The ESC-HF Pilot Survey findings indicate a very high standard of inpatient HF treatment but at the same time unsatisfactory current ambulatory HF therapy in Poland.

Aims To assess the proportion of patients with heart failure and reduced ejection fraction (HFrEF) who are eligible for sacubitril/valsartan (LCZ696) based on the European Medicines Agency/Food and Drug Administration (EMA/FDA) label, the PARADIGM‐HF trial and the 2016 ESC guidelines, and the association between eligibility and outcomes. Methods and results Outpatients with HFrEF in the ESC‐EORP‐HFA Long‐Term Heart Failure (HF‐LT) Registry between March 2011 and November 2013 were considered. Criteria for LCZ696 based on EMA/FDA label, PARADIGM‐HF and ESC guidelines were applied. Of 5443 patients, 2197 and 2373 had complete information for trial and guideline eligibility assessment, and 84%, 12% and 12% met EMA/FDA label, PARADIGM‐HF and guideline criteria, respectively. Absent PARADIGM‐HF criteria were low natriuretic peptides (21%), hyperkalemia (4%), hypotension (7%) and sub‐optimal pharmacotherapy (74%); absent Guidelines criteria were LVEF>35% (23%), insufficient NP levels (30%) and sub‐optimal pharmacotherapy (82%); absent label criteria were absence of symptoms (New York Heart Association class I). When a daily requirement of ACEi/ARB ≥ 10 mg enalapril (instead of ≥ 20 mg) was used, eligibility rose from 12% to 28% based on both PARADIGM‐HF and guidelines. One‐year heart failure hospitalization was higher (12% and 17% vs. 12%) and all‐cause mortality lower (5.3% and 6.5% vs. 7.7%) in registry eligible patients compared to the enalapril arm of PARADIGM‐HF. Conclusions Among outpatients with HFrEF in the ESC‐EORP‐HFA HF‐LT Registry, 84% met label criteria, while only 12% and 28% met PARADIGM‐HF and guideline criteria for LCZ696 if requiring ≥ 20 mg and ≥ 10 mg enalapril, respectively. Registry patients eligible for LCZ696 had greater heart failure hospitalization but lower mortality rates than the PARADIGM‐HF enalapril group.

There is a positive correlation between the fall in aldosterone concentration 24 hours after cardioversion and maintenance of sinus rhythm during 30 days of observation.

The velocity of left atrium appendage (LAA) wall motion during atrial fibrillation (AF) is a potential marker of mechanical remodelling. In this study, we investigated whether the velocity of LAA wall motion during AF predicted the success of electrical cardioversion and long-term sinus rhythm maintenance. Standard echocardiographic data were obtained by transthoracic echocardiography, and LAA wall motion velocities were measured by transoesophageal echocardiography. With logistic regression and receiver operating characteristic curve analyses, we related echocardiographic and clinical data to cardioversion outcomes and sinus rhythm maintenance at 12 months. Of 121 patients prospectively included in the study, electrical cardioversion restored sinus rhythm in 97 (81.2%), and 51 (42%) patients maintained sinus rhythm at 12 months. Patients in whom cardioversion restored sinus rhythm had higher LAA wall motion velocities than did the patients with failed cardioversions (p <0.001). Compared to patients with AF at 12 months, patients who maintained sinus rhythm had lower maximum and end-diastolic left atrial volumes (p � 0.01), lower E/e' ratios (p = 0.005), higher s' values (p = 0.013), and higher LAA motion velocities (p < 0.001). On multivariate logistic regression, only LAA wall motion velocity and E/e' ratios remained significant predictors of sinus rhythm maintenance at 12 months (p � 0.04). LAA wall motion velocity was also a significant predictor of sinus rhythm maintenance when corrected for clinical variables (p = 0.039). Conclusion: LAA wall motion velocity, as a marker of mechanical remodelling, can predict short-term and long-term sinus rhythm maintenance after electrical cardioversion in AF.

Although electrical cardioversion of atrial fibrillation (AF) is frequently performed, initial energy requirements for cardioversion of persistent AF is still a matter of debate. The aim of the study was to determine the efficacy of biphasic shocks for transthoracic cardioversion of persistent AF and to predict adequate initial energy. A prospective study enrolled 94 consecutive patients with persistent AF, who were referred for elective cardioversion with a biphasic waveform. The paddles were placed in the anterolateral position. A step-up protocol was used to estimate the cardioversion threshold. The initial shock energy was 50 J, with subsequent increments to 100, 200, and 300 J in the event of cardioversion failure. The mean age of the study group was of about 65 years (6 +/- 11 years) and a median duration of AF was 65 days (3-324). Sixty-two out of 94 patients were men, 55% of the study population was classified as having well-controlled hypertension. The overall success rate of cardioversion was 89%, with a mean 2.2 +/- 1.4 shocks, and effective J 217.8 +/- 113 delivered during repeated cardioversions. The success rate of low energy shocks: 50 and 50 +100 J was 51%. By logistic regression analysis the only independent predictor of success at low energy shock was shorter duration of AF (r =-0.51; P = 0.02). Patients with shorter duration of AF have a higher probability for successful cardioversion with low energy. In patients with longer AF duration, a 200 J shock should be considered for cardioversion as the initial energy.

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IntroductionAtrial fibrillation (AF) is the most common arrhythmia and leads to a five-fold increased risk of stroke compared to persons with sinus rhythm. A soluble form of thrombomodulin (sTM) is a recognized marker of endothelial dysfunction and may contribute to the hypercoagulable state in AF. The aim of the study was to evaluate plasma concentration of sTM in persistent AF patients before and after sinus rhythm recovery following direct current cardioversion (CV).Material and methodsIn 45 effectively anticoagulated consecutive patients, with persistent non-valvular AF, and normal left ventricular function, CV was performed. Blood samples for sTM assessment were collected twice: 24 hours before and 24 hours after CV.ResultsIn 43 patients sinus rhythm was obtained. The mean plasma sTM level was significantly lower in AF patients compared to the control group with sinus rhythm and without anticoagulation (38.5 ±9.9 ng/ml vs. 44.1 ±9.1 ng/ml, p = 0.04). Plasma sTM levels did not change 24 hours after successful CV (36.7 ±9.5 ng/ml vs. 38.5 ±9.9 ng/ml, p = 0.16).ConclusionsPlasma sTM concentration was lower in patients with persistent AF and normal left ventricle systolic function than in patients with sinus rhythm, presumably due to chronic oral anticoagulant therapy in the AF group. CV has no impact on sTM plasma level evaluated 24 hours after sinus rhythm restoration.

StreszczeniePodstawowym problemem terapeutycznym u chorego z migotaniem przedsionków (AF), poza ustaleniem wskazań do leczenia przeciwkrzepliwego, jest wybór strategii utrzymania rytmu zatokowego lub kontroli częstości rytmu komór. W wytycznych z 2016 roku zaleca się wybór strategii utrzymania rytmu zatokowego "tylko" w celu zmniejszenia objawów wynikających z arytmii. W dotychczas przeprowadzonych badaniach nad wyborem strategii leczenia u pacjentów z AF nie ujawniono przewagi jednej strategii nad drugą. W wieloośrodkowych badaniach, takich jak AFFIRM, RACE, STAF, PIAF, HOT CAFE, nie wykazano różnic między obiema strategiami pod kątem umieralności oraz częstości powikłań sercowo-naczyniowych, choć w wielu analizach post-hoc przedstawiono dowody przewagi strategii utrzymania rytmu zatokowego, uwzględniając tak zwane miękkie punkty końcowe, takie jak poprawa wydolności fizycznej czy poprawa profilu humoralnego. Mimo zalecanego w wytycznych paradygmatu utrzymania rytmu zatokowego "tylko" do poprawy w zakresie objawów u pacjenta, badania obserwacyjne wskazują, że pacjentów z przywróconym i utrzymanym rytmem zatokowym cechuje lepsze rokowanie. A artykule przedstawiono aktualny stan wiedzy dotyczący wyboru strategii postę-powania u pacjentów z niezastawkowym AF.Słowa kluczowe: migotanie przedsionków, kardiowersja, leczenie antyarytmiczne, doustne antykoagulanty Cardiologica 2017; 12, 6: 570-579 Folia