Amyloid deposition as a cause of atrial remodeling in persistent valvular atrial fibrillation

left untreated. Therefore, to optimize the probability that AF patients will maintain sinus rhythm, it is important to recognize and adequately treat OSA, a common comorbid condition. FM

a combination of time to first recurrence of PAF or to discontinuation of therapy. Results: The mean time to first recurrence of PAF or discontinuation of therapy was significantly lower in the placebo arm (106 d) than in the three drug arms (146 –150 d), with no significant differences among the three active-treatment arms. The prevalence of drug-related death, syncope or ventricular tachycardia ranged from 0.8 –1.6% and did not differ significantly among the four study arms. Conclusions: The combination of Q/V is as safe and effective as sotalol for the treatment of PAF. Perspective: Many electrophysiologists stopped using quinidine for AF when class IC drugs that were better tolerated and that did not cause QT prolongation became available. It will be interesting to see whether this study, along with another recent trial demonstrating that the combination of Q/V is safer and more effective than sotalol for preventing recurrent AF after cardioversion, will result in a resurgence in the use of quinidine. If the two main drawbacks of quinidine (diarrhea and torsade de pointes) are minimized by the concomitant use of verapamil, quinidine, which is relatively inexpensive, may again become an attractive treatment option. FM

Amyloid Deposition As a Cause of Atrial Remodeling in Persistent Valvular Atrial Fibrillation Leone O, Boriani G, Chiappini B, et al. Eur Heart J 2004;25: 1237– 41. Study Question: How often is there amyloid deposition in the right and left atria of patients with chronic atrial fibrillation (AF)? Methods: Histological studies were performed on tissue samples of excised right (n⫽62) and left (n⫽66) atrial appendages from 72 patients (mean age 64 years) undergoing mitral valve surgery who had chronic AF for a mean of 4 years. Amyloid deposits were identified using Congo red stain. Fifty-two patients with no history of AF who underwent heart transplantation served as a control group. Results: Amyloid deposits were present in 46% of patients with chronic AF, compared to 12% of control patients. There was not a significant difference between the right and left atrial appendages in the prevalence of amyloid deposits. Both AF duration (odds ratio [OR] 1.02 per month) and female gender (OR 8.8) were independently associated with the presence of amyloid deposits. Conclusions: Atrial amyloidosis is common in patients with valvular chronic AF and correlates with female gender and the duration of AF. Perspective: Some investigators have hypothesized that amyloid deposition plays a role in the remodeling process in chronic AF, and that therapy aimed at preventing or reversing atrial amyloidosis might promote sinus rhythm. This hypothesis has been based on observational data such as those presented in this study. However, the correlation between AF and amyloid deposits does not necessarily imply a causal relationship, and experimental studies will be needed to determine the role of atrial amyloidosis in the generation or perpetuation of AF. FM

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest Stiell IG, Wells GA, Field B, et al. N Engl J Med 2004;351: 647–56. Study Question: What is the incremental value of advanced cardiac life support (ACLS) in a program of rapid defibrillation for out-of-hospital cardiac arrest? Methods: In this prospective, multicenter trial, outcomes following cardiac arrest, before and after the addition of ACLS to a program of rapid defibrillation, were compared. In the first 1391 patients, resuscitation focused on immediate defibrillation by the first-responders. In the next 4247 patients, advanced life support also was employed by paramedics trained in ACLS, including intubation and administration of IV drugs. The primary end point was survival to hospital discharge. Results: A defibrillator was available at the scene within 8 min after cardiac arrest in 92% of patients. Survival to hospital discharge was 5% and was not improved by the addition of ACLS to the program of rapid defibrillation. A witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and defibrillation within 8 min were all strongly associated with survival, with odds ratios of 3.4 – 4.4. Conclusions: The institution of ACLS interventions in an emergency medical-services system designed to enable rapid defibrillation does not have a measurable impact on survival after out-of-hospital cardiac arrest. Perspective: This study demonstrates that healthcare resources aimed at preventing sudden death are most effi-

Suppression of Paroxysmal Atrial Tachyarrhythmias—Results of the SOPAT Trial Patten M, Maas R, Bauer P, et al. Eur Heart J 2004;25: 1395– 404. Study Question: How safe and effective is combination therapy with quinidine ⫹ verapamil (Q/V) compared to sotalol in patients with paroxysmal atrial fibrillation (PAF)? Methods: In this multicenter study, 1033 patients (mean age 60 years) with PAF were randomly assigned to one of four study arms: (1) Q/V, 160/80 mg tid (n⫽263); (2) Q/V, 160/80 mg bid (n⫽255); (3) sotalol, 160 bid (n⫽264); (4) placebo (n⫽251). Daily rhythm recordings were obtained with a transtelephonic monitor. The primary end point was

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