical course of recent-onset atrial fibrillation treated with oral propafenone. An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation. Impact of Atrial Fibrillation on Exercise Capacity in Heart Failure With Preserved Ejection Fraction: A RELAX Trial Ancillary Study Atrial fibrillation and quality of life after pacemaker implantation for sick sinus syndrome: data from the Mode Selection Trial (MOST). High-dose atorvastatin and risk of atrial fibrillation in patients with prior stroke or transient ischemic attack: analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Acute and long-term effects of atrioventricular junction ablation and VVIR pacemaker in symptomatic patients with chronic lone atrial fibrillation and normal ventricular response. Optimal heart failure therapy and successful cardioversion in heart failure patients with atrial fibrillation. Vernakalant Hydrochloride for the Rapid Conversion of Atrial Fibrillation After Cardiac Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial Effect of lipid lowering on new-onset atrial fibrillation in patients with asymptomatic aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFÉ-II Study) Exercise capacity in atrial fibrillation: a substudy of the Sotalol-Amiodarone Atrial Fibrillation Efficacy Trial (SAFE-T). Rationale and design of the Apixaban for the Reduction of Thrombo‐Embolism in Patients With Device‐Detected Sub‐Clinical Atrial Fibrillation (ARTESiA) trial Atorvastatin prevents atrial fibrillation in patients with bradyarrhythmias and implantation of an atrial-based or dual-chamber pacemaker: a prospective randomized trial.
Background Atrial fibrillation ( AF ) is frequently encountered in patients with heart failure ( HF ) and is also a predictor of morbidity and mortality in this population . Recent experimental studies have shown electrical and structural atrial remodeling with increased fibrosis in animals with HF and have suggested a preventive effect of ACE inhibitors ( ACEi ) on the development of AF . To verify the hypothesis that ACEi prevent the development of AF in patients with HF , we conducted a retrospective analysis of the patients from the Montreal Heart Institute ( MHI ) included in the Studies Of Left Ventricular Dysfunction ( SOLVD ) . Methods and Results Clinical charts were review ed and serial ECGs interpreted by a single cardiologist blinded to drug allocation . Patients with AF or flutter on the baseline ECG were excluded . Baseline characteristics were obtained from the SOLVD data bases . The mean follow‐up was 2.9±1.0 years . Of the 391 patients r and omly assigned at MHI , 374 were in sinus rhythm at the time of r and om assignment , with 186 taking enalapril and 188 taking placebo .  Baseline characteristics were similar in the two groups except for a higher incidence of previous myocardial infa rct ion in the enalapril group . Fifty‐five patients had AF during the follow‐up : 10 ( 5.4 % ) in the enalapril group and 45 ( 24 % ) in the placebo group ( P<0.0001 ) . By Cox multivariate analysis , enalapril was the most powerful predictor for risk reduction of AF ( hazard ratio , 0.22 ; 95 % CI , 0.11 to 0.44 ; P<0.0001 ) . Conclusions Treatment with the ACEi enalapril markedly reduces the risk of development of atrial fibrillation in patients with left ventricular dysfunction . ( Circulation . 2003;107:2926‐2931 . OBJECTIVE To determine the importance of rhythm regulation or rate control in patients with permanent atrial fibrillation ( AF ) and normal left ventricular function . PATIENTS AND INTERVENTIONS Thirty six patients with a mixed fast and slow ventricular response rate to their AF were  r and omised to either His bundle ablation ( HBA ) and VVIR pacemaker ( HBA group ) or VVI pacemaker and atrioventricular modifying drugs ( Med group ) . Outcomes assessed at one , three , six , and 12 months included exercise duration and quality of life . RESULTS Exercise duration significantly improved from baseline in both groups . There was no difference in outcome between the groups ( Med + 40%v HBA + 20 % , p = NS ) . The heart rate profile on exercise was similarly slowed in both groups compared to baseline . Quality of life significantly improved in both treatment arms for the modified Karolinska question naire ( KQ ) ( Med + 50%v HBA + 50 % , p = NS ) and the Nottingham health profile ( NHP ) ( Med + 40 % v HBA + 20 % , p = NS ) . However , for the individual symptom scores of each question naire more were improved in the Med group ( KQ-Med 6 improvedv HBA 4 , NHP-Med 3 vHBA 1 ) . Left ventricular function was equally preserved by both treatments during follow up . CONCLUSION In these patients control of ventricular response rate with either HBA + VVIR pacemaker or atrioventricular modifying drugs + VVI pacemaker will lead to a significant improvement in exercise duration and quality of life . Rhythm regulation by HBA did not confer additional benefit , suggesting rate control alone is necessary for the successful symptomatic treatment of these patients in permanent AF Chronic atrial fibrillation ( AF ) is a common arrhythmia with significant morbidity and mortality . AF has been the subject of considerable attention and intensive clinical research in recent years . Current opinion on the management of AF favors the restoration and maintenance of normal ventricular rhythm . This has several potential benefits , including the alleviation of arrhythmia-associated symptoms and hemodynamic improvements . Maintenance of frequents normalization of ventricular rhythm ( NVR ) can be achieved with antiarrhythmic drug therapy or with AV node radiofrequency ablation ( RFA ) and permanent ventricular pacing . Recent interest has focused on the use of class III antiarrhythmic agents , such as amiodarone hydrochloride . This investigation compared amiodarone to AV node RFA and permanent pacing of the His-bundle area in maintaining NVR in patients with resistant chronic AF . After 12 months of treatment with amiodarone ( 200 to 400 mg/d ) 30 % of patients remained in NVR , 30 % were in transitional phase of improvement , and 40 % showed negative effect . Only a few patients in this group developed ocular or hepatic side effects . On one year follow-up was achieved in 100 % of cases without any clinical ly significant side effects being seen . In conclusion , analysis of the results of this study suggests that low-dose amiodarone is well tolerated in the management of chronic AF in a selected patient population . The more aggressive interventional radiofrequency ablation technique is significantly more effective and more reliable in the long-term clinical treatment of drug-resistant AF Background Oral anticoagulation prevents ischemic strokes in patients with atrial fibrillation ( AF ) . Early detection of AF and subsequent initiation of oral anticoagulation help to prevent strokes in AF patients . Implanted cardiac pacemakers and defibrillators allow seamless detection of atrial high rate episodes ( AHRE ) , but the best antithrombotic therapy in patients with AHRE is not known . Rationale Stroke risk is higher in pacemaker patients with AHRE than in those without , but the available data also show that stroke risk in patients with AHRE is lower than in patients with AF . Furthermore , only a minority of patients with AHRE will develop AF , many strokes occur without a temporal relation to AHRE , and AHRE can reflect other arrhythmias than AF or artifacts . An adequately powered controlled trial of oral anticoagulation in patients with AHRE is needed . Design The Non – vitamin K antagonist Oral anticoagulants in patients with Atrial High rate episodes ( NOAH – AFNET 6 ) trial tests whether oral anticoagulation with edoxaban is superior to prevent the primary efficacy outcome of stroke or cardiovascular death compared with aspirin or no antithrombotic therapy based on evidence ‐based indications . The primary safety outcome will be major bleeding . NOAH – AFNET 6 will r and omize 3,400 patients with AHRE , but without documented AF , aged ≥65 years with at least 1 other stroke risk factor , to oral anticoagulation therapy ( edoxaban ) or no anticoagulation . All patients will be followed until the end of this investigator‐driven , prospect i ve , parallel‐group , r and omized , event‐driven , double‐blind , multicenter phase IIIb trial . Patients will be censored when they develop AF and offered open‐label anticoagulation . The sponsor is the Atrial Fibrillation NETwork ( AFNET ) . The trial is supported by the DZHK ( German Centre for Cardiovascular Research ) , the BMBF ( German Ministry of Education and Research ) , and Daiichi Sankyo Europe . Conclusion NOAH – AFNET 6 will provide robust information on the effect of oral anticoagulation in patients with atrial high rate episodes detected by implanted devices . Graphical abstract Figure . No Caption available 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 AIMS Permanent atrial fibrillation develops in many patients after ablation and pacing therapy .  We compared a strategy that initially allowed patients to remain in atrial fibrillation with a strategy that initially attempted to restore and maintain sinus rhythm . METHODS AND RESULTS In this multicentre r and omized controlled trial , 68 patients affected by severely symptomatic paroxysmal atrial fibrillation were assigned , after successful atrioventricular junction ablation and pacing treatment  , to antiarrhythmic drug therapy with amiodarone , propafenone , flecainide or sotalol and were compared with 69 patients assigned , after successful AV junction ablation and pacing treatment , to no antiarrhythmic drug therapy . The patients were followed-up for 12 to 24 months ( mean 16+/-4 ) . The drug arm patients had a 57 % reduction in the risk of developing permanent atrial fibrillation ( 21 % vs 37 % , P=0.02 ) . Evaluation after 12 months revealed similar quality of life scores and echocardiographic parameters in the two groups , but the drug arm patients had more episodes of heart failure and hospitalizations ( P=0.05 ) . The outcome was similar between the 40 patients who developed permanent atrial fibrillation and the 97 who did not . CONCLUSION Conventional antiarrhythmic therapy reduces the risk of development of permanent atrial fibrillation after ablation and pacing therapy . The present data do not support the concept that the development of permanent atrial fibrillation is related to an adverse outcome when a perfect control of heart rate is obtained by ablation and pacing Background — Atrial fibrillation ( AF ) is common among patients with heart failure and preserved ejection fraction ( HFpEF ) , but its clinical profile and impact on exercise capacity remain unclear . RELAX ( Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in HFpEF ) was a multicenter r and omized trial testing the impact of sildenafil on peak VO2 in stable out patients with chronic HFpEF . We sought to compare clinical features and exercise capacity among patients with HFpEF who were in sinus rhythm ( SR ) or AF . Methods and Results — RELAX enrolled 216 patients with HFpEF , of whom 79 ( 37 % ) were in AF , 124 ( 57 % ) in SR , and 13 in other rhythms . Participants underwent baseline cardiopulmonary exercise testing , echocardiogram , biomarker assessment , and rhythm status assessment before r and omization . Patients with AF were older than those in SR but had similar symptom severity , comorbidities , and renal function . & bgr;-blocker use and chronotropic indices were also similar . Despite comparable left ventricular size and mass , AF was associated with worse systolic ( lower EF , stroke volume , and cardiac index ) and diastolic ( shorter deceleration time and larger left atria ) function compared with SR . Pulmonary artery systolic pressure was higher in AF . Patients with AF had higher N-terminal pro-B-type natriuretic peptide , aldosterone , endothelin-1 , troponin I , and C-telopeptide for type I collagen levels , suggesting more severe neurohumoral activation , myocyte necrosis , and fibrosis . Peak VO2 was lower in AF , even after adjustment for age , sex , and chronotropic response , and VE/VCO2 was higher . Conclusions — AF identifies an HFpEF cohort with more advanced disease and significantly reduced exercise capacity . These data suggest that evaluation of the impact of different rate or rhythm control strategies on exercise tolerance in patients with HFpEF and AF is warranted . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00763867 BACKGROUND In the Mode Selection Trial ( MOST ) of 2,010 patients with sinus node dysfunction , dual-chamber-paced patients had less atrial fibrillation ( AF ) and heart failure and had slightly improved health-related quality of life ( QOL ) compared with rate modulated right ventricular-paced patients . Our objective was to assess the impact of AF on QOL within MOST . METHODS We analyzed serial QOL measures ( Short Form-36 , Specific Activity Scale , time trade-off ) in 3 groups : ( 1 ) those without AF ; ( 2 ) those with paroxysmal AF ( PAF ) , but not chronic AF ( CAF ) ; and ( 3 ) those with CAF . We carried forward the last known QOL before crossover for all subsequent time points in patients r and omized to rate modulated right ventricular pacing who crossed over to dual-chamber pacing for severe pacemaker syndrome . RESULTS Three hundred seventeen patients ( 15.8 % ) had AF in the year after implantation , 206 patients within 3 months ( 191 PAF , 15 CAF ) , and another 159 ( 124 PAF , 35 CAF ) between 3 and 12 months . There were no significant differences among groups in individual Short Form-36 subscales or time trade-off scores at 12 months as compared with baseline or 3 months . Cardiovascular health status was better at 12 months as compared with baseline or 3 months in those without AF . CONCLUSIONS Atrial fibrillation after pacemaker implantation in elderly patients with sick sinus syndrome was not a major determinant of QOL . However , there was a trend toward better cardiovascular functional status in patients without AF BACKGROUND Observational analyses and short-term r and omized trials have suggested that statins reduce occurrence or recurrence of atrial fibrillation ( AF ) . We tested the hypothesis that long-term treatment with high-dose atorvastatin reduces occurrence of AF in patients with prior stroke or transient ischemic attack . METHODS We examined development of new AF in the SPARCL trial that compared atorvastatin 80 mg daily with placebo in 4,731 patients with prior stroke or transient ischemic attack . Patients who had chronic or paroxysmal AF or were taking medications for treatment or prophylaxis of AF at the time of enrollment were excluded .  Atrial fibrillation was identified from electrocardiograms su bmi tted to a blinded central electrocardiographic laboratory and from investigators ' adverse event reports . RESULTS Patients were followed up for a median of 4.8 years , corresponding to > 20,000 patient-years of observation with a median of 5 electrocardiograms per patient . The primary efficacy measure , the time from r and omization to first occurrence of new AF , did not differ between treatment groups . By intention to treat , there were 139 cases of new AF in the atorvastatin group and 122 cases in the placebo group , corresponding to incidence rates of 1.32 and 1.14 cases per 100 patient-years observation ( hazard ratio 1.15 , 95 % CI 0.90 - 1.46 , P = .26 ) . On-treatment analysis yielded similar findings , with incidence rates of 1.26 and 1.01 cases per 100 patient-years observation in the atorvastatin and placebo groups , respectively ( hazard ratio 1.25 , 95 % CI 0.94 - 1.67 , P = .12 ) . CONCLUSION High-dose atorvastatin does not prevent development of AF in patients with prior stroke or transient ischemic attack INTRODUCTION The precise role of irregular ventricular response in atrial fibrillation ( AF ) has not been fully eluci date d. This study examined the independent effects of rhythm regularity in patients with chronic AF . METHODS AND RESULTS This study included 50 patients who had chronic lone AF and a normal ventricular rate . Among these patients , 21 who underwent AV junction ablation and implantation of a VVIR pacemaker constituted the ablation group ; the other 29 patients were the medical group .  Acute hemodynamic findings were measured in 21 ablation patients before ablation ( during AF , baseline ) and 15 minutes after ablation ( during right ventricular pacing ) . Compared with baseline data , ablation and pacing therapy increased cardiac output ( 4.7 + /- 0.8 vs 5.2 + /- 0.9 L/min ; P = 0.05 ) , decreased pulmonary capillary wedge pressure ( 16 + /- 5 vs 13 + /- 4 mmHg ; P = 0.001 ) , and decreased left ventricular end-diastolic pressure ( 14 + /- 4 vs 11 + /- 3 mmHg ; P < 0.05 ) . After 12 months , the ablation group patients showed lower scores in general quality of life ( -20 % ; P < 0.001 ) , overall symptoms ( -24 % ; P < 0.001 ) , overall activity scale ( -23 % ; P = 0.004 ) , and significant increase of left ventricular ejection fraction ( 44 % + /- 6 % vs 49 % + /- 5 % ; P = 0.02 ) by echocardiographic examination . CONCLUSION AV junction ablation and pacing in patients with chronic AF and normal ventricular response may confer acute and long-term benefits beyond rate control by eliminating rhythm irregularity BACKGROUND Effectiveness , safety , and other factors associated with success of cardioversion ( CV ) of atrial fibrillation ( AF )  have not yet been evaluated in patients with reduced left ventricular ejection fraction . We studied 148 consecutive patients with left ventricular dysfunction ( ejection fraction < or = 45 % ) , who underwent electrical CV for AF in our department . The patients had New York Heart Association heart failure ranging from class II to IV . The overall CV success rate was 71 % . We relied on univariate and multivariate regression and sought variables influencing success rate . Conversion success did not correlate with New York Heart Association class . Instead , we found that the greatest predictor was the degree of heart failure treatment . Patients receiving beta-blockers , angiotensin-converting enzyme inhibitors or angiotension receptor blockers , plus mineralocorticoid receptor blockers had the greatest chance for conversion success . Success was more likely in patients with coronary artery disease ( 91 % ) than in patients with nonischemic cardiomyopathy . CONCLUSIONS Cardioversion is a safe and effective method for the restoration of sinus rhythm in patients with AF and reduced left ventricular ejection fraction . Our findings underscore the value of aggressive heart failure treatment before CV in patients with AF Background —Postoperative atrial arrhythmias are common and are associated with considerable morbidity . This study was design ed to evaluate the efficacy and safety of vernakalant for the conversion of  atrial fibrillation ( AF ) or  atrial flutter ( AFL ) after cardiac surgery . Methods and Results —This was a prospect i ve , r and omized , double-blind , placebo-controlled trial of vernakalant for the conversion of AF or AFL  after coronary artery bypass graft , valvular surgery , or both . Patients were r and omly assigned 2:1 to receive a 10-minute infusion of 3 mg/kg vernakalant or placebo . If AF or AFL was present after a 15-minute observation period , then a second 10-minute infusion of 2 mg/kg vernakalant or placebo was given . The primary end point was the conversion of postcardiac surgery AF or AFL to sinus rhythm within 90 minutes of dosing . In patients with AF , 47 of 100 ( 47 % ) who received vernakalant converted to SR compared with 7 of 50 ( 14 % ) patients who received placebo ( P<0.001 ) . The median time to conversion was 12 minutes . Vernakalant was not effective in converting postoperative AFL to sinus rhythm . Two serious adverse events occurred within 24 hours of vernakalant administration ( hypotension and complete atrioventricular block ) . There were no cases of torsades de pointes , sustained ventricular tachycardia , or ventricular fibrillation . There were no deaths . Conclusions —Vernakalant was safe and effective in the rapid conversion of AF to sinus rhythm in patients who had AF after cardiac surgery . Clinical Trial Registration — clinical trials.gov . Identifier : NCT00125320 BACKGROUND Lipid-lowering drugs , particularly statins , have anti-inflammatory and antioxidant properties that may prevent atrial fibrillation ( AF ) . This effect has not been investigated on new-onset AF in asymptomatic patients with aortic stenosis ( AS ) . METHODS Asymptomatic patients with mild-to-moderate AS ( n = 1,421 ) were r and omized ( 1:1 ) to double-blind  simvastatin 40 mg and ezetimibe 10 mg combination or placebo and followed up for a mean of 4.3 years . The primary end point was the time to new-onset AF adjudicated by 12-lead electrocardiogram  at a core laboratory reading center . Secondary outcomes were the correlates of new-onset AF with nonfatal nonhemorrhagic stroke and a combined end point of AS-related events . RESULTS During the course of the study , new-onset AF was detected in 85 ( 6 % ) patients ( 14.2/1,000 person-years of follow-up ) . At baseline , patients who developed AF were , compared with those remaining in sinus rhythm , older and had a higher left ventricular mass index a smaller aortic valve area index . Treatment with simvastatin and ezetimibe was not associated with less new-onset AF ( odds ratio 0.89 [ 95 % CI 0.57 - 1.97 ] , P = .717 ) . In contrast , age ( hazard ratio [ HR ] 1.07 [ 95 % CI 1.05 - 1.10 ] , P < .001 ) and left ventricular mass index ( HR 1.01 [ 95 % CI 1.01 - 1.02 ] , P < .001 ) were independent predictors of new-onset AF . The occurrence of new-onset AF was independently associated with 2-fold higher risk of AS-related outcomes ( HR 1.65 [ 95 % CI 1.02 - 2.66 ] , P = .04 ) and 4-fold higher risk of nonfatal nonhemorrhagic stroke ( HR 4.04 [ 95 % CI 1.18 - 13.82 ] , P = .03 ) . CONCLUSIONS Simvastatin and ezetimibe were not associated with less new-onset AF . Older age and greater left ventricular mass index were independent predictors of AF development . New-onset AF was associated with a worsening of prognosis Background : Atrial fibrillation ( AF ) and heart failure ( HF ) often coexist . The aim was to investigate whether restoring sinus rhythm ( SR ) could improve cardiac function , symptoms , exercise capacity and quality of life ( QoL ) in patients with chronic heart failure . Methods : Patients with HF and persistent AF receiving guideline -recommended treatments , including anticoagulants , were eligible for the study . Patients were r and omised to either rhythm ( treated with amiodarone for at least 3 months prior to attempting biphasic external cardioversion and continued amiodarone long-term if SR was restored ) or rate control . Anticoagulants were continued throughout the study regardless of rhythm , unless contraindications developed . Both groups were treated with beta blockers and /or digoxin to reduce the heart rate to < 80 bpm at rest and < 110 bpm after walking . Symptoms , walk distance ( 6-minute corridor walk test , 6MWT ) , QoL and cardiac function were assessed at baseline and 1 year . Results : 61 patients with HF and persistent AF ( median duration 14 months ( IQR 5 to 32 ) ) were r and omly assigned to a rate or rhythm control strategy . Of patients assigned to rhythm control ( n = 30 ) , 66 % were in SR at 1 year , and 90 % of those assigned to rate control ( n = 31 ) achieved the heart rate target . At 1 year , NYHA class ( p = 0.424 ) and 6MWT distance ( p = 0.342 ) were similar between groups but patients assigned to rhythm control had improved LV function ( p = 0.014 ) , NT-proBNP concentration ( p = 0.046 ) and QoL ( p = 0.019 ) compared with those assigned to rate control . Greatest improvement was seen in patients in whom SR was maintained . Conclusion : Restoring SR in patients with AF and heart failure may improve QoL and LV function when compared with a strategy of rate control BACKGROUND Therapy for chronic atrial fibrillation ( AF ) focuses on rate versus rhythm control , but little is known about the effects of common therapeutic interventions on exercise tolerance in AF . METHODS Six hundred fifty-five patients with chronic AF underwent maximal exercise testing at baseline and 8 weeks , 6 months , and 1 year after r and omization to sotalol , amiodarone , or placebo therapy and attempted direct current cardioversion . Analyses of baseline determinants of exercise capacity , predictors of change in exercise capacity at 6 months and 1 year , and the short- and long-term effects of cardioversion on exercise capacity were made . RESULTS Age , obesity , and presence of symptoms accompanying AF were inversely associated with baseline exercise capacity , but these factors accounted for only 10 % of the variance in exercise capacity . Patients most likely to benefit from cardioversion were those most limited initially , younger , not obese or hypertensive , and with an uncontrolled ventricular rate at baseline . Conversion to sinus rhythm ( SR ) result ed in significant reductions in resting ( approximately 25 beat/min ) and peak exercise ( approximately 40 beat/min ) heart rates at 6 months and 1 year ( P < .001 ) . Successful cardioversion improved exercise capacity by 15 % at 8 weeks , and these improvements were maintained throughout the year . This improvement was observed both among those who maintained SR and those with intermittent AF . CONCLUSION Cardioversion result ed in a sustained improvement in exercise capacity over the course of 1 year , and this improvement was similar between those in SR and those with SR and recurrent AF . Patients most likely to improve with treatment tended to be younger and nonobese and have the greatest limitations initially Background Device‐detected sub clinical atrial fibrillation ( AF ) refers to infrequent , short‐lasting , asymptomatic AF that is detected only with long‐term continuous monitoring . Sub clinical AF is common and associated with an increased risk of stroke ; however , the risk of stroke with sub clinical AF is lower than for clinical AF , and very few patients with sub clinical AF alone have been included in large AF anticoagulation trials . The net benefit of anticoagulation in patients with sub clinical AF is unknown . Design ARTESiA is a prospect i ve , multicenter , double‐blind , r and omized controlled trial , recruiting patients with sub clinical AF detected by an implanted pacemaker , defibrillator , or cardiac monitor , and who have additional risk factors for stroke . Patients with clinical AF documented by surface electrocardiogram will be excluded from the study . Participants will be r and omized to receive either apixaban ( according to st and ard AF dosing ) or aspirin 81 mg daily . The primary outcome is the composite of stroke , transient ischemic attack with diffusion‐weighted magnetic resonance imaging evidence of cerebral infa rct ion , and systemic embolism . Approximately 4,000 patients will be enrolled from around 230 clinical sites , with an anticipated mean follow‐up of 36 months until 248 adjudicated primary outcome events have occurred . Summary ARTESiA will determine whether oral anticoagulation therapy with apixaban compared with aspirin reduces the risk of stroke or systemic embolism in patients with sub clinical AF and additional risk factors BACKGROUND Increasing evidence suggests that atrial fibrillation ( AF ) is an inflammatory disease . Statins is an anti-inflammatory agent . The present study was conducted to test the efficacy of atorvastatin in preventing paroxysmal AF or atrial high rate episodes ( AHEs ) in patients with bradyarrhythmias and implantation of an atrial-based or dual-chamber pacemaker . METHODS The effect of atorvastatin on time to the first attack of AF or AHE ( > or = 180 per minute and > or = 1 or 10 minutes ) , which was accurately detected by pacemaker interrogation , was evaluated in an open-label prospect i ve r and omized design for 1 year of follow-up . RESULTS Fifty-two patients ( 23 males , 70 + /- 13 years old ) were r and omized to the  statin group ( atorvastatin 20 mg/d ) and 54 ( 25 males , 72 + /- 13 years old ) to the  nonstatin group . Event-free survivals from AHE > or = 1 minute were not significantly different between the 2 groups ( log-rank P = .410 ) . However , patients in the nonstatin group were more likely to develop AHE > or = 10 minutes than those in the statin group ( log-rank P = .028 ) . Atrial high rate episode > or = 10 minutes occurred in 3 ( 5.8 % ) of 51 patients in the statin group after 1 year of follow-up , and 10 ( 19.2 % ) of 52 patients ( odds ratio 0.26 , P = .041 ) in the nonstatin group . The mean left atrial volume of the statin group was significantly lower than that of the nonstatin group at the end of follow-up ( 39.7 + /- 1.7 vs 43.7 + /- 1.9 mL , P < .0001 ) . CONCLUSIONS The present study demonstrated the efficacy of atorvastatin in preventing significant AF ( > or = 10 minutes ) and left atrial enlargement in patients with bradyarrhythmias and implantation of a pacemaker
Statistical heterogeneity between included studies was not detected ( chi(2 ) = 1.68 , P = 0.43 , I(2 ) = 0 % ) , although significant clinical differences were found in terms of study design , patient population s , statins use and dosage and AF-monitoring capabilities .
Statins may represent a novel treatment strategy to prevent the occurrence of AF in patients with PM , especially for those who had a PM implanted due to sinus node dysfunction .
Patients with permanent pacemakers ( PM ) are at high risk of developing atrial fibrillation ( AF ) .
Minimal ventricular pacing modalities have been demonstrated to reduce AF in such patients , although they are not suitable for patients with advanced atrioventricular conduction disease .
Recent evidence s suggest that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors ( i.e. statins ) may represent a new strategy to prevent AF in patients at risk .
In this article , we sought to review data regarding the effectiveness of statin therapy in preventing AF patients with a PM .