on Behalf of the ACE (Anticoagulation in Cardioversion using Enoxaparin) Study Group Background-Anticoagulation in cardioversion of atrial fibrillation is currently performed with unfractionated heparin (UFH) and oral anticoagulants, with or without guidance by transesophageal echocardiography (TEE). Low-molecularweight heparins may reduce the risk of bleeding, may obviate the need for intravenous access, and do not require frequent anticoagulation monitoring. Methods and Results-In a randomized, prospective multicenter trial, we compared the safety and efficacy of enoxaparin administered subcutaneously with intravenous UFH followed by the oral anticoagulant phenprocoumon in 496 patients scheduled for cardioversion of atrial fibrillation of Ͼ48 hours' and Յ1 year's duration. Patients were stratified to cardioversion with (nϭ431) and without (nϭ65) guidance by TEE. The study aimed to demonstrate noninferiority of enoxaparin compared with UFHϩphenprocoumon with regard to the incidence of embolic events, all-cause death, and major bleeding complications. Secondary end points included successful cardioversion, maintenance of sinus rhythm until study end, and minor bleeding complications. Of 496 randomized patients, 428 were analyzed per protocol. Enoxaparin was noninferior to UFHϩphenprocoumon with regard to the incidence of the composite primary end point in a per-protocol analysis (7 of 216 patients versus 12 of 212 patients, respectively; Pϭ0.016) and in an intention-to-treat analysis (7 of 248 patients versus 12 of 248 patients, respectively; Pϭ0.013). There was no significant difference between the 2 groups in the number of patients reverted to sinus rhythm. Conclusions-Enoxaparin is noninferior to UFHϩphenprocoumon for prevention of ischemic and embolic events, bleeding complications, and death in TEE-guided cardioversion of atrial fibrillation. Its easier application and more stable anticoagulation may make it the preferred drug for initiation of anticoagulation in this setting.

Objective: Slow breathing is a relaxation exercise recommended for lowering blood pressure (BP). Biofeedback may improve patient adherence and enhance BP lowering effects. Since the pulse arrival time (PAT) is inversely proportional to BP, it can be used to estimate BP changes. Approach: In this pilot study, 30 patients (age 62.9 (SD 7.7) years, 11 F/19 M, Sys. BP 133.0 (SD 17.1) mmHg, Dia. BP 83.8 (SD 10.6) mmHg) performed a device-guided slow breathing exercise. PAT was measured by ECG and plethysmography and immediately presented to the patient, and respiratory sinus arrhythmia (RSA) was calculated retrospectively to measure the adherence to the instructed respiratory rate. Main results: Respiratory rate was 13.6 (SD 1.9) bpm at baseline and 5.4 (SD 1.0) bpm during guided breathing. PAT continuously and progressively increased from 231.5 (SD 20.3) to 237.3 (SD 18.5) ms (p < 0.001). The median deviation of RSA from the guided respiratory rate was 0.06 (IQR 0.19) bpm. In three patients, a deviation of > 0.20 bpm was detected, and two of them showed no increase in PAT. In total, 25 patients responded with increase in PAT. Significance: In this pilot study we have shown that biofeedback of PAT and RSA are feasible and can further improve motivation and adherence. Furthermore, we have shown that the exercise increased PAT, which indicates a reduction in BP. Due to its ease of use, this method is ideal for home use and self-monitoring.