Cognitive behavioral therapy for symptomatic paroxysmal atrial fibrillation: effects on physical activity, sleep and heart rate variability

<i>Circulation: Arrhythmia and Electrophysiology</i> Editors’ Picks

Introduction: The Cryo-FIRST study (NCT01803438) demonstrated that pulmonary vein isolation (PVI) with cryoballoon catheter ablation (CA) is superior to antiarrhythmic drug (AAD) therapy as a first line treatment for the prevention of atrial arrhythmia recurrence in patients with paroxysmal atrial fibrillation (PAF). Earlier CA may also be beneficial for improving quality of life (QoL). Hypothesis: We hypothesized that PVI with cyroballoon CA is superior to AAD therapy for improving QoL in treatment naïve patients with PAF. Methods: Patients with symptomatic PAF free of heart disease who had not been administered AAD therapy for &gt;48 hours were enrolled at 18 sites in 9 countries. Patients were randomized (1:1) to cryoballoon CA (Arctic Front Advance, Medtronic) or AAD therapy (Class IC or III). Subjects were followed at 1, 3, 6, 9, and 12 months. QoL was evaluated using the Atrial Fibrillation Effect on Quality of Life (AFEQT) and SF-36 v2 questionnaires. Health domains and component scores from the SF-36 were transformed to norm-based T scores. Mean adjusted differences between arms were compared at each follow-up. Results: Of the 218 patients randomized (age 52±13 years, 68% male) 86% completed the 12-month follow-up. Crossovers occurred in 9% of subjects (N=20, CA-to-AAD: N=1, AAD-to-CA: N=19). There were no group differences in baseline AFEQT or SF-36 scores. The mean AFEQT summary score was more favorable in the CA vs. AAD group at 12 months (88.9 vs. 78.1 points, respectively). The adjusted difference was 9.9 points (95%CI: 5.5-14.2; P &lt; .0001, Figure). A significant adjusted mean difference favoring CA was observed for the SF-36 physical component score at months 3 (1.8 points, p=0.031) and 9 (2.0 points, p=0.018). No other differences were observed in the physical or mental component scores between groups. Conclusions: Cryoballoon CA was superior to AAD therapy for improving AF-specific QoL in treatment naïve patients with symptomatic PAF.

Background The Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire has recently been validated to measure the impact of atrial fibrillation on quality of life, but a clinically important difference in AFEQT score has not been well defined. Methods and Results To determine the clinically important difference in overall AFEQT (score range= 0 [worst] to 100 [best]) and selected subscales, we analyzed data in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry, a United States-based outpatient atrial fibrillation registry. AFEQT was assessed at baseline and 1 year in a subset of 1347 ORBIT-AF patients from 80 US sites participating in ORBIT-AF from June 2010 to August 2011. The mean change method was used to relate changes in 1-year AFEQT scores to clinically important changes in the physician assessment of European Heart Rhythm Association functional status (1 class improvement and separately 1 class deterioration). Clinically important differences and 95% CI corresponding to either a 1 European Heart Rhythm Association class improvement or deterioration were 5.4 (3.6-7.2) and -4.2 (-6.9 to -1.5) AFEQT points, respectively. Similarly, clinically important difference values were seen for a 1 European Heart Rhythm Association class improvement for the AFEQT subscales Activities of Daily Living and Symptoms: 5.1 (2.5-7.6) and 7.1 (5.3-9.0) AFEQT points, respectively. Conclusions Based on the anchor of 1 European Heart Rhythm Association class change, changes in AFEQT score of + or -5 points are clinically important changes in patients' health. Clinical Trial Registration URL: https://clinicaltrials.gov . Unique identifier: NCT01165710.

Abstract. The goal of the study was to investigate the effect of magnesium orotate as a part of complex therapy in sinus rhythm restoring in patients with AF paroxysm, as well as to evaluate its effectiveness and effect on LQo with long-term use.&#x0D; Materials and research methods. We examined 56 patients (16 women and 40 men) with an average age of (61,5 ± 4,3) years with paroxysmal atrial fibrillation. All patients were divided into two groups. Patients of the 1st group (n=28) underwent medical cardioversion with amiodarone and magnesium orotate. Patients of the 2nd group (n=28) received only amiodarone. The time of sinus rhythm restoration, parameters of electrical instability of the atrial and ventricular myocardium after sinus rhythm restoration, patients life quality 3 months after discharge - were assessed in both groups.&#x0D; Results. The study allowed to reveal that the addition of magnesium orotate to the basic therapy of patients with atrial fibrillation increases the effectiveness of medical cardioversion and reduces the time of its onset. When using amiodarone and magnesium orotate, signs of electrical instability of the atrial myocardium (the number of paired and supraventricular extrasystoles) are significantly less according to the results of Holter electrocardiogram monitoring compared with amiodarone monotherapy. Atrial fibrillation caused a life quality parameters deviations in the form of an increase in the severity of the disease symptoms, physical activity limitation and psycho-emotional sphere disorders. 3 months after the treatment, it was noted that life quality in patients of the 1st group (complex therapy using magnesium orotate) was higher compared to patients of the 2nd group due to the improvement in the indicators of the "psycho-emotional" component.&#x0D; Conclusions. The addition of magnesium orotate to the basic therapy of paroxysmal atrial fibrillation can significantly improve the clinical course of the disease in patients and their life quality after 3 months treatment period.

Many patients with severe obstructive sleep apnea (OSA) do not complain of excessive daytime sleepiness (EDS), possibly due to increased sympathetic nervous activity (SNA) and accompanying heightened alertness. We hypothesized that in patients with OSA, those without subjective EDS (Epworth Sleepiness Scale, ESS score < 11) would have higher very low frequency (VLF) heart rate variability (HRV) during sleep, reflecting greater sympathetic heart rate modulation than patients with an ESS score ≥ 11. Patients with severe OSA (AHI ≥ 30: 26 with and 65 without heart failure) were divided into those with and without EDS. Heart rate (HR) signals were acquired in stage 2 sleep during periods of recurrent apneas and hypopneas and submitted to coarse graining spectral analysis, which extracts harmonic, neurally mediated contributions to HRV from total spectral power. Because the apnea-hyperpnea cycle entrains muscle SNA at VLF (0 to 0.04 Hz), VLF power was our principal between-group comparison. Subjects without EDS had higher harmonic VLF power (944 ± 839 vs 447 ± 461 msec(2), p = 0.003) than those with EDS, irrespective of the presence or absence of heart failure (1218 ± 944 vs 426 ± 299 msec(2), p = 0.043, and 1029 ± 873 vs 503 ± 533 msec(2), p = 0.003, respectively). ESS scores correlated inversely with VLF power in all (r = -0.294, p = 0.005) and in heart failure subjects (r = -0.468, p = 0.016). Patients with severe OSA but without EDS have higher VLF-HRV than those with EDS. This finding suggests that patients with severe OSA but without EDS have greater sympathetic modulation of HRV than those with EDS that may reflect elevated adrenergically mediated alertness. Taranto Montemurro L; Floras JS; Picton P; Kasai T; Alshaer H; Gabriel JM; Bradley TD. Relationship of heart rate variability to sleepiness in patients with obstructive sleep apnea with and without heart failure.

ObjectiveLeisure-time physical activity (LTPA) has considerable benefits for cardiovascular health and longevity, while occupational physical activity (OPA) is associated with an elevated cardiovascular risk. This “health paradox” may be explained by different effects on the autonomic nervous system from OPA and LTPA. Thus, we aimed to investigate whether objectively measured OPA and LTPA are differentially associated with autonomic regulation among workers.MethodsThe study comprised 514 blue-collar workers from the Danish cohort DPHACTO. Physical activity (i.e. walking, climbing stairs, running and cycling) was assessed objectively using accelerometers worn on the thigh, hip and trunk over multiple working days. During this period, a heart rate monitor was used to sample heart period intervals from the ECG signal. Heart rate and heart rate variability (HRV) indices were analyzed during nocturnal sleep as markers of autonomic regulation. Multiple regression analysis was used to determine the main effects of OPA and LTPA and their interaction on heart rate and HRV, adjusting for multiple confounders.ResultsStatistically significant interaction was found between OPA and LTPA on heart rate (adjusted p<0.0001) and HRV indices in time (rMSSD, adjusted p = 0.004) and frequency-domains (HF, adjusted p = 0.022; LF, adjusted p = 0.033). The beneficial effect of LTPA on nocturnal heart rate and HRV clearly diminished with higher levels of OPA, and high levels of both OPA and LTPA had a detrimental effect.ConclusionWe found contrasting associations for objectively measured OPA and LTPA with heart rate and HRV during sleep. Differential effects of OPA and LTPA on autonomic regulation may contribute to the physical activity health paradox.

Managing atrial fibrillation in the CRT patient: Controversy or consensus?

Objective To evaluate the predictors of quality of life(QoL)changes in atrial fibrillation(AF)patients with low CHADS2 score 6 months after radiofrequency ablation(RFA). Methods AF patients with low CHADS2 score(CHADS2 score<2)undergoing RFA were selected from Chinese Atrial Fibrillation Registry(CAFR)from April 2011 to February 2013.The cohort was then divided into four groups according to their baseline symptoms based on European Heart Rhythm Association(EHRA). We quantified the changes of QoL from baseline to 6 months after RFA using Atrial Fibrillation Effect on QualiTy-of-life(AFEQT)questionnaire.Multivariable linear regression modeling was then conducted to determine predictive factors of the QoL changes from baseline to 6 months after RFA. Results A total of 144 patients with low CHADS2(61.20±10.12)years old were selected from CAFR.Health status improvement was marked and clinically meaningful during the six months follow-up among the EHRA Ⅱ(23.17, p<0.001), Ⅲ(32.08, p<0.001)and Ⅳ(61.73, p=0.004)groups, but no significant difference was seen in the EHRA I. Domain of treatment satisfaction was found to improve statistically significantly but not clinically meaningfully in the following 6 months after RFA in the EHRA Ⅱ(6.22, p=0.03)and Ⅲ(15.06, p<0.001)groups, but not in the EHRA Ⅰ and Ⅳ groups.The most important predictor for improved health status(OR: 2.40, 95%CI: 1.32-4.37, p=0.004)and treatment satisfaction(OR: 1.95, 95%CI: 1.02-3.73, p=0.045)after 6 months was EHRA stratification at baseline. Conclusion In most AF patients with low CHADS2 score, QoL was increased in the six months after RFA.Knowledge of the predictors of this increase may aid physicians to timely differentiate between patients who most likely will benefit most from RFA in terms of QoL. Key words: Atrial fibrillation; Radiofrequency ablation; Low CHADS2 score; Atrial Fibrillation Effect on QualiTy-of-life

In middle-aged persons, moderate physical activity energy expenditure (PAEE) has been shown to be associated with increased vagal-related heart rate variability (HRV) indexes and better health status. The purpose of this study was to determine whether a very high PAEE has greater effect on vagal-related HRV indexes and self-estimates of well-being in middle-aged subjects having distinct long-term physical activity profiles. Forty-four subjects were divided into three groups on the basis of the sport score of the Modified Baecke Questionnaire for Older Adults: sedentary (SED, n = 15), moderately-trained (MT, n = 16), and highly-trained subjects (HT, n = 13). PAEE was estimated by triaxial accelerometry during one week. Time and frequency domain HRV indexes were determined during quiet periods in the morning on 5-min R-R interval segments under controlled breathing. Quality of life was evaluated using the SF-36 health survey questionnaire. PAEE was significantly different for each group (374.5 +/- 13.8, 616.8 +/- 22.4, and 1086.6 +/- 43.2 kcal . day (-1) for SED, MT, and HT, respectively, p < 0.001). MT presented significantly higher vagal-related HRV indexes than SED and HT (p < 0.05). None of the HRV indexes was significantly greater in HT than in SED. MT and HT had similar health status scores, which were significantly higher than for SED. These results indicate that in middle-aged subjects, habitual moderate PAEE is associated with greater vagal tone and self-estimates of well-being compared to low PAEE. In contrast, very high PAEE is associated with similar vagal-related indexes as low PAEE, despite better overall health status.

Heart Rate Variability (HRV) can be quantified using a myriad of mathematical indices, but the lack of systematic and empirical comparison between these indices complicates the evaluation and interpretation of HRV data. This study assessed the reliability, consistency, and generalizability of structural relationships among 89 HRV indices using a consensus-clustering approach. We analyzed 635 short-term resting-state electrocardiogram (ECG) recordings from two samples of college students with differing psychological profiles. Results from a sample with elevated internalizing symptoms (N = 233)-collected across two sessions, 1 week apart-were compared to evaluate the test-retest reliability of the HRV clusters. To further assess the stability and generalizability of these HRV clusters beyond individuals with elevated internalizing symptoms, these results were compared with a second sample not selected based on psychological symptoms (N = 203). We identified 21 clusters of 70 HRV indices with cross-method, test-retest, and cross-sample robustness. Based on the robust empirical convergence and the relative popularity of some HRV indices in the extant literature, we recommend 13 HRV indices for short-term recordings of resting-state HRV (under 10 min): RMSSD, SDNN, RSA (Porges-Bohrer or Peak-to-Trough method), RSA (Gates method), SD1/SD2 or CSI, SampEn, HF or LnHF, DFA α1, DFA α2, one of the MDFA α1 features, one of the MDFA α2 features, one of the heart rate asymmetry indices, and one of the heart rate fragmentation indices. This approach mitigates the biases that can arise from redundant or highly correlated indices, facilitates clearer interpretation, and enhances the validity of conclusions drawn from HRV analyses.

In patients with normal hearts, increased vagal tone is associated with onset of paroxysmal atrial fibrillation (AF). Vagal denervation of the atria renders AF less inducible. Circumferential pulmonary vein isolation (CPVI) is effective for treating paroxysmal and persistent AF, and has been shown to impact heart rate variability (HRV) indices, in turn, reflecting vagal denervation. We examined the impact of CPVI on HRV indices, and evaluated the relationship between vagal modification and AF recurrence. Electrocardiogram recordings were collected from 83 consecutive patients (63 male, 20 female, age 56.9 ± 9.3 years) undergoing CPVI for paroxysmal (n = 56) or persistent (n = 27) AF. Recordings were obtained over 10 minutes preprocedure, and at intervals up to 12 months. Antiarrhythmic medications were suspended prior to CPVI, and were resumed for 3 months following. Success was defined as no recurrence of atrial arrhythmia lasting longer than 30 seconds. In patients with successful procedures (n = 56, 42 paroxysmal, 14 persistent), HRV indices were significantly altered, with respect to preprocedure levels, over a sustained period. However, patients with recurrence (n = 27, 14 paroxysmal, 13 persistent) demonstrated similar HRV to their preprocedure levels over the follow-up period. Our results suggest that patients experiencing recurrence after a single CPVI have HRV attenuated by the procedure only intermittently, whereas patients with one successful CPVI experience a sustained change. A short-term HRV recording is a convenient and potentially important marker for recurrence of atrial arrhythmia in a population undergoing CPVI.

Radiofrequency catheter ablation (RFA) has emerged as an important treatment strategy for atrial fibrillation (AF). The potential cost-effectiveness of RFA for AF, relative to antiarrhythmic drug (AAD) therapy, has not been fully explored from a US perspective. We constructed a Markov disease simulation model for a hypothetical cohort of patients with drug-refractory paroxysmal AF, treated either with RFA with/without AAD or AAD alone. Costs and quality-adjusted life-years were projected over 5 years. Model inputs were drawn from published clinical trial and registry data, from new registry and trial data analysis, and from data prospectively collected from patients with AF treated with RFA at our institution. We assumed no benefit from ablation on stroke, heart failure or death, but did estimate changes in quality-adjusted life expectancy using data from several AF cohorts. In the base case scenario, cumulative costs with the RFA and AAD strategies were $26,584 and $19,898, respectively. Over 5 years, quality-adjusted life expectancy was 3.51 quality-adjusted life-years with RFA versus 3.38 for the AAD group. The incremental cost-effectiveness ratio for RFA versus AAD was thus $51,431 per quality-adjusted life-year. Model results were most sensitive to time horizon, the relative utility weights of successful ablation versus unsuccessful drug therapy, and to the cost of an ablation procedure. RFA with/without AAD for symptomatic, drug-refractory paroxysmal AF appears to be reasonably cost-effective compared with AAD therapy alone from the perspective of the US health care system, based on improved quality of life and avoidance of future health care costs.

Turnusmäßig sind die aktualisierten Leitlinien der European Society of Cardiology (ESC) zum Management von Vorhofflimmern 2024 erschienen. Trotz bedeutender Fortschritte in der Prävention, Diagnostik und Therapie ist das Vorhofflimmern die häufigste anhaltende Rhythmusstörung und hat einen großen Einfluss auf die Betroffenen, ihr Umfeld und das Gesundheitswesen. Die prägnanten Leitlinien fokussieren auf evidenzgestützte Empfehlungen und praktische Umsetzbarkeit einschließlich klarer Schaubilder und Behandlungspfade. Die ganzheitliche Betreuung des Patienten und seiner Komorbiditäten wird in einem umfassenden AF-CARE-Konzept in den Vordergrund gestellt. Es beinhaltet „C“ Komorbiditäten und Risikofaktorenmanagement, „A“ Vermeidung von Schlaganfall und Thrombembolien, „R“ Reduktion von Symptomen durch Rhythmus- oder Frequenzkontrolle und dynamische „E“ Re-Evaluation. Bei paroxysmalem Vorhofflimmern ist die Ablation jetzt Erstlinientherapie. Aktuelle Daten für Device-detektiertes Vorhofflimmern und Trigger-induziertes Vorhofflimmern wurden aufgenommen. Eine maximale Involvierung von Patienten u. a. durch parallel publizierte Patientenleitlinien wird zur gemeinsamen, informierten Entscheidungsfindung befürwortet.

PURPOSE: Growing evidence suggests that associations of sedentary time (ST) or physical activity (PA) with cardiovascular health may differ by domain (leisure vs. occupational). We examined associations between leisure and occupational ST and PA with heart rate variability (HRV) in women. METHODS: Cross-sectional data were obtained at the Pregnancy Outcomes and Community Health Study follow-up exam (POUCHmoms) which occurred 7 to 15 years after the study pregnancy. Women (n = 522; age = 37.7 ± 5.7 yr; 59% white) who self-reported leisure and occupational ST and PA (hours/day) using the Modifiable Activity Questionnaire and had a valid HRV assessment were included in the analysis. Five minutes of resting HRV (average heart rate, standard deviation of normal R-R intervals [SDNN], root mean square of successive differences [RMSSD], and high frequency [HF]) were calculated from seated ECG data using Kubios software. All HRV indexes were natural log (ln) transformed due to skewness. Progressive generalized linear mixed models evaluated associations of leisure and occupational ST and PA with HRV while adjusting for potential confounders (demographics and health-related factors) [Model 1], and mediators (clinical variables) [Model 2]. RESULTS: In Model 1, higher leisure ST was associated with greater HR, lower lnSDNN, and lower lnRMSSD indicating unfavorable HRV (Table 1). After adjusting for mediators (Model 2), higher leisure ST remained associated with greater HR, but other associations were attenuated. Higher leisure PA was associated with higher lnSDNN, lnRMSSD, and lnHF in all models. Occupational ST and PA were not associated with HRV. CONCLUSION: Associations between ST and PA with HRV appeared to differ by activity domain. Decreasing ST and increasing PA during leisure time are potential behavioral targets to improve HRV in women.Table 1: Associations between leisure and occupational ST and PA with heart rate and HRV (n = 522)

Success of early versus late repeat ablation after electric pulmonary vein isolation for atrial fibrillation