Cardioversion of atrial fibrillation in obese patients: Results from the Cardioversion‐BMI randomized controlled trial

Voskoboinik, Aleksandr; Moskovitch, Jeremy; Plunkett, George; Bloom, Jason; Wong, G.; Nalliah, C.; Prabhu, Sandeep; Sugumar, Hariharan; Paramasweran, Ramanathan; McLellan, A.; Ling, Liang‐Han; Goh, Cheng Yee; Noaman, Samer; Fernando, Himawan; Wong, Maria M.; Taylor, Andrew J.; Kalman, Jonathan M.; Kistler, Peter M.

doi:10.1111/jce.13786

Cited by 49 publications

(40 citation statements)

References 20 publications

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“…Thirdly, the myocardial fibrotic process in HFpEF may affect the conduction system, which contributes to chronotropic incompetence and can lead to serious bradyarrhythmias and increased mortality if patients are prescribed AVN blocking drugs . Conduction system disease requiring pacemaker therapy is common in HFpEF, particularly in those with AF . The rate‐slowing effects of AVN blocking drugs may contribute to their adverse effects on mortality or negate any independent action to prolong survival .…”

Section: Therapeutic Challenges In Patients With a Metabolic Disordermentioning

confidence: 99%

“…211,212 Conduction system disease requiring pacemaker therapy is common in HFpEF, particularly in those with AF. 213 The rate-slowing effects of AVN blocking drugs may contribute to their adverse effects on mortality or negate any independent action to prolong survival. 207,208,211,212 Regardless of the mechanism, the totality of evidence raises doubts about the current approach to the use of AVN blocking drugs for rate control when treating AF (and latent HFpEF) in obesity or type 2 diabetes.…”

Section: Atrioventricular Node Blocking Drugsmentioning

confidence: 99%

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Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Packer

2019

European J of Heart Fail

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Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk‐to‐benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post‐ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.

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Section: Therapeutic Challenges In Patients With a Metabolic Disordermentioning

confidence: 99%

Section: Atrioventricular Node Blocking Drugsmentioning

confidence: 99%

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Packer

2019

European J of Heart Fail

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“…Given these difficulties, physicians may consider rhythm control of AF as a primary strategy. However, both obesity and diabetes decrease the probability of success following electrical cardioversion, because epicardial adipose tissue expansion promotes the recurrence of AF . Similarly, biomarkers of an underlying HFpEF (ie, abnormalities of LV diastolic filling or left atrial geometry) identify patients who are unlikely to achieve and sustain sinus rhythm, whether the AF is treated electrically or pharmacologically .…”

Section: Heightened Risks Of Rate‐control Strategies For Af In Obesitmentioning

confidence: 99%

“…However, both obesity and diabetes decrease the probability of success following electrical cardioversion, because epicardial adipose tissue expansion promotes the recurrence of AF. [51][52][53] Similarly, biomarkers of an underlying HFpEF (ie, abnormalities of LV diastolic filling or left atrial geometry) identify patients who are unlikely to achieve and sustain sinus rhythm, whether the AF is treated electrically or pharmacologically. [54][55][56] Additionally, both obesity and diabetes are accompanied by a high rate of AF recurrence following catheter ablation.…”

Section: Heightened Risks Of Rate-control Strategies For Af In Obesmentioning

confidence: 99%

Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re‐evaluation

Packer

2019

Cardiovasc electrophysiol

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Atrial fibrillation (AF) is common in patients with obesity and diabetes; the arrhythmia (if long‐standing) is typically managed by rate control and anticoagulation. However, the coexistence of these two metabolic disorders complicates therapeutic options for rate control. The likely pathogenesis of AF in these patients is an expansion of epicardial adipose tissue whose inflammation is transmitted to the left atrium causing electromechanical remodeling. However, this same process is also transmitted to the left ventricle (LV), impairing its distensibility and its ability to tolerate volume, leading to heart failure with preserved ejection fraction. Unfortunately, the latter diagnosis (although commonly present in patients with AF and a coexistent metabolic disorder) is often ignored. To achieve rate control, physicians prescribe intensive treatment with atrioventricular (AV) nodal–blocking drugs, often at doses that are titrated to blunt exercise as well as resting heart rate responses. However, strict rate control (target rate, <80/min) is associated with somewhat worse outcomes than lenient rate control (target rate, <110/min). Furthermore, any rate slowing that facilitates diastolic filling may aggravate filling pressures that are already disproportionately increased because the LV is stiff and overfilled as a result of cardiac inflammation. Rate slowing in AF with beta blockers may not achieve the benefit expected from the blockade of adrenergically mediated cardiotoxicity, and some AV nodal–blocking drugs (digoxin and dronedarone) can increase the risk of death in patients with AF. Finally, cardiac fibrosis in obesity and diabetes may affect the conduction system, which can predispose to serious bradyarrhythmias if patients are prescribed AV nodal–blocking drugs.

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“…Despite the epidemic that obesity has become, and the remarkable increase in the prevalence of atrial fibrillation, there has never been a properly controlled study to answer important questions. Thus, Voskoboinik et al deserve our thanks for their effort to provide information in this relatively data‐free zone. Their principal finding jives well with conventional wisdom and previous studies and should be heeded: when cardioverting patients with a high body mass index (BMI) use paddles, not patches to optimize the chances of first shock success.…”

mentioning

confidence: 99%

Cardioversion of obese patients: What is the weight of evidence?

Kowey

Ahmad

2018

Cardiovasc electrophysiol

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Disclosures: None Funding informationThis study was supported in part by the William Wikoff Smith Chair in Cardiovascular Research As eager medical residents at a busy heart hospital, the opportunity to participate in the drama of cardiac resuscitation was abundant.Our population's demographic translated into a high percentage of morbidly obese among the unfortunate souls who needed our emergent ministration. So it was fairly early in my (PRK) career that I began to reflect on the adequacy of the methods we have traditionally used to cardiovert and defibrillate patients in whom the heart was distant from our paddles, functionally insulated from the electrical energy meant to reverse their arrhythmias and in some cases to save their lives.Unfortunately, the answers to the questions with which we pestered our attending physicians remain largely unanswered. Specifically, when a morbidly obese patient needs to be shocked for whatever reason, which approach offers the best chance of success? Even more importantly, how do we know if the methods we commonly employ in clinical practice have the same chance of success and the same safety profile in this vulnerable, high-risk patient population?Clearly, the advent of the biphasic waveform has improved cardioversion and defibrillation success across the board and facilitated the development and implementation of better implantable technology. 1,2 But the question remains as to whether we need to do anything else to optimize outcomes in morbidly obese patients.To this date, the answer has not been clear. 3 We have assumed that using higher energies or higher paddle pressure might be helpful, but the data have not been conclusive. 4 This is particularly important because the use of high-energy shocks, particularly if delivered in rapid succession without heat dissipation, has the potential to cause myocardial necrosis. 5 Despite the epidemic that obesity has become, and the remarkable increase in the prevalence of atrial fibrillation, there has never been a properly controlled study to answer important questions. Thus, Voskoboinik et al 6 deserve our thanks for their effort to provide information in this relatively data-free zone.Their principal finding jives well with conventional wisdom and previous studies and should be heeded: when cardioverting patients with a high body mass index (BMI) use paddles, not patches to optimize the chances of first shock success. Within this context, one ancillary finding regarding the lack of difference between shock vectors also seems plausible, although the results in other contexts have not been uniform. 7Given the size of their study and its design, Voskoboinik et al 6 were not able to answer several other critical questions. First, paddle pressure. As the authors point out, while most of us advocate firm pressure to reduce transthoracic impedance, there is a good deal of intra-and interoperator variability. I (PRK) have a distinct memory of watching one of my fellow interns, a 5-foot spitfire, attempting to gain purchase and place firm ...

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Cardioversion of atrial fibrillation in obese patients: Results from the Cardioversion‐BMI randomized controlled trial

Cited by 49 publications

References 20 publications

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment

Heightened risk of intensive rate control in patients with atrial fibrillation who are obese or have type 2 diabetes: A critical review and re‐evaluation

Cardioversion of obese patients: What is the weight of evidence?

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