Incidence of Stroke or Systemic Embolism in Paroxysmal Versus Sustained Atrial Fibrillation: The Fushimi Atrial Fibrillation Registry Pathophysiologic correlates of thromboembolism in nonvalvular atrial fibrillation: I. Reduced flow velocity in the left atrial appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-III] study). Optimal treatment strategy for patients with paroxysmal atrial fibrillation: J-RHYTHM Study. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Thromboembolic prophylaxis in nonrheumatic atrial fibrillation: utilization patterns, efficacy, and complications in a long-term follow-up of community patients. Repeated catheter ablation of atrial fibrillation: how to predict outcome? Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial Predictors of thromboembolism in atrial fibrillation: II. Echocardiographic features of patients at risk. The Stroke Prevention in Atrial Fibrillation Investigators. Significance of paroxysmal atrial fibrillation complicating acute myocardial infarction in the thrombolytic era. SPRINT and Thrombolytic Survey Groups. Rationale and design of the Apixaban for the Reduction of Thrombo‐Embolism in Patients With Device‐Detected Sub‐Clinical Atrial Fibrillation (ARTESiA) trial Predictors of VT/VF-occurrence in ICD patients: results from the PROFIT-Study. [Study of combined anticoagulant (fluindione)-aspirin therapy in patients with atrial fibrillation at high risk for thromboembolic complications. A randomized trial (FFAACS)]. Cryoballoon versus radiofrequency catheter ablation for paroxysmal atrial fibrillation. Atrial fibrillation and paroxysmal atrial fibrillation detection in patients with acute ischemic stroke. Periprocedural Stroke and Bleeding Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation With Different Anticoagulation Management: Results From the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) Rand Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis.
Background and Purpose — There is controversy on the relationship of the type of atrial fibrillation ( AF ) to stroke . Although several studies show that patients with paroxysmal AF ( PAF ) have a stroke risk similar to those with persistent or permanent AF , recent studies suggest that PAF is associated with a lower rate of stroke . Limited data on stroke risk associated with PAF are evident in Asian population s. Methods — The Registry Study of Atrial Fibrillation Patients in Fushimi-ku ( Fushimi AF Registry ) is a community-based survey of patients with AF in Fushimi-ku , Kyoto , Japan . Patients were categorized into 2 types of AF : PAF or sustained ( persistent or permanent ) AF . We compared clinical events between PAF  ( n=1588 ) and  sustained AF ( n=1716 ) . Results — Patients with PAF were younger , had less comorbidities , and received oral anticoagulants ( OAC ) less commonly . A lower risk of stroke/systemic embolism during follow-up period in the patients with PAF was consistently observed ( non-OAC users : hazard ratio , 0.45 ; 95 % confidence intervals , 0.27–0.75 ; P<0.01 and OAC users : hazard ratio , 0.59 ; 95 % confidence interval , 0.35–0.93 ; P=0.03 ) . The composite end point of stroke/systemic embolism/all-cause mortality was also lower in PAF , whether among OAC users ( hazard ratio , 0.77 ; 95 % confidence interval , 0.59–0.99 ; P=0.046 ) or non-OAC users ( hazard ratio , 0.59 ; 95 % confidence interval , 0.46–0.75 ; P<0.01 ) . On multivariate analysis , PAF was an independent predictor of lower stroke/systemic embolism risk . Conclusions — In this large cohort of Japanese patients with AF , PAF was independently associated with lower incidence of stroke/systemic embolism than sustained AF . This may aid decision making for anticoagulation , especially in those patients with AF with few stroke risk factors . Clinical Trial Registration — URL : http://www.umin.ac.jp/ctr/index.htm . Unique identifier : UMIN000005834 Stroke associated with atrial fibrillation ( AF ) is mainly due to embolism of thrombus formed during stasis of blood in the left atrial appendage ( LAA ) . Pathophysiologic correlates of appendage flow velocity as assessed by transesophageal echocardiography ( TEE ) in patients with AF have not been defined . To evaluate the hypothesis that reduced velocity is associated with spontaneous echocardiographic contrast and thrombus in the LAA and with clinical embolic events , we measured LAA flow velocity by TEE in 721 patients with nonvalvular AF entering the Stroke Prevention in Atrial Fibrillation ( SPAF-III ) study . Patient features , TEE findings , and subsequent cardioembolic events were correlated with velocity by multivariate analysis . Patients in AF during TEE displayed lower peak ante grade ( emptying ) flow velocity ( Anu(p ) ) than those with intermittent AF in sinus rhythm during TEE ( 33 cm/s vs 61 cm/s , respectively , P < .0001 ) . Anu(p ) < 20 cm/s was associated with dense spontaneous echocardiographic contrast ( P < .001 ) , appendage thrombus ( P < .01 ) , and subsequent cardioembolic events ( P < .01 ) . Independent predictors of Anu(p ) < 20 cm/s included age ( P = .009 ) , systolic blood pressure ( P < .001 ) , sustained AF ( P = .01 ) , ischemic heart disease ( P = .01 ) , and left atrial area ( P = .04 ) . Multivariate analysis found both Anu(p ) < 20 cm/s ( relative risk 2.6 , P = .02 ) and clinical risk factors ( relative risk 3.3 , P = .002 ) independently associated with LAA thrombus . LAA Anu(p ) is reduced in AF and associated with spontaneous echocardiographic contrast , appendage thrombus , and cardioembolic stroke . Systolic hypertension and aortic atherosclerosis , independent clinical predictors of stroke in patients with AF , also correlated with LAA Anu(p ) . Our results support the role of reduced LAA Anu(p ) in the generation of stasis , thrombus formation , and embolism in patients with AF , although other mechanisms also contribute to stroke Background Although previous clinical trials demonstrated the non-inferiority of a rate control to rhythm control strategy for management of atrial fibrillation ( AF ) , the optimal treatment strategy for paroxysmal AF ( PAF ) remains unclear . Methods and Results A r and omized , multicenter comparison of rate control vs rhythm control in Japanese patients with PAF ( the Japanese Rhythm Management Trial for Atrial Fibrillation ( J-RHYTHM ) study ) was conducted . The primary endpoint was a composite of total mortality , symptomatic cerebral infa rct ion , systemic embolism , major bleeding , hospitalization for heart failure , or physical/psychological disability requiring alteration of treatment strategy . In the study , 823 patients with PAF were followed for a mean period of 578 days . The primary endpoint occurred in 64 patients ( 15.3 % ) assigned to rhythm control and in 89 patients ( 22.0 % ) to rate control ( P=0.0128 ) . No significant differences between the treatment strategies were observed in the incidences of death , stroke , bleeding and heart failure . Meanwhile , significantly fewer patients requested changes of assigned treatment strategy in the rhythm control vs the rate control group , which was accompanied by improvement in AF-specific quality of life scores . Conclusion The J-RHYTHM study showed that rhythm control was associated with fewer primary endpoints than rate control . However , mortality and cardiovascular morbidity were not affected by the treatment strategy ( umin-CTR No. C000000106 ) AIMS The impact of some risk factors for stroke and bleeding , and the value of stroke and bleeding risk scores , in atrial fibrillation ( AF ) , has been debated , as clinical trial cohorts have not adequately tested these . Our objective was to investigate risk factors for stroke and bleeding in AF , and application of the new CHA(2)DS(2)-VASc and HAS-BLED schemes for stroke and bleeding risk assessment s , respectively . METHODS AND RESULTS We used the Swedish Atrial Fibrillation cohort study , a nationwide cohort study of 182 678 subjects with a diagnosis of AF at any Swedish hospital between 1 July 2005 and 31 December 2008 , who were prospect ively followed for an average of 1.5 years ( 260 000 years at risk ) . With the use of the National Swedish Drug Registry , all patients who used an oral anticoagulant  anytime during follow-up were identified . Most of the analyses were made on a subset of 90 490 patients who never used anticoagulants .  Risk factors for stroke , the composite thromboembolism endpoint ( stroke , TIA , or systemic embolism ) , and bleeding , and the performance of published stroke and bleeding risk stratification schemes were investigated . On multivariable analysis , significant associations were found between the following ' new ' risk factors and thromboembolic events ; peripheral artery disease [ hazard ratio ( HR ) 1.22 ( 95 % CI 1.12 - 1.32 ) ] , ' vascular disease ' [ HR 1.14 ( 1.06 - 1.23 ) ] , prior myocardial infa rct ion [ HR 1.09 ( 1.03 - 1.15 ) ] , and female gender [ HR 1.17 ( 1.11 - 1.22 ) ] . Previous embolic events , intracranial haemorrhage ( ICH ) , hypertension , diabetes , and renal failure were other independent predictors of the composite thromboembolism endpoint , while thyroid disease ( or hyperthyroidism ) was not an independent stroke risk factor . C-statistics for the composite thromboembolic endpoint with the CHADS(2 ) and CHA(2)DS(2)-VASc schemes were 0.66 ( 0.65 - 0.66 ) and 0.67 ( 0.67 - 0.68 ) , respectively . On multivariable analysis , age , prior ischaemic stroke or thromboembolism , prior major bleeding events , and hypertension were significant predictors of ICH and major bleeding . Heart failure , diabetes , renal failure , liver disease , anaemia or platelet/coagulation defect , alcohol abuse , and cancer were other significant predictors for major bleeding , but not ICH . The ability for predicting ICH and major bleeding with both bleeding risk schemes ( HEMORR(2)HAGES , HAS-BLED ) were similar , with c-statistics of ~0.6 . CONCLUSION Several independent risk factors ( prior ICH , myocardial infa rct ion , vascular disease , and renal failure ) predict ischaemic stroke and /or the composite thromboembolism endpoint in AF , but thyroid disease ( or hyperthyroidism ) was not an independent risk factor for stroke . There is a better performance for CHA(2)DS(2)-VASc over CHADS(2 ) schemes for the composite thromboembolism endpoint . While both tested bleeding risk schemes have similar predictive value , the HAS-BLED score has the advantage of simplicity The Canadian Cardiovascular Society ( CCS ) published the complete set of 2010 Atrial Fibrillation ( AF ) Guidelines in the January , 2011 issue of the Canadian Journal of Cardiology . During its deliberations , the CCS Guidelines Committee engaged to a timely review of future evidence , with periodic composition of focused up date s to address clinical ly important advances . In 2011 , results were published from 3 pivotal AF trials : the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonist for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) , the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ( ARISTOTLE ) study , and the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of St and ard Therapy ( PALLAS ) , comparing dronedarone with placebo in patients with permanent AF and additional cardiovascular disease risk-factor burden . Each of these large r and omized trials provided clear results with major implication s for AF management . Other important evidence that has emerged since the 2010 Guidelines includes findings about prediction instruments for AF-associated stroke and bleeding risk , stroke risk in paroxysmal-AF patients , risk-benefit considerations related to oral anticoagulation in patients with chronic kidney disease , and risk/benefit considerations in the use of antiplatelet agents , alone and in combination with each other or with oral anticoagulants , in AF patients . The Guidelines Committee judged that this extensive and important new evidence required focused updating of the 2010 Guidelines with respect to stroke prevention and rate/rhythm control . This report presents the details of the new recommendations , along with the background and rationale OBJECTIVES To define the incidence , contemporary utilization patterns , efficacy , and complications of  thromboembolic prophylactic treatment in patients with chronic ( CAF ) and paroxysmal atrial fibrillation ( PAF ) . BACKGROUND Although recent r and omized trials with antithrombotic therapy in nonrheumatic atrial fibrillation ( AF ) patients emphasized the benefits of warfarin in preventing stroke , warfarin treatment is still far from optimal . METHODS A retrospective analysis of the medical records of 506 patients with nonrheumatic PAF or CAF from 23 clinics in the north of Israel , including an interview with the patients ' family physician . RESULTS ( 1 ) The most effective treatment for preventing thromboembolic events ( a reduction of 75.9 % ) was warfarin at an international normalized ratio ( INR ) intensity of 2 - 3 . ( 2 ) After diagnosis , 26.9 % of the patients were treated with warfarin . ( 3 ) During the follow-up period ( not following a thromboembolic event ) , an additional 26.9 % of the patients began treatment with warfarin . ( 4 ) Elderly patients ( p<0.001 ) , patients with  limited activity of daily living ( ADL ) ( p<0.012 ) or instrumental activity of daily living ( IADL ) ( p<0.001 ) , and patients with PAF ( p<0.0001 ) were less likely to be treated with warfarin . ( 5 ) Three new risk factors found for thromboembolic event were limited ADL ( p<0.001 ) , limited IADL ( p<0.002 ) , and extended duration of AF ( p<0.006 ) . CONCLUSIONS Less than optimal utilization patterns of thromboembolic prophylactic treatment with anticoagulants were found , especially regarding elderly patients , patients with limited ADL and IADL , and patients with PAF , despite the fact that their thromboembolic risk is as high or higher than that of other patients with AF BACKGROUND Pre-procedural predictors ( PP ) of  atrial fibrillation ( AF ) recurrence ( AFR ) after repeated catheter ablation of AF ( RCAF )  are unknown . The aim of this study was identification of PP of outcome after RCAF . METHODS AND RESULTS In 213 patients ( 73 % male ) with drug-refractory AF ( 47 % paroxysmal AF ; PAF ) RCAF was performed . CHADS2 , CHA2DS2-VASc and ALARMEc ( AF type , Left Atrium size , Renal insufficiency , MEtabolic syndrome , cardiomyopathy ) scores were calculated for each patient . Complete success was defined as no AFR . After RCAF , 125 patients ( 59 % ) were free of atrial flutter or atrial tachycardia ( AFLAT ) on long-term follow-up ( FU ) . The univariate predictors of AFR were : type of AF ( non-PAF vs. PAF , P=0.001 ) , normalized left atrium area ( NLA ≥10.25 vs. NLA < 10.25 , P=0.012 ) and estimated glomerular filtration rate ( < 68ml/min vs. ≥68ml/min , P=0.048 ) . The independent predictors of AFLAT-free survival after RCAF were non-PAF ( P=0.002 ) and NLA ≥10.25 ( P=0.018 ) . Among combined predictors , only ALARMEc score , and neither CHADS2 or CHA2DS2-VASc , predicted outcome after RCAF ( P<0.0001 ) . CONCLUSIONS RCAF results in a moderate success rate on very long-term FU . Lower success was observed in patients with non-PAF and enlarged LA . ALARMEc score allows for clear description of expected outcome after RCAF Aim Anticoagulation prophylaxis for stroke is recommended for at-risk patients with either persistent or paroxysmal atrial fibrillation ( AF ) . We compared outcomes in patients with persistent vs. paroxysmal AF receiving oral anticoagulation . Methods and results Patients r and omized in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation ( ROCKET-AF ) trial ( n = 14 264 ) were grouped by baseline AF category : paroxysmal or persistent . Multivariable adjustment was performed to compare thrombo-embolic events , bleeding , and death between groups , in high-risk subgroups , and across treatment assignment ( rivaroxaban or warfarin ) . Of 14 062 patients , 11 548 ( 82 % ) had persistent AF and 2514 ( 18 % ) had paroxysmal AF . Patients with persistent AF were marginally older ( 73 vs. 72 , P = 0.03 ) , less likely female ( 39 vs. 45 % , P < 0.0001 ) , and more likely to have previously used vitamin K antagonists ( 64 vs. 56 % , P < 0.0001 ) compared with patients with paroxysmal AF . In patients r and omized to warfarin , time in therapeutic range was similar ( 58 vs. 57 % , P = 0.94 ) . Patients with persistent AF had higher adjusted rates of stroke or systemic embolism ( 2.18 vs. 1.73 events per 100-patient-years , P = 0.048 ) and all-cause mortality ( 4.78 vs. 3.52 , P = 0.006 ) . Rates of major bleeding were similar ( 3.55 vs. 3.31 , P = 0.77 ) . Rates of stroke or systemic embolism in both types of AF did not differ by treatment assignment ( rivaroxaban vs. warfarin , Pinteraction = 0.6 ) . Conclusion In patients with AF at moderate-to-high risk of stroke receiving anticoagulation , those with persistent AF have a higher risk of thrombo-embolic events and worse survival compared with paroxysmal AF OBJECTIVE To identify echocardiographic predictors of arterial thromboembolism in patients with nonrheumatic atrial fibrillation and to determine whether these add to clinical variables for risk stratification . DESIGN Cohort study of patients assigned to placebo in a r and omized clinical trial . SETTING Five hundred sixty-eight in patients and out patients with nonrheumatic atrial fibrillation assigned to placebo therapy at 15 U.S. medical centers from 1987 to 1989 in the Stroke Prevention in Atrial Fibrillation study . Patients were followed for a mean of 1.3 years . MEASUREMENTS M-mode and two-dimensional ( 2-D ) echocardiograms performed at study entry and interpreted by local cardiologists . The predictive value of 14 echocardiographic variables for later ischemic stroke or systemic embolism was assessed by multivariate analysis . MAIN RESULTS Left ventricular dysfunction from 2-D echocardiograms ( P = 0.003 ) and the size of the left atrium from M-mode echocardiograms ( P = 0.02 ) were the strongest independent predictors of later thromboembolism . Multivariate analysis of these two independent echocardiographic predictors with the three independent clinical predictors of thromboembolism ( history of hypertension , recent congestive heart failure , previous thromboembolism ) identified 26 % of the cohort with a low risk for thromboembolism ( 1.0 % per year ; 95 % Cl , 0.2 % to 4.0 % ) . Compared with risk stratification using clinical variables alone , echocardiographic results altered thromboembolic risk stratification in 18 % of the entire cohort and in 38 % of those without clinical risk factors . CONCLUSIONS Both left ventricular and left atrial variables are significant predictors of thromboembolism in patients with nonvalvular atrial fibrillation . Our results challenge traditional views of the pathogenesis of ischemic stroke in patients with atrial fibrillation and suggest that st and ard echocardiography contributes to risk stratification , differentiating the one third of patients without clinical risk factors who are at increased risk for stroke from the remainder who may not need antithrombotic prophylaxis BACKGROUND Paroxysmal atrial fibrillation ( PAF ) is considered a frequent complication of acute myocardial infa rct ion ( AMI ) , associated with increased in-hospital and long-term mortality rates . This notion is based on data collected before thrombolysis and additional modern methods of treatment became widely available , and no information is available on the significance of PAF in the general population with AMI in the thrombolytic era . The aim of the present study was to define the incidence , associated clinical parameters , and short- and long-term prognostic significance of PAF in patients with AMI in the thrombolytic era . METHODS AND RESULTS A prospect i ve , nationwide survey was conducted of 2866 consecutive patients admitted with AMI in all 25 coronary care units in Israel during January/February 1992 , 1994 , and 1996 ( thrombolytic era [ TE ] ) . The data were compared with a previous Israeli study of 5803 patients with AMI hospitalized in 1981 through 1983 ( prethrombolytic era [ PTE ] ) . Patients in the TE with PAF were older and had a worse risk profile than those without PAF . PAF in the TE was independently associated with increased 30-day ( odds ratio , 1.32 ; 95 % confidence interval , 0.92 to 1.87 ) and 1-year ( relative risk , 1.33 ; 95 % confidence interval , 1.05 to 1.68 ) mortality rates . The incidence of PAF ( 8.9 % and 9.9 % ) and the 30-day ( 25.1 % and 27.6 % ) and 1-year ( 38.4 % and 42.5 % ) mortality rates of patients with PAF were similar in the TE and PTE , although PAF in the TE occurred in older and sicker patients than those in the PTE . After adjustment for conventional risk factors , PAF was associated with significantly lower 30-day ( odds ratio , 0.64 ; 95 % confidence interval , 0.44 to 0.94 ) and 1-year ( relative risk , 0.69 ; 95 % confidence interval , 0.54 to 0.88 ) mortality rates compared with the PTE . CONCLUSIONS Patients with AMI who develop PAF in the TE have significantly worse short- and long-term prognoses than patients without PAF , mostly due to their worse risk profile . After adjustment for confounding factors , patients with PAF in the TE have a better overall outcome than counterparts in the PTE , probably reflecting the better management of patients with AMI in the TE 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 AIMS Identification of risk factors for ventricular tachycardia/ventricular fibrillation ( VT/VF ) occurrence in patients with implantable cardioverter-defibrillators ( ICD )  is reasonable , because ICD patients with multiple risk factors might benefit from more aggressive anti-arrhythmic therapy for the prevention of arrhythmic events . Furthermore , in the era of prophylactic ICD therapy and limited healthcare re sources , additional markers are needed for improved patient selection . METHODS AND RESULTS Thus , in Prospect i ve Analysis of Risk Factor for Appropriate ICD Therapy ( PROFIT ) , we prospect ively analyzed the role of ejection fraction ( EF ) , N-terminal probrain natriuretic peptide ( NT-proBNP ) , New York Heart Association ( NYHA ) class , atrial fibrillation , and QRS- duration as independent predictors for VT/VF occurrence in 250 ICD patients . Kaplan-Meier analysis showed that EF<40 % ( log-rank P=0.001 ) , NT-proBNP levels higher than median ( > or=405 ng/L ; log-rank P=0.04 ) , QRS- duration > or=150 ms ( log-rank P=0.016 ) , permanent atrial fibrillation ( log-rank P=0.008 ) , and higher NYHA class ( log-rank P=0.029 ) were associated with VT/VF occurrence . By multivariate Cox regression analysis EF , QRS- duration and atrial fibrillation remained significantly associated with appropriate VT/VF therapy , whereas there was no relationship among NT-proBNP , NYHA class , and VT/VF occurrence . Stratifying patients according to the number of their independent risk factors ( EF<40 % , AF , QRS-width > or=150 ms ) showed that patients with greater than or equal to two risk factors had a 100 % 2-year risk of VT/VF occurrence , whereas patients with no or one risk factor had a 19.3 and 25 % 2-year risk , respectively . CONCLUSIONS EF<40 % , permanent atrial fibrillation , and QRS > or=150 ms are independent predictors for VT/VF occurrence in predominantly secondary prophylactic ICD patients . Combining all independent predictors , we developed a risk score for VT/VF occurrence identifying a subgroup of patients with two or more risk factors who had a 100 % 2-year risk . Future studies will reveal if this risk score helps to identify ICD patients suitable for empirical anti-arrhythmic therapy and to improve patient selection for prophylactic ICD therapy BACKGROUND A combination of low-dose aspirin ( A ) and anticoagulation ( AC ) may provide better protection against thromboembolic events compared with AC alone in high-risk patients with atrial fibrillation ( AF ) . METHODS We performed a multicentric placebo-controlled double blind-trial to test the preventive efficacy against thromboembolic events of the addition of aspirin ( A ) ( 100 mg ) or placebo ( P ) to anticoagulant treatment in patients with high-risk atrial fibrillation . A total of 157 patients were included , with atrial fibrillation and previous thromboembolic event or older than 65 years with either a history of hypertension , a recent episode of heart failure or a left ventricular dysfunction . All patients received fluindione ( F ) and P or F and A , with an INR target between 2 and 2.6 . The primary endpoint was a combined endpoint of stroke ( ischaemic or haemorrhagic ) , myocardial infa rct ion , systemic arterial emboli or vascular death . RESULTS The study had to be stopped prematurely owing to a too low recruitment rate . During follow-up ( 0.84 years ) 3 non-fatal thromboembolic events were recorded ( 1P , 2A ) and 6 patients died ( 3P , 3A ) , none of them from a thromboembolic complication . However , 3 deaths were secondary to severe haemorrhagic complications ( 1P , 2A ) . Non-fatal haemorrhagic complications occurred more often in group A ( n = 10 , 13.1 pour cent ) compared with group P ( n = 1 , 1.2 pour cent ) , p = 0.003 . CONCLUSION The FFAACS study was not able to show any therapeutic benefit from the addition of aspirin to anticoagulant in patients with high-risk AF . Such a combination increased the incidence rate of bleeding complications , which therefore greatly reduces its potential overall benefit BACKGROUND Catheter ablation is an established treatment for atrial fibrillation ( AF ) .  Cryoballoon ablation ( CBA ) has emerged as an alternative to radiofrequency ablation ( RFA ) . However , there are few data comparing these modalities for treatment of paroxysmal AF ( pAF ) in the U.S. POPULATION The purpose of this study was to compare procedural times , safety , and efficacy of CBA against RFA . METHODS A single-center prospect i ve cohort study evaluated patients who underwent catheter ablation for pAF using CBA or RFA between January 1 , 2010 and October 31 , 2013 . Patients with prior ablation and those without rhythm follow-up for at least 3 months were excluded . The primary end point was freedom from AF , atrial flutter , and atrial tachycardia ( FFAF ) > 30 seconds after a 3-month blanking period without requirement for antiarrhythmic drugs . We also compared rates of successful pulmonary vein isolation ( PVI ) , fluoroscopy and procedure times , and major complication rates . RESULTS A total of 201 patients were included ( CBA = 101 , RFA = 100 ) . The rate of successful PVI was 99.3 % in CBA versus 97.4 % in RFA ( P = 0.08 ) . Procedure times were shorter with CBA ( 192.9 ± 44.0 minutes vs 283.7 ± 78.0 minutes , P < 0.001 ) as well as total fluoroscopy times ( 46.0 ± 22.4 minutes vs 73.0 ± 30.1 minutes , P < 0.001 ) . Overall complication rates were equivalent ; however , fewer cardiac perforations occurred with CBA ( 0 % vs 4 % , P = 0.042 ) . The 1-year FFAF rates were 60.3 % for CBA and 61.1 % for RFA ( log rank P = 0.93 ) . CONCLUSION CBA was associated with equivalent 1-year FFAF rate as RFA for pAF . Procedure and fluoroscopy times were shorter for CBA and fewer cardiac perforations occurred BACKGROUND Studies about continuous electrocardiographic ( ECG ) monitoring in detection of paroxysmal atrial fibrillation ( PAF ) in Asian patients with acute ischemic stroke are very limited . We looked for the prevalence and associated factors of atrial fibrillation ( AF ) and PAF in Thai patients with acute ischemic stroke . METHODS In all , 204 patients with acute ischemic stroke were prospect ively included .  Snapshot 12-lead ECG and continuous ECG monitoring for at least the first 24 hours were performed . Multivariate analyses were performed to find out the associated factors of AF and PAF . RESULTS AF was diagnosed in 31 patients ( 15 % ) and PAF in 15 patients ( 7 % ) . Twelve and 3 patients with PAF were diagnosed by continuous ECG monitoring and snapshot 12-lead ECG , respectively . Mean duration of continuous ECG monitoring and mean time to detect PAF were 55 and 23 hours , respectively . Multivariate analysis revealed that age of 70 years or older ( odds ratio [ OR ] 3.52 , 95 % confidence interval [ CI ] 1.68 - 7.35 , P = .001 ) and heart diseases ( OR 4.26 , 95 % CI 1.14 - 15.95 , P = .031 ) were associated with AF and PAF . CONCLUSIONS AF/PAF was one of the common causes of ischemic stroke in Thai patients . Most PAF was detected by continuous ECG monitoring . Snapshot 12-lead ECG and continuous ECG monitoring should be recommended in all patients with acute ischemic stroke Background — Periprocedural thromboembolic and hemorrhagic events are worrisome complications of catheter ablation for atrial fibrillation ( AF ) . The periprocedural anticoagulation management could play a role in the incidence of these complications . Although ablation procedures performed without warfarin discontinuation seem to be associated with lower thromboembolic risk , no r and omized study exists . Methods and Results — This was a prospect i ve , open-label , r and omized , parallel-group , multicenter study assessing the role of continuous warfarin therapy in preventing periprocedural thromboembolic and hemorrhagic events after radiofrequency catheter ablation . Patients with CHADS2 score ≥1 were included . Patients were r and omly assigned in a 1:1 ratio to the off-warfarin or on-warfarin arm . The incidence of thromboembolic events in the 48 hours after ablation was the primary end point of the study . The study enrolled 1584 patients : 790 assigned to discontinue warfarin ( group 1 ) and 794 assigned to continuous warfarin ( group 2 ) . No statistical difference in baseline characteristics was observed . There were 39 thromboembolic events ( 3.7 % strokes [ n=29 ] and 1.3 % transient ischemic attacks [ n=10 ] ) in group 1 : two events ( 0.87 % ) in patients with paroxysmal AF , 4 ( 2.3 % ) in patients with persistent AF , and 33 ( 8.5 % ) in patients with long-st and ing persistent AF . Only 2 strokes ( 0.25 % ) in patients with long-st and ing persistent AF were observed in group 2 ( P<0.001 ) . Warfarin discontinuation emerged as a strong predictor of periprocedural thromboembolism ( odds ratio , 13 ; 95 % confidence interval , 3.1–55.6 ; P<0.001 ) . Conclusion — This is the first r and omized study showing that performing catheter ablation of AF without warfarin discontinuation reduces the occurrence of periprocedural stroke and minor bleeding complications compared with bridging with low-molecular-weight heparin . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01006876 BACKGROUND Atrial fibrillation ( AF ) is a major risk factor ( RF ) for ischemic stroke . Its prevalence and prognostic impact in patients with atherothrombosis are unclear . METHODS Risk factors , drug usage , and 1-year cardiovascular ( CV ) outcomes ( CV death , myocardial infa rct ion [ MI ] , and stroke ) were compared in  AF and non-AF patients from the REduction of Atherothrombosis for Continued Health ( REACH ) Registry , an international , prospect i ve cohort of 68,236 stable out patients with established atherothrombosis or > or=3 atherothrombotic RFs . RESULTS Atrial fibrillation and 1-year follow-up data are available for 63,589 patients . The prevalence of AF was , 12.5 % , 13.7 % , 11.5 % , and 6.2 % among coronary artery disease , CV disease , peripheral artery disease , and RF-only patients , respectively . Of the 6,814 patients with AF , 6.7 % experienced CV death , nonfatal MI , or nonfatal stroke within a year . The annual incidence of nonfatal stroke ( 2.4 % vs 1.6 % , P<.0001 ) and unstable angina ( 6.0 % vs 4.0 % , P<.00001 ) was higher , and CV death was more than double ( 3.2 % vs 1.4 % , P<.0001 ) , in AF versus non-AF patients . In these patients with or at high risk of atherothrombosis , most patients with AF received antiplatelet agents , but only 53.1 % were treated with oral anticoagulants . Even with high CHADS2 ( congestive heart failure , hypertension , aging , diabetes mellitus , and stroke ) scores , anticoagulant use did not exceed ( 59 % ) . The rate of bleeding requiring hospitalization was higher in AF versus non-AF patients ( 1.5 % vs 0.8 % , P<.0001 ) , possibly related to the more frequent use of anticoagulants ( 53.1 % vs 7.1 % ) . CONCLUSIONS Atrial fibrillation is common in patients with atherothrombosis , associated with more frequent fatal and nonfatal CV outcomes , and underuse of oral anticoagulants
Non-paroxysmal atrial fibrillation is associated with a highly significant increase in thromboembolism and death .
AIMS Thromboembolic risk stratification schemes and clinical guidelines for atrial fibrillation ( AF ) regard risk as independent of classification into paroxysmal ( PAF ) and non-paroxysmal atrial fibrillation ( NPAF ) .
The aim of the current study was to conduct a systematic review evaluating the impact of AF type on thromboembolism , bleeding , and mortality .