title: Differences in Clinical and Functional Outcomes of Atrial Fibrillation in Women and Men: Two-Year Results From the ORBIT-AF Registry. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials The diagnostic accuracy of the MyDiagnostick to detect atrial fibrillation in primary care Stroke severity in atrial fibrillation. The Framingham Study. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. A randomised controlled trial and cost-effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in people aged 65 and over. The SAFE study. Asymptomatic atrial fibrillation: demographic features and prognostic information from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study.
abstract: IMPORTANCE Despite the frequency of  atrial fibrillation ( AF )  in clinical practice , relatively little is known about sex differences in symptoms and quality of life and how they may affect treatment and outcomes . OBJECTIVE To determine whether symptoms , quality of life , treatment , and outcomes differ between women and men with AF . DESIGN , SETTING , AND PARTICIPANTS This observational cohort study included 10 135 patients with AF . The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation is a prospect i ve , nationwide , multicenter outpatient registry of patients with incident and prevalent AF enrolled at 176 sites between June 2010 and August 2011 . MAIN OUTCOMES AND MEASURES Symptoms , quality of life as measured by Atrial Fibrillation Effects on Quality of Life scores , AF treatment , cardiovascular outcomes , stroke or non- central nervous system embolism , and all-cause mortality . RESULTS Overall , 4293 of the cohort ( 42 % ) were female . Compared with men , women were older ( 77 years ; interquartile range [ IQR ] , 69 - 83 , vs 73 years ; IQR , 65 - 80 ; P < .001 ) and had higher median CHA2DS2-VASc scores ( 5 ; IQR , 4 - 6 , vs 3 ; IQR , 2 - 5 ; P < .001 ) , but less sleep apnea ( 578 [ 13.5 % ] vs 1264 [ 21.6 % ] ; P < .001 ) . Only 32.1 % of women ( n = 1378 ) were asymptomatic ( European Heart Rhythm Association class I ) compared with 42.5 % of men ( n = 2483 ) in unadjusted analyses ( P < .001 ) . Women had lower ( more severe ) unadjusted baseline overall Atrial Fibrillation Effects on Quality of Life scores ( n = 2007 ; 80 ; IQR , 62 - 92 vs 83 ; IQR , 69 - 94 ; P < .001 ) . Women had similar rates of anticoagulation and similar time in therapeutic range . In follow-up , women experienced lower risk-adjusted all-cause mortality ( adjusted hazard ratio , 0.57 ; 95 % CI , 0.49 - 0.67 ) and cardiovascular death ( adjusted hazard ratio , 0.56 ; 95 % CI , 0.44 - 0.72 ) ; however , they had a higher risk for stroke or non- central nervous system embolism ( adjusted hazard ratio , 1.39 ; 95 % CI , 1.05 - 1.84 ; P = .02 ) compared with men . CONCLUSIONS AND RELEVANCE Women with AF have more symptoms and worse quality of life . Despite higher risk , women have lower risk-adjusted all-cause and cardiovascular death compared with men , but higher stroke rates . Future studies should focus on how treatment and interventions specifically affect AF-related quality of life and cardiovascular outcomes in women . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01165710 ACCF : American College of Cardiology Foundation ACCP : American College of Chest Physicians ACS : acute coronary syndrome ACT : Atrial arrhythmia Conversion Trial ADONIS : American – Australian – African trial with DronedarONe In atrial fibrillation or flutter for the maintenance of Sinus rhythm AF : atrial fibrillation AHA : American Heart Association AND ROMEDA : ANtiarrhythmic trial with DROnedarone in Moderate-to-severe congestive heart failure Evaluating morbidity DecreAse APHRS : Asia Pacific Heart Rhythm Society aPTT : activated partial thromboplastin time ARB : angiotensin-receptor blocker ARISTOTLE : Apixaban for Reduction In STroke and Other ThromboemboLic Events in atrial fibrillation ATHENA : A placebo-controlled , double-blind , parallel arm Trial to assess the efficacy of dronedarone 400 mg b.i.d . for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ATRIA : AnTicoagulation and Risk factors In Atrial fibrillation AVERROES : Apixaban VErsus acetylsalicylic acid ( ASA ) to Reduce the Rate Of Embolic Stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment AVRO : A prospect i ve , r and omized , double-blind , Active-controlled , superiority study of Vernakalant vs. amiodarone in Recent Onset atrial fibrillation b.i.d : bis in die ( twice daily ) b.p.m . : beats per minute CABANA : Catheter ABlation vs . ANtiarrhythmic drug therapy for Atrial fibrillation CABG : coronary artery bypass graft CAP : Continued Access to Protect AF CHA2DS2-VASc : Congestive heart failure or left ventricular dysfunction Hypertension , Age ≥75 ( doubled ) , Diabetes , Stroke (doubled)-Vascular disease , Age 65–74 , Sex category ( female ) CHADS2 : Congestive heart failure , Hypertension , Age ≥75 , Diabetes , Stroke ( doubled ) CI : confidence interval CRAFT : Controlled R and omized Atrial Fibrillation Trial CrCl : creatinine clearance DAFNE : Dronedarone Atrial FibrillatioN study after Electrical cardioversion DIONYSOS : R and omized Double blind trIal to evaluate efficacy and safety of drOnedarone ( 400 mg b.i.d . ) vs . amiodaroNe ( 600 mg q.d . for 28 daYS , then 200 mg qd thereafter ) for at least 6 mOnths for the maintenance of Sinus rhythm in patients with atrial fibrillation EAST : Early treatment of Atrial fibrillation for Stroke prevention Trial EHRA : European Heart Rhythm Association ECG : electrocardiogram EMA : European Medicines Agency ERATO : Efficacy and safety of dRonedArone for The cOntrol of ventricular rate during atrial fibrillation EURIDIS : EURopean trial In atrial fibrillation or flutter patients receiving Dronedarone for the maIntenance of Sinus rhythm FAST : atrial Fibrillation catheter Ablation vs . Surgical ablation Treatment FDA : Food and Drug Administration Flec-SL : Flecainide Short-Long trial HAS-BLED : Hypertension , Abnormal renal/liver function , Stroke , Bleeding history or predisposition , Labile INR , Elderly , Drugs/alcohol concomitantly HF-PEF : heart failure with preserved ejection fraction HF-REF : heart failure with reduced ejection fraction HR : hazard ratio HRS : Heart Rhythm Society ICH : intracranial haemorrhage INR : international normalized ratio i.v . : intravenous J-RHYTHM : Japanese RHYTHM management trial for atrial fibrillation LAA : left atrial appendage LoE : level of evidence LVEF : left ventricular ejection fraction MANTRA-PAF : Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation NICE : National Institute for Health and Clinical Excellence NOAC : novel oral anticoagulant NSAID : non-steroidal anti-inflammatory drug NYHA : New York Heart Association OAC : oral anticoagulant or oral anticoagulation o.d . : omni die ( every day ) PALLAS : Permanent Atrial fibriLLAtion outcome Study using dronedarone on top of st and ard therapy PCI : percutaneous coronary intervention PREVAIL : Prospect i ve R and omized EVAluation of the LAA closure device In patients with atrial fibrillation v s. Long-term warfarin therapy PROTECT AF : WATCHMAN LAA system for embolic PROTECTion in patients with Atrial Fibrillation PT : prothrombin time RAAFT : Radio frequency Ablation Atrial Fibrillation Trial RE-LY : R and omized Evaluation of Long-term anticoagulant therapY with dabigatran etexilate ROCKET-AF : Rivaroxaban Once daily oral direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in atrial fibrillation RRR : relative risk reduction TE : thromboembolism TIA : transient ischaemic attack t.i.d . : ter in die ( three times daily ) TOE : transoesophageal echocardiogram TTR : time in therapeutic range VKA : vitamin K antagonist Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition , taking into account the impact on Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Background Atrial fibrillation is very common in people aged 65 or older . This condition increases the risk of death , congestive heart failure and thromboembolic conditions . Many patients with atrial fibrillation are asymptomatic and a cerebrovascular accident ( CVA ) is often the first clinical presentation . Guidelines concerning the prevention of CVA recommend monitoring the heart rate in patients aged 65 or older . Recently , the MyDiagnostick ( Applied Biomedical Systems BV , Maastricht , The Netherl and s ) was introduced as a new screening tool which might serve as an alternative for the less accurate pulse palpation . This study was design ed to explore the diagnostic accuracy of the MyDiagnostick for the detection of atrial fibrillation . Methods A phase II diagnostic accuracy study in a convenience sample of 191 subjects recruited in primary care . The majority of participants were patients with a known history of atrial fibrillation ( n = 161 ) .  Readings of the MyDiagnostick were compared with electrocardiographic recordings . Sensitivity and specificity and their 95 % confidence interval were calculated using 2x2 tables . Results A prevalence of 54 % for an atrial fibrillation rhythm was found in the study population at the moment of the study . A combination of three measurements with the MyDiagnostick for each patient showed a sensitivity of 94 % ( 95 % CI 87 – 98 ) and a specificity of 93 % ( 95 % CI 85 – 97 ) . Conclusion The MyDiagnostick is an easy-to-use device that showed a good diagnostic accuracy with a high sensitivity and specificity for atrial fibrillation in a convenience sample in primary care . Future research is needed to determine the place of the MyDiagnostick in possible screening or case-finding strategies for atrial fibrillation BACKGROUND AND PURPOSE Stroke occurring with atrial fibrillation ( AF )  is more likely to be fatal or more severe than non-AF stroke based on clinical series , but data from prospect i ve epidemiological studies are sparse and inconsistent . METHODS Over 40-year follow-up of the original 5070 Framingham cohort , 501 initial ischemic strokes , including 103 with AF , were analyzed . Stroke severity was rated as none , mild , moderate , severe , or fatal . Since 1981 , functional status indicated by the Barthel index has been evaluated acutely and at 3 , 6 , and 12 months . Severity and functional status of AF strokes were compared with non-AF strokes using chi 2 test and Student 's t test . Thirty-day mortality was assessed by logistic regression analyses . RESULTS AF was associated with increased stroke severity ( P = .048 ) . Thirty-day mortality was greater in AF strokes than in non-AF strokes ( 25 % versus 14 % ) . The multivariate-adjusted odds ratio for 30-day mortality for AF subjects was 1.84 ( 95 % confidence interval , 1.04 to 3.27 ) . Since 1981 , follow-up was available for 150 initial ischemic strokes , including 30 with AF . Compared with the non-AF group , the AF group had poorer survival and more recurrences during 1 year of follow-up . The AF subjects had lower mean Barthel index scores acutely ( 29.6 versus 58.6 , P < .001 ) and at 3 months ( P = .005 ) , 6 months ( P = .003 ) , and 12 months ( P = .130 ) after stroke among survivors . CONCLUSIONS Ischemic stroke associated with AF was nearly twice as likely to be fatal as non-AF stroke . Recurrence was more frequent , and functional deficits were more likely to be severe among survivors . Since stroke is usually the initial manifestation of embolism in AF , prevention is critical to reducing disability and mortality OBJECTIVES The present study determined the incidence and time course of atrial fibrillation ( AF ) recurrences  in patients with a history of AF and fitted with an implantable monitoring device .  BACKGROUND The long-term risk of undetected recurrence of AF in patients receiving stable antiarrhythmic therapy remains uncertain . METHODS In 110 patients with a class I indication for physiologic pacing and a history of AF , a pacemaker with dedicated functions for AF detection and electrogram storage was implanted , and antiarrhythmic drug treatment was optimized . Patients were regularly followed up with evaluation of AF-related symptoms , a  resting electrocardiogram ( ECG ) , and  interrogation of device memory .  The incidence of AF recurrences lasting > 48 h in asymptomatic patients presenting in sinus rhythm ( SR ) at the respective follow-up visit constituted the primary end point of this prospect i ve study . RESULTS During 19 + /- 11 months , 678 follow-up visits were performed . Atrial fibrillation was documented in 51 patients ( 46 % ) by ECG recording and in 97 patients ( 88 % ) by a review of stored electrograms ( p < 0.0001 ) . Device interrogation revealed AF recurrences lasting > 48 h in 50 patients , 19 of whom ( 38 % ) were completely asymptomatic and in SR at subsequent follow-up . In 11 ( 16 % ) of 67 patients with device-confirmed freedom from AF for > or =3 months , AF lasting > 48 h recurred subsequently . CONCLUSIONS This prospect i ve study demonstrates a high incidence of recurrent AF despite optimized antiarrhythmic therapy . Of particular note , AF relapses > 48 h remained totally asymptomatic in a significant proportion of patients . Freedom from AF for > or =3 months did not preclude subsequent long-lasting AF recurrence OBJECTIVES To determine the most cost-effective method of screening for  atrial fibrillation ( AF ) in the population aged 65 years and over , as well as its prevalence and incidence in this age group . Also to evaluate the relative cost-effectiveness of different methods of recording and interpreting the electrocardiogram ( ECG ) within a screening programme . DESIGN Multicentred r and omised controlled trial . Purpose fully selected general practice s were r and omly allocated to 25 intervention practice s and 25 control practice s. SETTING Fifty primary care centres across the West Midl and s , UK . PARTICIPANTS Patients aged 65 years and over . INTERVENTIONS GPs and practice nurses in the intervention practice s received education on the importance of AF detection and ECG interpretation . Patients in the intervention practice s were r and omly allocated to systematic ( n = 5000 ) or opportunistic screening ( n = 5000 ) . Prospect i ve identification of pre-existing risk factors for AF within the screened population enabled comparison between targeted screening of people at higher risk of AF and total population screening . MAIN OUTCOME MEASURES AF detection rates in systematic ally screened and opportunistically screened population s in the intervention practice s were compared with AF detection rate in 5000 patients in the control practice s. The screening period was 12 months . RESULTS Baseline prevalence of AF was 7.2 % , with a higher prevalence in males ( 7.8 % ) and patients aged 75 years and over ( 10.3 % ) . The control population demonstrated higher baseline prevalence ( 7.9 % ) than either the systematic ( 6.9 % ) or opportunistic ( 6.9 % ) intervention population . In the control population 47 new cases were detected ( incidence 1.04 % per year ) . In the opportunistic arm 243 patients without a baseline diagnosis of AF were found to have an irregular pulse , with 177 having an ECG , yielding 31 new cases ( incidence 0.69 % per year ) . A further 44 cases were detected outside the screening programme ( overall incidence 1.64 % per year ) . In the systematic arm 2357 patients had an ECG yielding 52 new cases ( incidence 1.1 % per year ) . Of these , 31 were detected by targeted screening and a further 21 by total population screening . A further 22 cases were detected outside the screening programme ( overall incidence 1.62 % per year ) . In terms of ECG interpretation , computerised decision support software ( CDSS ) gave a sensitivity of 87.3 % , a specificity of 99.1 % and a positive predictive value ( PPV ) of 89.5 % compared with the gold st and ard ( cardiologist reporting ) . GPs and practice nurses performed less well . The only difference in performance between intervention population s and controls was that practice nurses from the control arm performed less well than with intervention practice nurses on interpretation of limb-lead ( PPV 38.8 % versus 20.8 % ) and single-lead ( PPV 37.7 % versus 24.0 % ) ECGs . The within-trial economic evaluation results showed the lowest incremental cost to be for the opportunistic arm , with an incremental cost-effectiveness ratio of 337 pounds Sterling for each additional case detected compared to the control arm . Opportunistic screening dominated both more intensive screening strategies . Model-based analyses showed small differences in cost and quality -adjusted life-years for different methods and intensities of screening , but annual opportunistic screening result ed in the lowest number of ischaemic strokes and greatest proportion of cases of AF diagnosed . Probabilistic sensitivity results indicated that there was a probability of approximately 60 % that screening from the age of 65 years was cost-effective in both men and women . CONCLUSIONS The results of the study indicated that in terms of a screening programme for atrial fibrillation in patients 65 and over , the only strategy that improved on routine practice was opportunistic screening , model-based analyses indicated that there was a probability of approximately 60 % of annual opportunistic screening being cost effective . It is suggested that the following topics are worthy of further investigation : the effect of the implementation of a screening programme for AF on the uptake and maintenance of anticoagulation in patients aged 65 years and over ; an evaluation of the role of CDSS in the diagnosis of cardiac arrythmias ; the best method for routinely detecting paroxysmal AF ; ways of improving healthcare professionals ' performance in ECG interpretation ; development of a robust economic model to incorporate data on new therapeutic agents for use as thromboprophylactic agents for patients with AF , and an evaluation of the relative risk of stroke for patients with incident as opposed to prevalent AF BACKGROUND Atrial fibrillation  ( AF ) may occur without symptoms . Little is known about demographic features and prognostic information in patients with asymptomatic AF . METHODS In the AFFIRM study , 4060 patients were r and omized to either rhythm or rate control . At baseline , patients were identified as asymptomatic if they answered " no " to a 15-item question naire related to cardiac symptoms during AF in the 6 months before study entry . RESULTS There were 481 ( 12 % ) asymptomatic patients at baseline . Compared with symptomatic patients , asymptomatic patients were more often men and had a lower incidence of coronary artery disease and congestive heart failure , but had more cerebrovascular events . Asymptomatic patients had a longer duration of AF , a lower maximum heart rate , and better left ventricular function . They received fewer cardiac medications and fewer therapies to maintain sinus rhythm . At 5 years , there was a trend for better survival in asymptomatic patients ( 81 % vs 77 % , P = .058 ) , and they were more likely to be free from disabling stroke or anoxic encephalopathy , major bleeding , and cardiac arrest ( 79 % vs 67 % , P = .024 ) . However , mortality and major events were similar after correction for baseline differences . CONCLUSIONS Patients with asymptomatic AF have less serious heart disease but more cerebrovascular disease . Asymptomatic patients receive different therapies than symptomatic patients . However , the absence of symptoms and the differences in treatment does not confer a more favorable prognosis when differences in baseline clinical parameters are considered . Anticoagulation should be considered in these patients
target: Kardia Mobile ( AliveCor Ltd , Mountain View , CA , USA ) is the most cost-effective option in a full incremental analysis .
  Single time point lead-I ECG devices for the detection of AF in people with signs or symptoms of AF and an irregular pulse appear to be a cost-effective use of NHS re sources compared with MPP followed by a 12-lead ECG in primary or secondary care , given the assumptions used in the base-case model .
background: BACKGROUND Atrial fibrillation ( AF ) is the most common type of cardiac arrhythmia and is associated with an increased risk of stroke and congestive heart failure .
  Lead-I electrocardiogram ( ECG ) devices are h and held instruments that can be used to detect AF at a single time point in people who present with relevant signs or symptoms .
  OBJECTIVE To assess the diagnostic test accuracy , clinical impact and cost-effectiveness of using single time point lead-I ECG devices for the detection of AF in people presenting to primary care with relevant signs or symptoms , and who have an irregular pulse compared with using manual pulse palpation ( MPP ) followed by a 12-lead ECG in primary or secondary care .