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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAtrial fibrillation (AF) increases the risk of stroke, and this risk is further increased in a linear fashion with higher CHADS2 scores (representing congestive heart failure; hypertension; age =75 years; diabetes mellitus; and prior stroke, transient ischemic attack, or thromboembolism) [Crandall ME et al. \u003Cem\u003EPacing Clin Electrophysiol\u003C\/em\u003E 2009]. This article discusses catheter ablation (CA) to lower the risk of stroke in AF patients, echocardiographic contraindications for cardioversion, and the use of remote device monitoring to reduce stroke risk.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECerebrovascular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAtrial fibrillation (AF) increases the risk of stroke, and this risk is further increased in a linear fashion with higher CHADS\u003Csub\u003E2\u003C\/sub\u003E scores (representing \u003Cem\u003Ec\u003C\/em\u003Eongestive heart failure; \u003Cem\u003Eh\u003C\/em\u003Eypertension; \u003Cem\u003Ea\u003C\/em\u003Ege \u226575 years; \u003Cem\u003Ed\u003C\/em\u003Eiabetes mellitus; and prior \u003Cem\u003Es\u003C\/em\u003Etroke, transient ischemic attack, or thromboembolism) [Crandall ME et al. \u003Cem\u003EPacing Clin Electrophysiol\u003C\/em\u003E 2009]. The short- and long-term risks of stroke are lower in patients with AF who are treated with catheter ablation (CA), regardless of whether they receive anticoagulation (AC) therapy, stated John D. Day, MD, Intermountain Medical Center, Salt Lake City, Utah, USA.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EDr. Day presented an update on contemporary issues in the management of AF, including the role of CA. Although AC has been shown to reduce stroke risk, even in patients with coronary artery disease plus AF [Wyse DG et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2002], it is also associated with cerebral microbleeds (CMBs). Dr. Day raised his concern that long-term use of AC and the resulting CMBs may increase the long-term risk of developing dementia in these patients.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003ECMBs are more likely to occur with increased age and in patients on antiplatelet and AC therapy [Yates PA et al. \u003Cem\u003EFront Neurol\u003C\/em\u003E 2014]. The annual risk of CMBs in patients on warfarin therapy was 1% to 10% among 6 studies [Charidimou A et al. \u003Cem\u003EFront Neurol\u003C\/em\u003E 2012], and there is a paucity of data available regarding an association between CMBs and novel oral ACs (NOACs).\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EIn a longitudinal, observational study, patients with AF were found to have a higher risk of all forms of dementia compared with patients without AF (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Bunch TJ et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2010]. Moreover, the risk was much higher in patients aged \u0026lt;70 years (OR, 2.5 vs \u0026gt;70 years). A meta-analysis of 8 studies with 77,668 patients (15% with AF) and a mean follow-up of 7.7 years confirmed the higher risk of dementia in relation to AF (HR, 1.42; 95% CI, 1.17 to 1.72; p\u0026lt;0.001) [Santangeli P et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Atrial Fibrillation-Increased Risk of Dementia\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-752473099\u0022 data-figure-caption=\u0022Atrial Fibrillation-Increased Risk of Dementia\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15924\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EAtrial Fibrillation-Increased Risk of Dementia\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EAF=atrial fibrillation; MRI=magnetic resonance imaging.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Bunch TJ et al. Atrial fibrillation is independently associated with senile, vascular, and Alzheimer\u0027s dementia. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2010;7(4)433\u2013437. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EA single-center study with 37,908 patients showed that incidences of mortality, stroke, and dementia were lower for patients with AF who underwent CA compared with those treated medically or those who did not have AF [Bunch TJ et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2011]. Alzheimer\u0027s dementia developed in 0.2% of the CA-treated patients, compared with 0.9% of patients who received AF but no CA and 0.5% of no-AF patients (p\u0026lt;0.0001). These results are similar to others that have been presented, said Dr. Day, and confirmatory data are awaited from the Catheter Ablation Versus Antiarrhythmic Drug Therapy for Atrial Fibrillation trial [CABANA; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00911508\u0026amp;atom=%2Fspmdc%2F14%2F9%2F34.atom\u0022\u003ENCT00911508\u003C\/a\u003E] and Early Atrial Fibrillation Stroke Prevention Trial [EAST; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01288352\u0026amp;atom=%2Fspmdc%2F14%2F9%2F34.atom\u0022\u003ENCT01288352\u003C\/a\u003E].\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EECHOCARDIOGRAPHIC CONTRAINDICATIONS FOR CARDIOVERSION\u003C\/h2\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe identification of left atrial (LA) or LA appendage (LAA) thrombus by transesophageal echocardiography (TEE) is a contraindication for elective transthoracic electrical cardioversion (TEC) in patients with AF because of the risk of a thromboembolic event (TE), primarily stroke [Fuster V et al. \u003Cem\u003EEuropace\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EThrombus is defined as an echodense lesion that is present in multiple imaging planes and is clearly distinguishable from trabeculation and atrial endocardium. A thrombus is detected by TEE in 10% to 15% of patients with AF, and \u0026lt;1% of these patients have a TE after cardioversion. Ali Oto, MD, Hacettepe University, Ankara, Turkey, noted that patients with a left atrial thrombus should be treated with anticoagulation for 3 to 4 weeks and then have a repeat TEE examination to determine suitability for TEC.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EThe presence of sludge on TEE, which is defined as a dynamic and gelatinous but not solid or well-formed echodensity that is present throughout the entire cardiac cycle [Troughton RW et al. \u003Cem\u003EHeart\u003C\/em\u003E 2003], is a situation in which the physician must decide how to respond, because no studies have been conducted to determine the safety of TEC in this population. A retrospective 10-year survey of 2705 patients with AF who underwent TEE showed that the prevalence of LA or LAA sludge was approximately 2% [Yarmohammadi H et al. \u003Cem\u003EJ Am Soc Echocardiogr\u003C\/em\u003E 2012]. Furthermore, this study found no difference in the rate of TE in patients with LA or LAA thrombus or sludge as compared to patients without LA or LAA thrombus or sludge (about 4% in both groups).\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAnother finding on TEE, spontaneous echo contrast (SEC), is not a contraindication for TEC, but patients should receive prior therapeutic anticoagulation if possible, according to a review of 9 clinical studies [Patel SV, Flaker G. \u003Cem\u003EClin Cardiol\u003C\/em\u003E 2008]. SEC is defined as a swirl or smoke that is associated with low blood flow velocity [Troughton RW et al. \u003Cem\u003EHeart\u003C\/em\u003E 2003], and it has 4 grades depending on its intensity, its location, and the presence of swirling movement [Patel SV et al. \u003Cem\u003EClin Cardiol\u003C\/em\u003E 2007].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EREMOTE DEVICE MONITORING TO REDUCE STROKE RISK\u003C\/h2\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EAtrial arrhythmias recorded by cardiac implantable electronic devices (CIEDs) are an independent predictor of total mortality, stroke, and chronic AF [Glotzer TV et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2003]. Atrial high rate episodes (AHREs) were recorded in the memory of \u223c50% of CIEDs during the battery life span in this study, and most were asymptomatic. The level of AF burden that increases risk appears to vary among studies, ranging from 3.8 hours per day, associated with a 2.0% rate of TE (p=0.006) [Shanmugam N et al. \u003Cem\u003EEuropace\u003C\/em\u003E 2012], to \u22655.5 hours daily, associated with a 2.4% of TE (HR, 2.20; 95% CI, 0.96\u20135.05; p=0.06) [Glotzer TV et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E 2009]. Device-detected AHREs were associated with an increased risk of TE and stroke, regardless of the predevice history of AF [Shanmugam N et al. \u003Cem\u003EEuropace\u003C\/em\u003E 2012].\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EA risk stratification schema created by combining device-detected AHREs and clinical data provides another approach to assist in defining patients at low or high risk for stroke (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Botto GL et al. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2009]. Yet refinement of this schema with additional evidence is needed to determine when anticoagulation should be initiated, stated Renato P. Ricci, MD, S. Filippo Neri Hospital, Rome, Italy. After anticoagulation is initiated, it should not be discontinued even in the absence of device-detected AF.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Risk Stratification Schema Using Clinical Data and Device-Detected Events\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-752473099\u0022 data-figure-caption=\u0022Risk Stratification Schema Using Clinical Data and Device-Detected Events\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/9\/34\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15926\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003ERisk Stratification Schema Using Clinical Data and Device-Detected Events\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EAF=atrial fibrillation; AT=atrial tachycardia; FU=follow-up; MDT=Medtronic.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced from Botto GL et al. Presence and duration of atrial fibrillation detected by continuous monitoring: crucial implications for the risk of thromboembolic events. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2009;20(3):241\u2013248. With permission from John Wiley and Sons.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ERemote monitoring (RM) of CIEDs is being investigated to reduce TE risk. Only one randomized study has been reported, however, which was terminated early due to futility. The Combined Use of BIOTRONIK Home Monitoring and Predefined Anticoagulation to Reduce Stroke Risk study [IMPACT; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00559988\u0026amp;atom=%2Fspmdc%2F14%2F9%2F34.atom\u0022\u003ENCT00559988\u003C\/a\u003E] showed no difference at 5 years in the primary end point of first stroke, systemic embolism, or major bleed between the RM and usual-treatment patients (2.4 vs 2.3 event rate, respectively; HR, 1.06; p=0.732). The rate of major bleeding was 1.2 and 1.6, respectively, in the control (n=1361) and RM (n=1357) groups, compared with 0.1 for hemorrhagic stroke in both groups, noted Prof. Ricci. In the RM group, only 4.5% of patients who had appropriate anticoagulation (an international normalized ratio [INR] of 2 to 3) had an ischemic stroke, compared with 95.5% of those with an INR \u0026lt;2. This low stroke event rate may have limited the ability to detect a difference with remote monitoring, said Prof. Ricci. Furthermore, device-detected AF was found in only 35% to 50% of patients prior to stroke, and this was within 30 days of the stroke in only 8% to 22% of patients [Brambatti M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2014; Daoud EG et al. \u003Cem\u003EHeart Rhythm\u003C\/em\u003E 2011]; thus, this temporal dissociation is an emerging issue that must be explored.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/9\/34.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzp73h\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzp73h\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}