Clinical outcomes, management, healthcare resource utilization, and cost according to the CHA2DS2-VASc scores in Asian patients with nonvalvular atrial fibrillation

BACKGROUND

The prognosis among non-valvular atrial fibrillation (NVAF) patients with different CHA2DS2-VASc scores in the contemporary Asian population remains unclear. Additionally, there is a lack of research examining the disparities in management patterns, healthcare resource utilization (HCRU), and cost among these patients.

METHODS AND RESULTS

This retrospective cohort study assessed patients diagnosed with NVAF between January 2018 and July 2022. Patients were stratified into 3 cohorts by CHA2DS2-VASc scores: low-risk, intermediate-risk, and high-risk. One-year incidence rates and cumulative incidence of clinical outcomes (including ischemic stroke [IS], transient ischemic attack [TIA], arterial embolism [AE], and major bleeding [MB]) were calculated. Management patterns, HCRU, and cost were analyzed descriptively. Among 419,490 NVAF patients (mean age: 75.2 years, 45.1 % female), 16,541 (3.9 %) were classified as low-risk, 38,494 (9.2 %) as intermediate-risk, and 364,455 (86.9 %) as high-risk. The one-year incidence rates for IS, TIA, AE, and MB were 12.4 (95 % CI, 12.3-12.5), 1.1 (95 % CI, 1.0-1.1), 0.5 (95 % CI, 0.5-0.5), and 3.1 per 100 person-years (95 % CI, 3.1-3.2), with an increasing trend from the low-risk to the high-risk group, respectively. During follow-up, 16.4 % and 11.1 % of patients in the low-risk and high-risk cohorts received oral anticoagulants (OACs), respectively. In addition, significant differences in HCRU and cost were observed in these three cohorts.

CONCLUSION

This study demonstrates that contemporary Asian NVAF patients with higher CHA2DS2-VASc scores experience higher incidence of adverse outcomes and increased hospital resource consumption. Additionally, suboptimal management was present across all CHA2DS2-VASc score groups.

Validity of a smartwatch for detecting atrial fibrillation in patients after heart valve surgery: a prospective observational study

OBJECTIVES

Atrial fibrillation (AF) is a common early arrhythmia after heart valve surgery that limits physical activity. We aimed to evaluate the criterion validity of the Apple Watch Series 5 single-lead electrocardiogram (ECG) for detecting AF in patients after heart valve surgery.

DESIGN

We enrolled 105 patients from the University Hospital of North Norway, of whom 93 completed the study. All patients underwent single-lead ECG using the smartwatch three times or more daily on the second to third or third to fourth postoperative day. These results were compared with continuous 2-4 days ECG telemetry monitoring and a 12-lead ECG on the third postoperative day.

RESULTS

On comparing the Apple Watch ECGs with the ECG monitoring, the sensitivity and specificity to detect AF were 91% (75, 100) and 96% (91, 99), respectively. The accuracy was 95% (91, 99). On comparing Apple Watch ECG with a 12-lead ECG, the sensitivity was 71% (62, 100) and the specificity was 92% (92, 100).

CONCLUSION

The Apple smartwatch single-lead ECG has high sensitivity and specificity, and might be a useful tool for detecting AF in patients after heart valve surgery.

The bidirectional relationship between obstructive sleep apnea and atrial fibrillation: Pathophysiology, diagnostic challenges, and strategies - A narrative review

Atrial fibrillation (AF), is an irregular heart rhythm disorder that increases the risk of stroke, heart failure, and death. Obstructive sleep apnea is typified by intermittent airway blockages which results in low oxygen levels and disrupted sleep. These two conditions often coexist, with each worsening the other. Understanding this connection is critical to improve diagnosis and treatment. The relationship between atrial fibrillation and obstructive sleep apnea appears bidirectional. Obstructive sleep apnea increases the risk of atrial fibrillation through various mechanisms which are arrhythmogenic. Conversely, patients with atrial fibrillation are more likely to have undiagnosed obstructive sleep apnea, complicating their treatment. Screening modalities for obstructive sleep apnea are often inadequate. Polysomnography remains the most reliable tool but is costly and not practical for routine screening of all patients which limits early diagnosis and management. Continuous positive airway pressure (CPAP) therapy is the primary treatment for obstructive sleep apnea and can reduce atrial fibrillation recurrence by decreasing oxygen deprivation and sympathetic activity. However, adherence to continuous positive airway pressure is often low due to patient discomfort. Alternative therapies, such as mandibular advancement devices and hypoglossal nerve stimulation, offer promising options for patients who cannot tolerate continuous positive airway pressure. The interplay between atrial fibrillation and obstructive sleep apnea requires an integrated approach to diagnosis and treatment. Improving screening tools, enhancing treatment adherence, and evaluating alternative therapies are critical steps to reducing the impact of these conditions and improving patient outcomes.

Delayed diagnosis and missed opportunities in the early detection of atrial fibrillation: a cross-sectional study

INTRODUCTION

We analysed the frequency of atrial fibrillation (AF) delayed diagnosis and the factors associated with it in newly diagnosed patients.

METHODS

This was a descriptive, cross-sectional, multicentre study. Data were collected from newly diagnosed patients with AF through medical records review and interviews during cardiology, internal medicine, primary care and emergency department consultations in Spain.

RESULTS

A total of 201 physicians participated in the study (64.2% cardiologists, 21.4% internists). 948 patients (58% men; mean age 72.8 years) were included. In 41.8% of patients, AF was classified as paroxysmal at diagnosis, 30.9% as persistent and 27.3% as permanent. The diagnosis was coincidental in 37%. It was considered that a delayed diagnosis occurred in 49.3% of patients. This delay was associated with the presence of permanent or persistent AF, older age or valvular disease. 74.8% of patients had some contact with the healthcare system in the preceding year. The diagnosis could have been established between 1 and 6 months earlier in 50.7% of cases and more than six months earlier in 20.1%. 54.4% of the patients had experienced AF compatible symptomatology previously. Of these, 32.6% had a consultation without a diagnosis.

CONCLUSIONS

In a significant proportion of AF cases, there is a diagnostic delay. Many people with compatible symptoms neither seek consultations nor contact the healthcare system facilities. Consequently, the opportunity for early diagnosis is lost.

Atrial fibrillation and flutter and ocular diseases. The Ural eye and medical study and the Ural very old study

PURPOSE

To assess associations between atrial fibrillation/atrial flutter (AF) and ocular parameters and diseases.

METHODS

The population-based Ural Eye and Medical Study (UEMS) and the Ural Very Old Study (UVOS) included 4894 individuals (age: 40+ years) and 835 individuals (age: 85+ years), respectively.

RESULTS

In the UEMS, AF prevalence (80/4894; 1.6%; 95% CI: 1.3, 2.0) increased from 1/1029 (0.1%) in the age group of 40 to <50 years to 29/619 (4.7%) and 12/159 (7.5%) in the age groups of 70 to <80 years and 80+ years, respectively. Higher AF prevalence correlated with older age (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), urban region of habitation (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), higher prevalence of cardiovascular disease/stroke (OR: 2.50; 95% CI: 1.32, 4.72; p < 0.001) and lower prevalence of neck pain (OR: 0.35; 95% CI: 0.14, 0.85; p = 0.02), higher serum concentration of bilirubin (OR: 1.03; 95% CI: 1.02, 1.05; p < 0.001) and lower prothrombin index (OR: 0.96; 95% CI: 0.93, 0.99; p = 0.003), higher stage of arterial hypertension (OR: 1.52; 95% CI: 1.01, 2.28; p = 0.04) and higher ankle-brachial index (OR: 22.1; 95% CI: 4.45, 1.10; p < 0.001). In that model, AF prevalence was not associated with ocular parameters such as intraocular pressure (p = 0.52), retinal nerve fibre layer thickness (p = 0.70), refractive error (p = 0.13), axial length (p = 0.14), nuclear cataract degree (p = 0.50) and prevalence (p = 0.40), cortical cataract degree (p = 0.43) and presence (p = 0.17), lens pseudoexfoliation (p = 0.58), status after cataract surgery (p = 0.38), age-related macular degeneration prevalence (p = 0.63), open-angle glaucoma presence (p = 0.90) and stage (p = 0.55), angle-closure glaucoma prevalence (p = 0.99) and stage (p = 0.99), diabetic retinopathy prevalence presence (p = 0.37) and stage (p = 0.32), and myopic macular degeneration (p = 0.98). In the UVOS, similar results were obtained.

CONCLUSIONS

In these multi-ethnic populations from Russia, AF prevalence was not associated with any major ocular disease and may not play a major role in the pathogenesis of these disorders.

The burden of atrial fibrillation on emergency medical services: A population-based cohort study

BACKGROUND

Atrial fibrillation (AF) is a growing burden on healthcare resources, despite improvements in prevention and management. AF is a common cause of hospitalisation, and Emergency Medical Services (EMS) use. However, there is a paucity of data describing the burden of AF on EMS. We aimed to determine the prevalence, characteristics, and outcomes of patients presenting with AF to EMS using a large population-based sample.

METHODS

Consecutive attendances for AF in Victoria, Australia (January 2015-June 2019) were included if patients had a diagnosis of "AF" or "arrhythmia" with AF on electrocardiogram. Data were individually linked to emergency, hospital, and mortality records.

RESULTS

Of 2,613,056 EMS attendances, 16,525 were a first attendance for AF and linked to hospital records. Median (IQR) age was 76 (67,84) years (43% female). Seventy-eight percent had high thromboembolic risk (CHA2DS2-VASc score ≥ 2), and 72% had a heart rate ≥ 100 bpm. Forty-two percent of patients received no treatment by paramedics and 99.4% were transported to hospital. Fifty-three percent were discharged from ED. Median length of hospital stay was 2 days. Of 2542 cases reattended for AF, 19% occurred within 30 days, with increased odds for females and those of low socioeconomic status. Overall, 24% died during the study period, 12% within 30 days. Increasing age, heart failure, stroke, COPD, and low socioeconomic status increased the odds of 30-day mortality.

CONCLUSIONS

EMS utilisation for AF is common and associated with frequent reattendance. Further studies are required to investigate novel pathways of care to reduce AF burden on healthcare systems.

Prevalence of Atrial Fibrillation in Semiurban Nepal: Result From a Community-Based Cross-Sectional Screening

Background: Atrial fibrillation (AF) is a common morbid arrhythmia that can cause thromboembolic events such as stroke. Despite advancements in diagnostic technologies, a significant number of AF patients may remain undetected and undiagnosed, and these asymptomatic patients possess sufficient risk of cardioembolic stroke. Identifying such patients through appropriate screening techniques and timely initiation of systemic anticoagulation therapy is essential to prevent such life-threatening complications. Objectives: The objectives of this study encompass screening of AF among residents of the Dhulikhel Municipality and identifying its prevalence, along with evaluation of stroke risk and use of antithrombotic therapy in patients confirmed with AF. Methods: All residents of four wards of Dhulikhel Municipality, aged 50 years and above (n = 2048), underwent one-time electrocardiogram (ECG) screening using a portable 12-lead ECG machine. The cardiologist checked the cardiogram, and suspected AF cases were referred to the hospital for further evaluation and appropriate management. They were followed up to find out information on disease confirmation and management. Results: Out of 2048 participants, AF was detected in 16 participants, resulting in an overall prevalence of 0.78% (CI 0.4%-1.3%). The prevalence of AF was highest (2.98%) in population aged 80 years and above. Among individuals with AF, the median age was 71.5 (66.3-79.5) years, 50.0% were male and 75.0% had high stroke risk as indicated by a CHA2DS2-VASc score ≥ 2. Among these patients, only 41.66% were treated with oral anticoagulants (OACs), while 58.34% were treated either with single or dual antiplatelet therapy (DAPT). Conclusion: This study provided important insight into the prevalence of AF at the community level. Many AF patients were at high risk of stroke, but the OAC use was less than 50%. Screening of AF needs to be carried out on a larger scale in Nepal for early detection and timely management of the disease.

Frailty prevalence in older adults with atrial fibrillation: A cross-sectional study in a resource-limited setting

BACKGROUND/OBJECTIVES

Frailty is a common condition among older adults and is associated with an increased risk of adverse health outcomes, including mortality, disability, dysmobility, falls, and hospitalization. In patients with atrial fibrillation (AF), these risks are further exacerbated. However, evidence linking AF and frailty, particularly in the South American context, is limited. This study aimed to assess frailty and other geriatric conditions in older outpatients with atrial fibrillation in a resource-limited setting in Lima, Peru.

METHODS

In this cross-sectional study, we included adults aged 60 years and older diagnosed with atrial fibrillation who were attending outpatient check-ups. Patients who were hospitalized, receiving chemotherapy induction, or presenting with acute infections or exacerbations were excluded. Standardized questionnaires were used to assess frailty, cognitive impairment, and functional dependence. Statistical analysis was performed using R Studio version 4.3.1, with a significance level set at p < 0.05.

RESULTS

Among the 200 patients who agreed to participate (mean age 74.76 ± 8.42 years, 41% females), 28.5% exhibited frailty, and 46.5% were classified as prefrail. Frailty and prefrailty were significantly associated with older age (p<0.01), female gender (p = 0.01), illiteracy (p<0.01), heart failure (p<0.01), falls (p<0.05), cognitive impairment (p<0.01), and functional dependence (p<0.01). Multivariate analysis revealed significant associations between frailty and cognitive impairment (p<0.05), frailty and functional dependence (p<0.05), and cognitive impairment and functional dependence (p<0.05).

CONCLUSIONS

One-third of older outpatients with atrial fibrillation were identified as frail, while half were classified as prefrail. In this population, frailty frequently coexists with cognitive impairment and functional dependence, highlighting the need for timely screening and the implementation of evidence-based interventions for individuals with atrial fibrillation in resource-limited settings.

Kidney function, uric acid, and risk of atrial fibrillation: experience from the AMORIS cohort

BACKGROUND

Uric acid closely relates to both kidney disease and atrial fibrillation (AF), yet the extent to which it influences the kidney-AF association remains uncertain. We examined the relationship between kidney function and risk of AF, accounting for uric acid levels.

METHODS

A total of 308,509 individuals in the Swedish Apolipoprotein-Related Mortality Risk (AMORIS) cohort were included and their serum creatinine and uric acid were measured during 1985-1996. Ten-year incident AF was identified via linkage with the national registers. Glomerular filtration rate (eGFR) (ml/min/1.73 m2) was calculated with the 2009 Chronic Kidney Disease Epidemiology Collaboration equation. Hyperuricemia was defined as > 420 µmol/L for men and > 360 µmol/L for women.

RESULTS

Over a mean follow-up of 9.4 years, 10,007 (3.2%) incident AF cases occurred. After adjusting for age, sex, cardiovascular diseases, total cholesterol, triglycerides, and glucose, individuals with low eGFR (< 30 and 30-59 ml/min/1.73 m2 ) had a higher risk of AF compared to those with normal eGFR (60-89) (hazard ratio (HR) = 1.72, 95% confidence interval (CI):1.29-2.30; HR = 1.10, 95% CI: 1.03-1.18, respectively). After further adjusting for uric acid levels, the association disappeared (HR = 0.97, 95% CI: 0.72-1.30; HR = 0.93, 95% CI: 0.86-1.00, respectively). When stratifying by hyperuricemia yes/no, eGFR < 30 ml/min/1.73 m2 was associated with higher AF risk in a small group of individuals without hyperuricemia (HR = 2.58, 95% CI: 1.64-4.07).

CONCLUSION

Uric acid largely accounted for the relationship between eGFR and AF in this study. However, in individuals without hyperuricemia, eGFR in the lowest range (< 30 ml/min/1.73 m2) was still associated with increased risk of AF.

Causal effect of vascular endothelial growth factor on the risk of atrial fibrillation: a two-sample Mendelian randomization study

Background

Observational studies have found that vascular endothelial growth factor (VEGF) levels are associated with the risk of cardiovascular disease. However, it remains unclear whether VEGF levels have a causal effect on the risk of atrial fibrillation.

Methods

A two-sample Mendelian randomization (MR) study was conducted to explore the causal relationship between VEGF levels and the risk of atrial fibrillation. Genetic variants associated with VEGF [VEGF-A, VEGF-C, VEGF-D, VEGF receptor-2 (VEGFR-2), VEGFR-3] and atrial fibrillation (atrial fibrillation, atrial fibrillation and flutter) were used as instrumental variables. Data on genetic variants were obtained from published genome-wide association studies (GWAS) or the IEU Open GWAS project. Inverse-variance weighted (IVW) analysis was used as the primary basis for the results, and sensitivity analyses were used to reduce bias. Causal relationships were expressed as odds ratio (OR) with 95% confidence interval (CI), and a P-value of <0.1 corrected for False Discovery Rate (FDR) (PFDR  < 0.1) was considered to have a significant causal relationship.

Results

Genetically predicted high levels of VEGF-A [OR = 1.025 (95%CI: 1.004-1.047), PFDR  = 0.060] and VEGF-D [OR = 1.080 (95%CI: 1.039-1.123), PFDR  = 0.001]] were associated with an increased risk of atrial fibrillation, while no causal relationship was observed between VEGF-C (PFDR  = 0.419), VEGFR-2 (PFDR  = 0.784), and VEGFR-3 (PFDR  = 0.899) and atrial fibrillation risk. Moreover, only genetically predicted high levels of VEGF-D [OR = 1.071 (95%CI: 1.014-1.132), PFDR  = 0.087] increased the risk of atrial fibrillation and flutter. Sensitivity analysis demonstrated that the relationship between VEGF-D levels and the risk of atrial fibrillation was robust.

Conclusion

This study supports a causal association between high VEGF-D levels and increased risk of atrial fibrillation.

Multi-physics simulations reveal hemodynamic impacts of patient-derived fibrosis-related changes in left atrial tissue mechanics

Stroke is a leading cause of death and disability worldwide. Atrial myopathy, including fibrosis, is associated with an increased risk of ischemic stroke, but the mechanisms underlying this association are poorly understood. Fibrosis modifies myocardial structure, impairing electrical propagation and tissue biomechanics, and creating stagnant flow regions where clots could form. Fibrosis can be mapped non-invasively using late gadolinium enhancement magnetic resonance imaging (LGE-MRI). However, fibrosis maps are not currently incorporated into stroke risk calculations or computational electro-mechano-fluidic models. We present multi-physics simulations of left atrial (LA) myocardial motion and hemodynamics using patient-specific anatomies and fibrotic maps from LGE-MRI. We modify tissue stiffness and active tension generation in fibrotic regions and investigate how these changes affect LA flow for different fibrotic burdens. We find that fibrotic regions and, to a lesser extent, non-fibrotic regions experience reduced myocardial strain, resulting in decreased LA emptying fraction consistent with clinical observations. Both fibrotic tissue stiffening and hypocontractility independently reduce LA function, but together, these two alterations cause more pronounced effects than either one alone. Fibrosis significantly alters flow patterns throughout the atrial chamber, and particularly, the filling and emptying jets of the left atrial appendage (LAA). The effects of fibrosis in LA flow are largely captured by the concomitant changes in LA emptying fraction except inside the LAA, where a multi-factorial behavior is observed. This work illustrates how high-fidelity, multi-physics models can be used to study thrombogenesis mechanisms in patient-specific anatomies, shedding light onto the links between atrial fibrosis and ischemic stroke.

Key points

Left atrial (LA) fibrosis is associated with arrhythmogenesis and increased risk of ischemic stroke; its extent and pattern can be quantified on a patient-specific basis using late gadolinium enhancement magnetic resonance imaging.Current stroke risk prediction tools have limited personalization, and their accuracy could be improved by incorporating patient-specific information like fibrotic maps and hemodynamic patterns.We present the first electro-mechano-fluidic multi-physics computational simulations of LA flow, including fibrosis and anatomies from medical imaging. Mechanical changes in fibrotic tissue impair global LA motion, decreasing LA and left atrial appendage (LAA) emptying fractions, especially in subjects with higher fibrosis burdens. Fibrotic-mediated LA motion impairment alters LA and LAA flow near the endocardium and the whole cavity, ultimately leading to more stagnant blood regions in the LAA.

Identification of senescence-related genes for potential therapeutic biomarkers of atrial fibrillation by bioinformatics, human histological validation, and molecular docking

Background

Cellular senescence is pivotal in the occurrence and progression of atrial fibrillation (AF). This study aimed to identify senescence-related genes that could be potential therapeutic biomarkers for AF.

Methods

AF-related differentially expressed genes (DEGs) were identified using the Gene Expression Omnibus dataset. Weighted gene co-expression network analysis (WGCNA) was used to analyze important modules and potential hub genes. Integrating senescence-related genes, potential biomarkers were identified. Their differential expression levels were then validated in human atrial tissue, HL-1 cells, and Angiotensin II-infused mice. Finally, molecular docking analysis was conducted to predict potential interactions between potential biomarkers and the senolytic drug Navitoclax.

Results

We identified seven genes common to AF-related DEGs and senescence-related genes. Three significant modules were selected from WGCNA analysis. Taken together, three senescence-related genes (ETS1, SP1, and WT1) were found to be significantly associated with AF. Protein-protein interaction network analysis revealed biological connections among the predicted target genes of ETS1, SP1, and WT1. Notably, ETS1, SP1, and WT1 exhibited significant differential expression in clinical samples as well as in vitro and in vivo models. Molecular docking revealed favorable binding affinity between senolytic Navitoclax and these potential biomarkers.

Conclusions

This study highlights ETS1, SP1, and WT1 as crucial senescence-related genes associated with AF, offering potential therapeutic targets, with supportive evidence of binding affinity with senolytic Navitoclax. These findings provide novel insights into AF pathogenesis from a senescence perspective.

Epidemiology and clinical implications of atrial fibrillation among stroke patients in Ethiopia: a comprehensive systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is a significant risk factor for stroke, imposing a substantial burden on healthcare systems. While studies have shown varying AF prevalence among stroke patients, limited pooled data exists in low-resource settings like Ethiopia. This hinders our understanding of the problem's extent and limits effective prevention and management strategies. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence of atrial fibrillation among stroke patients in Ethiopia.

METHODS

The searches were carried out in electronic databases such as PubMed/MEDLINE, EMBASE, Science Direct, Web of Science, and Google Scholar. Observational study designs were selected, and studies published until 30 November 2023 addressing the prevalence of atrial fibrillation among stroke patients were identified. Endnote citation manager software version X9 for Windows was used to collect and organize the search outcomes and remove duplicate articles. The relevant data were extracted from the included studies using a format prepared in Microsoft Excel and exported to STATA 18.0 software for the outcome measures analyses and subgrouping.

RESULTS

Twenty-three research articles were included in the final analysis. These studies evaluated a total of 4,544 stroke patients, of whom 529 were diagnosed with atrial fibrillation (AF). The overall pooled prevalence of AF among stroke patients was 13% [95% CI: (10%, 17%)]. Subgroup analysis by region revealed that the highest pooled prevalence of AF was 16% [95% CI: (8%, 25%)] in the Amhara region, followed by the Oromia region at 15% [95% CI: (7%, 23%)]. In Addis Ababa City, the pooled prevalence of AF among stroke patients was 11% [95% CI: (7%, 15%)]. The Tigray region reported a pooled prevalence of 9% [95% CI: (6%, 11%)]. However, one study from the Southern Nations, Nationalities, and Peoples' Region reported a lower prevalence of AF among stroke patients at 7% [95% CI: (3%, 11%)].

CONCLUSION

In summary, the study revealed that AF is prevalent among stroke patients in Ethiopia, with regional differences in prevalence. The high prevalence of AF emphasizes the necessity for effective management strategies to prevent recurrent strokes.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD: CRD42024581661.

Associations of socioeconomic status and chronic stress with incident atrial fibrillation among older adults: A prospective cohort study from the UK biobank

BACKGROUND

This study aimed to assess the relationship between socioeconomic status (SES) and chronic stress on the incidence of atrial fibrillation (AF) in older adults, and the potential role of chronic stress in the association.

METHODS

This study included 122,494 UK Biobank participants aged ≥60 years without AF at baseline. Latent class analysis was used to define the SES of participants. Chronic stress was measured using allostatic load (AL), and participants were categorized into low, medium and high AL groups. The Cox proportional hazards model, mediation, and interaction analyses were conducted to investigate the associations between SES, AL, and AF risk.

RESULTS

Low SES (hazard ratio [HR]: 1.10; 95 % confidence interval [CI]: 1.04-1.15) and high AL (HR: 1.37; 95 % CI: 1.30-1.45) were associated with an increased risk of AF, respectively. Individuals in the low SES and high AL groups exhibited the highest risk of AF compared to those in the high SES and low AL groups (HR: 1.46; 95 % CI: 1.32-1.61). We identified additive and multiplicative interactions in the low SES and high AL groups (relative risk due to interaction: 0.12 (95 % CI: 0.02-0.22); P for interaction = 0.0385). AL also exerted a partial mediating effect on the association between SES and the incidence of AF (mediation proportion: 17.3 %; 95 % CI: 5.9-28.7 %).

CONCLUSIONS

Our study revealed significant associations between SES, chronic stress, and the incidence of AF in older adults. Chronic stress was also shown to partially mediate the association.

Left atrial appendage occlusion devices vs direct oral anticoagulants for atrial fibrillation: An updated systematic review and meta-analysis

BACKGROUND

Direct Oral Anticoagulants (DOACs) are the first line anticoagulation for patients with non-valvular atrial fibrillation (NVAF). Percutaneous Left Atrial Appendage Occlusion (LAAO) has emerged as a new therapy and its safety and effectiveness compared with DOACs are still controversial.

METHODS

A systematic review of randomized controlled trials and observational studies was conducted, focusing on patients with NVAF. Outcomes analyzed included: (1) all-cause mortality; (2) cardiovascular (CV) mortality; (3) thromboembolic events; (4) stroke or transient ischemic attack (TIA); (5) bleeding events; and a (6) composite of death, hemorrhagic, and thromboembolic events. We performed a subgroup analysis of major bleeding according to different definitions: (1) Bleeding Academic Research Consortium (BARC); (2) International Society on Thrombosis and Haemostasis (ISTH); and (3) other definitions.

RESULTS

Ten studies involving 18,507 patients were included, with 42.35 % undergoing LAAO. In pooled analysis, LAAO was associated with lower rates of all-cause mortality (HR 0.63; 95 % CI 0.50-0.80), cardiovascular mortality (HR 0.56; 95 % CI 0.45-0.70), and of the composite outcome (HR 0.73; 95 % CI 0.58-0.92). A trend towards lower stroke/TIA events was observed but not statistically significant. Overall bleeding events did not significantly differ between groups; using the ISTH definition, LAAO showed significantly lower incidence of bleeding events (HR 0.63; 95 % CI 0.43-0.91). No difference was found in thromboembolic events.

CONCLUSION

LAAO was associated with a significantly lower all-cause mortality and cardiovascular mortality, as well as the composite of death, hemorrhagic or thromboembolic events, as compared with DOACs.

Effectiveness of a Triple Antiarrhythmic Drug Strategy for Arrhythmia Recurrence after Persistent Atrial Fibrillation Ablation

BACKGROUND AND OBJECTIVE

Treating recurrent atrial arrhythmias after persistent atrial fibrillation (PeAF) ablation is often challenging. This single-center, prospective study aimed to observe the effectiveness of different combinations of oral antiarrhythmic drugs (AADs) in reverting to sinus rhythm (SR) in patients with recurrent atrial arrhythmias after PeAF ablation.

METHODS

Forty-five patients who experienced recurrent atrial arrhythmias after PeAF ablation were included. Based on their medication regimens, patients were divided into two groups, with the study group being a triple-drug group (digoxin combined with amiodarone/ propafenone and β-blocker), and the control group being a non-triple-drug group.

RESULTS

The rate of reversion to SR was significantly higher in the study group (n = 29) than in the control group (n = 16) at 3 weeks (34.48% vs. 0%, p < 0.01) and 1 month (44.84% vs. 6.25%, p = 0.02) after initiating AADs. No patients with asymptomatic bradycardia were observed in either group.

CONCLUSIONS

For patients with recurrent atrial arrhythmias after PeAF ablation, a regimen of low-dose digoxin combined with amiodarone/propafenone and β-blocker may effectively improve short-term reversion rates.

Considering User Experience and Behavioral Approaches in the Design of mHealth Interventions for Atrial Fibrillation: Systematic Review

BACKGROUND

Atrial fibrillation (AF) is a leading chronic cardiac disease associated with an increased risk of stroke, cardiac complications, and general mortality. Mobile health (mHealth) interventions, including wearable devices and apps, can aid in the detection, screening, and management of AF to improve patient outcomes. The inclusion of approaches that consider user experiences and behavior in the design of health care interventions can increase the usability of mHealth interventions, and hence, hopefully, yield an increase in positive outcomes in the lives of users.

OBJECTIVE

This study aims to show how research has considered user experiences and behavioral approaches in designing mHealth interventions for AF detection, screening, and management; the phases of designing complex interventions from the UK Medical Research Council (MRC) were referenced: namely, identification, development, feasibility, evaluation, and implementation.

METHODS

Studies published until September 7, 2022, that examined user experiences and behavioral approaches associated with mHealth interventions in the context of AF were extracted from multiple databases. The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were used.

RESULTS

A total of 2219 records were extracted, with only 55 records reporting on usability, user experiences, or behavioral approaches more widely for designing mHealth interventions in the context of AF. When mapping the studies onto the phases of the UK MRC's guidance for developing and evaluating complex interventions, the following was found: in the identification phase, there were significant differences between the needs of patients and health care workers. In the development phase, user perspectives guided the iterative development of apps, interfaces, and intervention protocols in 4 studies. Most studies (43/55, 78%) assessed the usability of interventions in the feasibility phase as an outcome, although the data collection tools were not designed together with users and stakeholders. Studies that examined the evaluation and implementation phase entailed reporting on challenges in user participation, acceptance, and workflows that could not be captured by studies in the previous phases. To realize the envisaged human behavior intended through treatment, review results highlight the scant inclusion of behavior change approaches for mHealth interventions across multiple levels of sociotechnical health care systems. While interventions at the level of the individual (micro) and the level of communities (meso) were found in the studies reviewed, no studies were found intervening at societal levels (macro). Studies also failed to consider the temporal variation of user goals and feedback in the design of long-term behavioral interventions.

CONCLUSIONS

In this systematic review, we proposed 2 contributions: first, mapping studies to different phases of the MRC framework for developing and evaluating complex interventions, and second, mapping behavioral approaches to different levels of health care systems. Finally, we discuss the wider implications of our results in guiding future mHealth research.

Sex- and age-specific differences in the use of antiarrhythmic therapies among atrial fibrillation patients: a nationwide cohort study

AIMS

Atrial fibrillation (AF) patients frequently require active rhythm control therapy to maintain sinus rhythm and reduce symptom burden. Our study assessed whether antiarrhythmic therapies (AATs) are used disproportionately between men and women after new-onset AF.

METHODS AND RESULTS

The nationwide Finnish anticoagulation in AF registry-based linkage study covers all patients with new-onset AF in Finland during 2007-2018. Study outcomes included initiation of AATs in the form of antiarrhythmic drugs (AADs), cardioversion, or catheter ablation. The study population constituted of 229 565 patients (50% females). Women were older than men (76.6 ± 11.8 vs. 68.9 ± 13.4 years) and had higher prevalence of hypertension or hyperthyroidism, but lower prevalence of vascular disease, diabetes, renal disease, and cardiomyopathies than men. Overall, 17.6% of women and 25.1% of men were treated with any AAT. Women were treated with AADs more often than men in all age groups [adjusted subdistribution hazard ratio (aSHR) 1.223, 95% confidence interval (CI) 1.187-1.261]. Cardioversions were also performed less often on women than on men aged <65 years (aSHR 0.722, 95% CI 0.695-0.749), more often in patients ≥ 75 years (aSHR 1.166, 95% CI 1.108-1.227), while no difference between the sexes existed in patients aged 65-74 years. Ablations were performed less often in women aged <65 years (aSHR 0.908, 95% CI 0.826-0.998) and ≥75 years (aSHR 0.521, 95% CI 0.354-0.766), whereas there was no difference in patients aged 65-74 years.

CONCLUSION

Women used more AAD than men in all age groups but underwent fewer cardioversion and ablation procedures when aged <65 years.

Atrial Fibrillation Surgery in Australia: Are We Doing Enough?

AIM

This study aimed to examine contemporary burden and treatment trends of atrial fibrillation (AF) in patients undergoing cardiac surgery in Australia and New Zealand. This allows comparison of contemporary practice with the Society of Thoracic Surgeons guideline recommendations for the surgical treatment of AF in patients undergoing cardiac surgery.

METHOD

A 10-year retrospective review of the Australian & New Zealand Society of Cardiac & Thoracic Surgeons National Cardiac Surgery Database was performed, examining all adult cardiac surgery patients from 2011 to 2021. Patients were grouped by the presence or absence of AF, and simple descriptive statistical analysis was performed to assess baseline demographics and premorbid condition of the patients. The incidence of AF was analysed by type of surgery. Trends for surgical treatment of AF were then analysed using simple descriptive statistics, examining isolated left atrial appendage ligation, isolated surgical ablation, and combined ligation and ablation.

RESULTS

In the last 10 years, the Australian & New Zealand Society of Cardiac & Thoracic Surgeons database has recorded 140,680 patients who underwent cardiac surgery. Atrial fibrillation (AF) was present in 21,077 patients (14%). Patients with AF were generally older (72.25 vs 66.65 years; p<0.001). Among patients undergoing cardiac surgery, AF was more common in female than in male patients (18% vs 13%, respectively). Patients with AF more often had a higher classification of dyspnoea according to the New York Heart Association and lower ejection fractions compared with their AF-free counterparts. The incidence of AF as a comorbid condition was more frequent in patients undergoing mitral valve surgery or combined coronary artery bypass grafting and valve surgery (aortic, mitral, or both) compared with those undergoing isolated coronary or aortic surgery. Only 11.90% (n=2,509) of patients with AF received a combined ablation and left atrial appendage ligation, and 19.54% (n=693) of those received a Cox-Maze IV ablation.

CONCLUSIONS

The burden of concomitant AF in patients undergoing cardiac surgery in Australia is higher than previously reported (14% vs 5%-11%). Despite strong recommendation for the surgical management of AF in patients undergoing cardiac surgery and clear evidence of its benefit, both left atrial appendage ligation and surgical ablation independently or concomitantly remain heavily underutilised in this cohort.

Prevalence and outcomes of heart failure phenotypes in patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is common in patients with heart failure (HF). Real-world data about long-term outcomes and rhythm control interventions use in AF patients with and without HF remain scarce.

METHODS

AF patients from two prospective, multicentre studies were classified based on the HF status at baseline into: HF with preserved ejection fraction (HFpEF), HF with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF), and no HF. The prespecified primary outcome was risk of HF hospitalisation. Other outcomes of interest included mortality, cardiovascular events, AF progression, and quality of life.

RESULTS

A total of 1265 patients with AF were analysed (mean age 69.6 years, women 27.4%) with a median follow-up of 5.98 years. Patients with HFpEF (n = 126) had a 2.69-fold and patients with HFrEF/HFmrEF (n = 308) had a 2.12-fold increased risk of HF hospitalisation compared to patients without HF (n = 831, p < 0.001). Similar results applied for all-cause and cardiovascular mortality. The risk for AF progression was higher for patients with HFpEF and HFrEF/HFmrEF (6.30 and 6.79 per 100 patient-years, respectively) compared to patients without HF (4.20). The use of rhythm control strategies during follow-up was least in the HFpEF population (4.56 per 100 patient-years) compared to 7.74 in HFrEF/HFmrEF and 8.03 in patients with no HF. With regards to quality of life over time, this was worst among HFpEF patients.

CONCLUSIONS

The presence of HFpEF among patients with AF carried a high risk of HF hospitalisations and AF progression, and worse quality of life. Rhythm control interventions were rarely offered to HFpEF patients. These results uncover an unmet need for enhanced therapeutic interventions in patients with AF and HFpEF.

Managing elderly patients with atrial fibrillation and multimorbidity: call for a systematic approach

INTRODUCTION

Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management, and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management.

AREAS COVERED

This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management.

EXPERT OPINION

Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.

INFORM-AF II-Phase 1 pilot randomised controlled trial evaluating the effect of an atrial fibrillation digital education programme: study protocol

AIM

To evaluate the effect of a novel, co-designed, digital AF educational program, 'INFORM-AF', to reduce re-hospitalisation of people with AF. The secondary aims are to examine the effect of the intervention on: (a) reducing cardiovascular-related hospitalisation, (b) increasing medication adherence, AF-related knowledge, and Atrial fibrillation (AF)-related quality of life and (c) determining the cost-effectiveness of the intervention.

BACKGROUND

AF is an increasingly prevalent cardiac arrythmia that involves complex clinical management. Comprehensive education is essential for successful self-management of AF and is associated with positive health-related outcomes. There has been an increase in technology-based education for AF. However, its effects on hospitalisation, medication adherence and patient-reported outcomes are unclear.

DESIGN

A prospective, randomised (1:1), open-label, blinded-endpoint, multicentre clinical trial.

METHODS

Eligible participants are aged 18 years or above, diagnosed with AF, and own a smartphone. The study will be conducted at two metropolitan hospitals. In the intervention group, participants will receive the AF educational program delivered via Qstream®. In the control group, participants will receive the Stroke Foundation 'Living with AF' booklet. The primary outcome is re-hospitalisation within 12 months from an indexed presentation or hospital admission.

CONCLUSION

This clinical trial is part of a developing program of work that will examine mHealth educational-behavioural interventions on cardiovascular outcomes. Findings from this pilot study will inform the development of a digital educational framework for patients living with AF.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

There remain many gaps in providing high-quality patient education for patients with AF. This trial will test a new theory-driven, smartphone-based education program on important clinical outcomes, including rehospitalisation.

IMPACT

This study evaluates a novel, co-designed, digital AF educational program, 'INFORM-AF', to reduce the re-hospitalisation of people with AF. Study results are expected to be reported in 2025. Findings are expected to inform practice recommendations for AF patient education that may be included in future clinical practice guideline recommendations.

REPORTING METHOD

SPIRIT Checklist.

PATIENT OR PUBLICATION CONTRIBUTION

JL is a consumer co-researcher on the project and provided critical input into intervention design, and feedback and input across the study duration.

Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative.

OBJECTIVE

This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD).

METHODS

Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies.

RESULTS

We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade.

CONCLUSIONS

Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO.

Risk of atrial fibrillation in patients with systemic sclerosis: a nationwide population-based study

OBJECTIVE

Atrial fibrillation (AF) is the most common arrhythmia in the general population, causing substantial economic burden, morbidity and mortality. The incidence rate and risk of AF in patients with SSc are unclear. We aimed to assess the incidence rate of AF in patients with SSc and the risk of incident AF in patients with SSc compared with the general population.

METHODS

The Korean National Health Insurance Service database was used as the data source. Patients with claims data for SSc between 2010 and 2017 were extracted from the database along with 1:5 age- and sex-matched controls. The index date was the earliest date with claims data for SSc between 2010 and 2017. The follow-up duration was from the index date to 2019. Multivariable Cox proportional hazard models were used to estimate the hazard ratio (HR) and 95% CI for AF in patients with SSc.

RESULTS

Overall, 2519 patients with SSc and 12 595 age- and sex-matched controls were included. Over a mean follow-up duration of 5.2 years (s.d. 2.6), the incidence rates of AF were 3.52 and 1.68 per 1000 person-years for patients with SSc and controls, respectively. Compared with controls, patients with SSc had a significantly higher risk of incident AF [adjusted HR 2.095 (95% CI 1.466, 2.994)].

CONCLUSION

Patients with SSc had a 2-fold higher risk of incident AF than controls. Given the significant economic burden, morbidity and mortality that AF poses, close monitoring for incident AF in patients with SSc is warranted.

Predictive value of the left atrioventricular coupling index for recurrence after radiofrequency ablation of paroxysmal atrial fibrillation

BACKGROUND

Although patients with paroxysmal atrial fibrillation (PAF) are preferred to undergo catheter ablation (CA), the high possibility of recurrence following surgery is still concerning. We aimed to evaluate the ability of the left atrioventricular coupling index (LACI), which is the ratio of the left atrium end-diastolic volume to the left ventricle end-diastolic volume, to predict PAF recurrence after CA.

METHODS

Patients with PAF undergoing CA for the first time between January 2018 and June 2021 were admitted and grouped by recurrence within a year. LACI was measured before CA using ultrasonography. Risk factors identified by multivariable logistic regression analysis, and the area under the receiver operating characteristic (ROC) curve was used to assess the ability of LACI to predict PAF recurrence after CAP.

RESULTS

Among the 204 patients treated at our hospital, 164 patients were included in the research after eliminating those who were lost to follow-up. Among them, 56 individuals had recurrence following a 90-day blanking period. Recurrence is more likely in elderly patients with high blood pressure. Patients who suffered recurrence exhibited lower left atrial ejection fraction and increased LACI, left atrial volume minimum, and left atrium volume index maximum. LACI was an independent risk factor for postoperative recurrence (OR: 1.526, 95% CI: 1.325-1.757, P < 0.001), and ROC displayed remarkable predictive value [area under the curve (AUC) = 0.868].

CONCLUSIONS

High LACI is significantly associated with postoperative recurrence in PAF patients, and LACI has incremental prognostic value to predict recurrence.

The association between left atrial appendage emptying velocity and atrial fibrillation recurrence after radiofrequency catheter ablation in patients with early persistent atrial fibrillation

OBJECTIVE

In the present study, we aimed to explore the association between left atrial appendage emptying velocity (LAAEV) measured by transesophageal echocardiography and atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA) in patients with early persistent atrial fibrillation (PeAF).

METHODS

We retrospectively analyzed patients with early PeAF who underwent their initial ablation procedure. The echocardiographic and clinical data of the enrolled patients were collected and recorded prior to the operation. Following adjustment for confounding factors, we investigated the relationship between the LAAEV and AF recurrence in patients with early PeAF after radiofrequency ablation.

RESULTS

The proportions of AF recurrence in the low, medium, and high LAAEV groups were 48.8%, 16.0%, and 13.1%, respectively. After adjusting for potential confounding factors, we observed a gradual decrease in the risk of AF recurrence with increasing LAAEV (odds ratio: 0.882, 95% confidence interval: 0.842-0.924, p<0.001). This trend was statistically significant (p<0.001), particularly when comparing the high and low LAAEV groups (odds ratio: 0.033, 95% confidence interval: 0.009-0.116, p<0.001). Curve fitting analysis demonstrated an approximate negative linear association between LAAEV and the probability of AF recurrence.

CONCLUSIONS

Among patients with early PeAF who successfully underwent their first RFCA, we found that the LAAEV within 24 h before the procedure was independently correlated with the risk of AF recurrence. Notably, this association was negative, indicating that higher LAAEV was associated with a lower risk of AF recurrence.

The role of systemic inflammatory indices in predicting atrial fibrillation and its complications: a narrative review

Atrial fibrillation (AF) is associated with increased morbidity and mortality. Inflammation and oxidative stress play critical roles in AF occurrence and its complications. Therefore, evaluating the circulating levels of inflammatory and oxidative stress biomarkers and their possible applications in AF diagnosis and management have been the focus of many efforts. The monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and neutrophil-to-lymphocyte ratio (NLR) are two non-invasive, available, and established markers that serve as indicators of inflammation and oxidative stress. This review summarizes the current literature regarding alterations in the NLR, MHR, and other composite markers of systemic inflammation in AF patients. Moreover, this review discusses the clinical performance of these markers in predicting AF occurrence, recurrence, and disease outcomes. The PubMed, Scopus, and ScienceDirect online databases were searched for relevant studies using appropriate keywords, including "atrial fibrillation", "monocyte to high-density lipoprotein cholesterol ratio", and "neutrophil to lymphocyte ratio". The results of this review revealed the association of elevated levels of systemic inflammatory markers, specifically the NLR and MHR with AF and its complications. This finding indicates the potential role of subclinical inflammation in the development of AF, emphasizing its consideration in both the prevention and treatment of AF and associated complications. Despite these promising findings, the utilization of these markers in routine clinical settings faces challenges, including low specificity and sensitivity and varying cut-off values across different studies.

Left atrial appendage thrombus is associated with a higher fractal dimension in patients with atrial fibrillation

PURPOSE

To assess the anatomical complexity of the left atrial appendage (LAA) using fractal dimension (FD) based on cardiac computed tomography angiography (CTA) and the association between LAA FD and LAA thrombosis.

MATERIALS AND METHODS

Patients with atrial fibrillation (AF) who underwent both cardiac CTA and transesophageal echocardiography (TEE) between December 2018 and December 2022 were retrospectively analyzed. Patients were categorized into normal (n = 925), circulatory stasis (n = 82), and thrombus groups (n = 76) based on TEE results and propensity score matching (PSM) was performed for subsequent analysis. FD was calculated to quantify the morphological heterogeneity of LAA. Independent risk factors for thrombus were screened using logistic regression. The diagnostic performance of FD and CHA2DS2-VaSc score for predicting thrombus was evaluated using the area under the receiver operating characteristics curve (AUC).

RESULTS

LAA FD was higher in the thrombus group (1.61 [1.49, 1.70], P < 0.001) than in the circulatory stasis (1.33 [1.18, 1.47]) and normal groups (1.30 [1.18, 1.42]) both before and after PSM. LAA FD was also an independent risk factor in the thrombus (OR [odds ratio] = 570,861.15 compared to normal, 41,122.87 compared to circulatory stasis; all P < 0.001) and circulatory stasis group (OR = 98.87, P = 0.001) after PSM. The diagnostic performance of LAA FD was significantly better than the CHA2DS2-VaSc score in identifying thrombus.

CONCLUSIONS

Patients with high LAA FD are more likely to develop LAA thrombus, and the use of FD provides an effective method for assessing the risk of thrombosis in AF patients, thereby guiding individualized clinical treatment.

Convergent ablation for persistent atrial fibrillation: A UK multicentre perspective

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and remains a major cause of morbidity and mortality. Unfortunately, a significant proportion of patients have persistent AF, for which conventional catheter ablation is less effective. However, convergent ablation has emerged in recent years as a hybrid treatment targeting both the epicardium and endocardium in a multidisciplinary joint cardiothoracic and electrophysiology procedure, with promising efficacy outcomes in recent studies. This treatment is increasingly being performed in the United Kingdom. This review article discusses the rationale and evidence behind convergent ablation, along with factors that need to be considered when setting up a successful ablation service.

Stereotactic arrhythmia radioablation (STAR) opens a new era in the treatment of arrhythmias?

Tachyarrhythmias are common cardiovascular emergencies encountered in clinical practice. Among these, atrial fibrillation (AF) and ventricular tachycardia (VT) pose significant hazards due to their prevalence and severity. Initially, non-invasive pharmacological antiarrhythmic interventions were the primary treatment modality; however, due to their limited control rates and side effects, invasive therapies have been introduced in recent years. These include catheter ablation, alcohol ablation, cardiac implantable electronic devices, and heart transplantation. Nonetheless, for some patients, invasive treatments do not offer a definitive cure for arrhythmias and carry the risk of recurrence, especially with AF and VT, where the relapse rates are high and the treatment for VT is correlated with the type of tachycardia present. Currently, novel non-invasive treatment methods are emerging, with stereotactic radioablation therapy becoming an effective alternative for the management of refractory tachyarrhythmias. This review provides an overview of the application background of Stereotactic Arrhythmia Radioablation (STAR) therapy and promising results from its use in animal models and clinical applications.

Predictive value of neutrophil to lymphocyte ratio for clinical outcome in patients with atrial fibrillation: a systematic review and meta-analysis

Background

The association between the Neutrophil-to-Lymphocyte Ratio (NLR) and the prognosis of Atrial Fibrillation (AF) has been extensively studied, yet clinical outcomes have varied. Consequently, this analysis was undertaken to explore the link between NLR and the prognostic markers of AF.

Methods

We conducted an exhaustive search across electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, to investigate the correlation between the NLR and indicators of adverse clinical outcomes associated with AF from the database establishment date through March 31, 2024. In this study, the recurrence rate of AF was the primary outcome measure, while the secondary outcome measures were mortality, stroke, and left atrial thrombus. Odds ratio (OR), relative risk (RR), hazard ratio (HR) and standard mean difference (SMD) with a 95% confidence interval (CI) were integrated for assessment, and the stability of prognostic outcomes and publication bias were verified by sensitivity analysis and Egger's test, respectively. Subgroup analyses were performed to pinpoint the sources of heterogeneity.

Results

This analysis included 20 studies, encompassing a total of 59,256 patients. Our statistical analysis of both categorical and continuous variables revealed that an elevated NLR was significantly associated with increased risks in AF patients for recurrence (categorical variable: OR = 1.39, 95% CI = 1.21-1.60; continuous variable: SMD = 0.49, 95% CI = 0.24-0.74), mortality (categorical variable: OR = 1.87, 95% CI = 1.59-2.20), stroke (categorical variable: OR = 1.56, 95% CI = 1.13-2.17; continuous variable: SMD = 0.77, 95% CI = 0.63-0.91), and left atrial thrombus (categorical variable: OR = 1.87, 95% CI = 1.27-2.75; continuous variable: SMD = 0.59, 95% CI = 0.30-0.89). Subgroup analyses found that high NLR was significantly linked to AF recurrence when the NLR was >3. High NLR was significantly linked to the risk of stroke in AF when the NLR was ≤3.

Conclusions

This study suggested that a high NLR is significantly linked to prognostic risk markers of AF, and NLR may be an effective biomarker for the prognosis of AF in clinical practice.

Systematic Review Registration

PROSPERO (CRD42024530970).

Transcriptomic Insights into the Atrial Fibrillation Susceptibility Locus near the MYOZ1 and SYNPO2L Genes

Genome-wide association studies have identified a locus on chromosome 10q22, where many co-inherited single nucleotide polymorphisms (SNPs) are associated with atrial fibrillation (AF). This study seeks to identify the impact of this locus on gene expression at the transcript isoform level in human left atria and to gain insight into potential causal variants. Bulk RNA sequencing was analyzed to identify myozenin 1 (MYOZ1) and synaptopodin 2-like (SYNPO2L) transcript isoforms and the association of common SNPs in this region with transcript isoform expression levels. Chromatin marks were used to suggest candidate regulatory SNPs in this region. Protein amino acid changes were examined for predicted functional consequences. Transfection of MYOZ1 and two SYNPO2L isoforms were performed to localize their encoded proteins in cardiomyocytes derived from stem cells. We identified one MYOZ1 transcript isoform and four SYNPO2L transcript isoforms, two of which encode proteins, while the other two encode long noncoding RNAs (lncRNAs). The risk allele of the strongest AF susceptibility SNP on chromosome 10q22 is associated with decreased MYOZ1 expression and increased expression of the two SNYPO2L lncRNA isoforms. There are many SNPs co-inherited with the top AF-associated SNP due to linkage disequilibrium (LD), including rs11000728, which we propose as the MYOZ1 regulatory SNP, confirmed by reporter gene transfection. In addition, this LD block includes three missense SNPs in the SYNPO2L gene, with the minor protective haplotype predicted to be detrimental to protein function. MYOZ1 and both protein isoforms of SYNPO2L were localized to the sarcomere. This is a complex locus with the potential for several SNPs in a haplotype to alter AF susceptibility by opposing effects on MYOZ1 and SYNPO2L lncRNA expression, along with effects on SYNPO2L protein function.

Association of cannabis use disorder with atrial fibrillation in young men without concomitant tobacco use: Insights from nationwide propensity matched analysis

BACKGROUND

Recent data are inconclusive regarding the risk of arrhythmias among young cannabis users. Furthermore, many young adults use both cannabis and tobacco, which could add a residual confounding effect on outcomes. So, we studied young men who have cannabis use disorder (CUD) excluding tobacco use disorder (TUD) to understand their independent association with atrial fibrillation (AF) and related outcomes.

AIM

To study the association of CUD with AF and related outcomes.

METHODS

We used weighted discharge records from National Inpatient Sample (2019) to assess the baseline characteristics and mortality rates for AF-related hospitalizations in young (18-44 years) men in 1:1 propensity-matched CUD + vs CUD- cohorts without TUD.

RESULTS

Propensity matched CUD + and CUD- cohorts consisted of 108495 young men in each arm. Our analysis showed an increased incidence of AF in black population with CUD. In addition, the CUD + cohort had lower rates of hyperlipidemia (6.4% vs 6.9%), hypertension (5.3% vs 6.3%), obesity (9.1% vs 10.9%), alcohol abuse (15.5% vs 16.9%), but had higher rates of anxiety (24.3% vs 18.4%) and chronic obstructive pulmonary disease (COPD) (9.8% vs 9.4%) compared to CUD-cohort. After adjustment with covariates including other substance abuse, a non-significant association was found between CUD + cohort and AF related hospitalizations (odd ratio: 1.27, 95% confidence interval: 0.91-1.78, P = 0.15).

CONCLUSION

Among hospitalized young men, the CUD + cohort had a higher prevalence of anxiety and COPD, and slightly higher proportion of black patients. Although there were higher odds of AF hospitalizations in CUD + cohort without TUD, the association was statistically non-significant. The subgroup analysis showed higher rates of AF in black patients. Large-scale prospective studies are required to evaluate long-term effects of CUD on AF risk and prognosis without TUD and concomitant substance abuse.

Pathways to precision medicine: deciphering the secrets of physiological and pathological atrial enlargement

Cardiac functional, morphological, and histological analysis, coupled with liquid chromatography and mass spectrometry, of two transgenic mouse models with cardiomyocyte-specific overexpression of insulin-like growth factor 1 receptor (IGF1R) or a dominant-negative PI3K mutant (DCM-dnPI3K) revealed distinctive functional and molecular profiles during physiological (driven by IGF1R overexpression) and pathological (driven by dn-PI3K overexpression) atrial remodeling. The current study confirmed previously reported findings, including ventricular dilatation and enhanced systolic function with no evidence of arrhythmia in IGF1R model, as well as ventricular hypertrophy and decreased systolic function with intermittent atrial fibrillation in DCM-dnPI3K model. Novel findings obtained from the left atrial (LA) characterization of female mice revealed that physiological atrial enlargement resulted from increased atrial myocyte size and was associated with preserved atrial function, as determined by maintained LA ejection fraction (EF). The proteomic profile of IGF1R transgenic (Tg) mice was enriched for metabolic remodeling and showed a protein expression pattern similar to that of healthy human atria; on the other hand, pathological atrial enlargement resulted from increased atrial fibrosis with normal myocyte size and was associated with impaired atrial function due to a reduced LA EF. The proteomic profile of DCM-dnPI3K mice was enriched to both metabolic and structural remodeling and showed a protein expression pattern similar to that of human AF atria.

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, disrupts the heart's rhythm through numerous small re-entry circuits in the atrial tissue, leading to irregular atrial contractions. The condition poses significant health risks, including increased stroke risk, heart failure, and reduced quality of life. Given the complexity of AF and its growing incidence globally, exercise-based cardiac rehabilitation (ExCR) may provide additional benefits for people with AF or those undergoing routine treatment for the condition.

OBJECTIVES

To assess the benefits and harms of ExCR compared with non-exercise controls for people who currently have AF or who have been treated for AF.

SEARCH METHODS

We searched the following electronic databases: CENTRAL in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS BIREME, and two clinical trial registers on 24 March 2024. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) that investigated ExCR interventions compared with any type of non-exercise control. We included adults 18 years of age or older with any subtype of AF or those who had received treatment for AF.

DATA COLLECTION AND ANALYSIS

Five review authors independently screened and extracted data in duplicate. We assessed risk of bias using Cochrane's RoB 1 tool as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots and by using standard Chi² and I² statistics. We performed meta-analyses using random-effects models for continuous and dichotomised outcomes. We calculated standardised mean differences where different scales were used for the same outcome. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 RCTs involving a total of 2039 participants with AF. All trials were conducted between 2006 and 2024, with a follow-up period ranging from eight weeks to five years. We assessed the certainty of evidence as moderate to very low. Five trials assessed comprehensive ExCR programmes, which included educational or psychological interventions, or both; the remaining 15 trials compared exercise-only cardiac rehabilitation with controls. The overall risk of bias in the included studies was mixed. Details on random sequence generation, allocation concealment, and use of intention-to-treat analysis were typically poorly reported. Evidence from nine trials (n = 1173) suggested little to no difference in mortality between ExCR and non-exercise controls (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; 101 deaths; low-certainty evidence). Based on evidence from 10 trials (n = 825), ExCR may have little to no effect on SAEs (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; 28 events; low-certainty evidence). Evidence from four trials (n = 378) showed that ExCR likely reduced AF recurrence (measured via Holter monitoring) compared to controls (RR 0.70, 95% CI 0.56 to 0.88; I² = 2%; moderate-certainty evidence). ExCR may reduce AF symptom severity (mean difference (MD) -1.59, 95% CI -2.98 to -0.20; I² = 61%; n = 600; low-certainty evidence); likely reduces AF symptom burden (MD -1.61, 95% CI -2.76 to -0.45; I² = 0%; n = 317; moderate-certainty evidence); may reduce AF episode frequency (MD -1.29, 95% CI -2.50 to -0.07; I² = 75%; n = 368; low-certainty evidence); and likely reduces AF episode duration (MD -0.58, 95% CI -1.14 to -0.03; I² = 0%; n = 317; moderate-certainty evidence), measured via the AF Severity Scale (AFSS) questionnaire. Moderate-certainty evidence from six trials (n = 504) showed that ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) of the 36-item Short Form Health Survey (SF-36) (MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on the physical component summary measure was very uncertain (MD 1.75, 95% CI -0.31 to 3.81; I² = 52%; very low-certainty evidence). ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (peak oxygen uptake (VO2peak) and 6-minute walk test) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre compared to home-based, exercise dose, exercise only compared to comprehensive programmes, and aerobic training alone compared to aerobic plus resistance programmes. Using univariate meta-regression, there was evidence of significant association between location of trial and length of longest follow-up on exercise capacity.

AUTHORS' CONCLUSIONS

Due to few randomised participants and typically short-term follow-up, the impact of ExCR on all-cause mortality or serious adverse events for people with AF is uncertain. ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as the mental components of HRQoL. ExCR may improve AF symptom severity, episode frequency, and VO2peak. Future high-quality RCTs are needed to assess the benefits of ExCR for people with AF on patient-relevant outcomes including AF symptom severity and burden, AF recurrence, AF-specific quality of life, and clinical events such as mortality, readmissions, and serious adverse events. High-quality trials are needed to investigate how AF subtype and clinical setting (i.e. primary and secondary care) may influence ExCR effectiveness.

Direct-to-catheter ablation versus second line catheter ablation for persistent atrial fibrillation: Effect on arrhythmia recurrence, AF burden, early left atrium remodeling and quality of life

BACKGROUND

Catheter ablation has obtained class 1 indication in ablation of young, healthy patients with symptomatic paroxysmal atrial fibrillation (AF). Anti-arrhythmic drugs (AADs) remain first-line therapy before ablating persistent AF (PersAF). We sought to evaluate the efficacy of a direct-to-catheter ablation approach against catheter ablation post AADs in PersAF.

METHODS

In this DECAAF II subanalysis, patients were stratified into two subgroups: 'Direct-to-catheter' group comprising patients who had not received AADs prior to ablation, and'second-line ablation' group, comprising patients who had been on any AAD therapy at any time before ablation. Patients were followed over 18 months. The primary outcome was AF recurrence. Secondary outcomes included AF burden, quality of life (QoL) that assessed by the AFSS and SF-36 scores, and changes in the left atrial volume index (LAVI) assessed by LGE-MRI scans.

RESULTS

The analysis included 815 patients, with 279 classified as'direct-to-catheter' group and 536 classified as'Second-line ablation' group. The primary outcome was similar between both groups (44.8% vs 44.4%, p > 0.05), as was AF burden (20% vs 16%, p > 0.05). Early remodeling, reflected by LAVI reduction, was similar between the groups (9.1 [1.6-18.0] in the second-line ablation group and 9.5 [2.5-19.7] in the direct-to-catheter group, p > 0.05). QoL pre/post ablation was also similar (p > 0.05). On multivariate analysis, history of AAD was not predictive of AF recurrence(p > 0.05).

CONCLUSION

Prior AAD therapy demonstrated minimal impact on atrial remodeling and QoL improvement, in addition to limited benefit on AF recurrence and burden post-ablation in patients with PersAF. Additional studies are warranted to explore the efficacy of catheter ablation as a first-line therapy in PersAF.

Impact of changes in left heart geometry on predicting new-onset atrial fibrillation in patients with hypertension

BACKGROUND

Hypertension-induced left ventricular hypertrophy (LVH) increases end-diastolic LV pressure and contributes to left atrial enlargement (LAE), which are associated with development of atrial fibrillation. However, the impact of LVH and LAE and their regression following antihypertensive therapy on atrial fibrillation incidence remains unclear.

METHODS

This retrospective analysis included consecutive patients with sinus rhythm who underwent echocardiography at hypertension diagnosis and after 6-18 months between 2006 and 2021 at tertiary care centres in Korea. LVH was defined as LV mass index greater than 115 g/m2 (men) and greater than 95 g/m2 (women), and LAE was defined as LA volume index greater than 42 ml/m2. The occurrence of new-onset atrial fibrillation (NOAF) was assessed in relation to changes in LVH and LAE status.

RESULTS

Among the 1464 patients included, 163 (11.1%) developed NOAF during a median 63.8 [interquartile range (IQR) 35.9-128.5] months of surveillance period. New-onset LVH [adjusted hazard ratio (aHR) 1.88, 95% confidence interval (CI) 1.20-2.94, P = 0.006] and LAE (aHR 1.89, 95% CI 1.05-3.40, P = 0.034) were significant predictors of NOAF. Conversely, regression of LVH (aHR 0.51, 95% CI 0.28-0.91, P = 0.022) or LAE (aHR 0.30, 95% CI 0.15-0.63, P = 0.001) was associated with a reduced risk for developing NOAF. Patients with both LVH and LAE at follow-up echocardiography had a higher risk for NOAF (aHR 4.30, 95% CI 2.81-6.56, P < 0.001) than those with either LVH or LAE or those with neither.

CONCLUSION

The changes in left heart geometry can serve as a predictive marker for NOAF in patients with hypertension.

Potentially inappropriate prescribing in polymedicated older adults with atrial fibrillation and multimorbidity: a Swedish national register-based cohort study

Introduction

Current research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults.

Methods

Swedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (≥65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls.

Results

PIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88-2.07]) and overall mortality (HR = 2.09 [2.03-2.16]), CV (HR = 1.34 [1.30-1.37]) and overall hospitalisation (HR = 1.48 [1.46-1.51]), stroke (HR = 1.93 [1.78-2.10]), bleeding (HR = 1.10 [1.01-1.21]), and falls (HR = 1.63 [1.56-1.71]).

Conclusion

The present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population.

Fed-CL- an atrial fibrillation prediction system using ECG signals employing federated learning mechanism

Deep learning has shown great promise in predicting Atrial Fibrillation using ECG signals and other vital signs. However, a major hurdle lies in the privacy concerns surrounding these datasets, which often contain sensitive patient information. Balancing accurate AFib prediction with robust user privacy remains a critical challenge to address. We suggest Federated Learning , a privacy-preserving machine learning technique, to address this privacy barrier. Our approach makes use of FL by presenting Fed-CL, a advanced method that combines Long Short-Term Memory networks and Convolutional Neural Networks to accurately predict AFib. In addition, the article explores the importance of analysing mean heart rate variability to differentiate between healthy and abnormal heart rhythms. This combined approach within the proposed system aims to equip healthcare professionals with timely alerts and valuable insights. Ultimately, the goal is to facilitate early detection of AFib risk and enable preventive care for susceptible individuals.

The Role of P Wave Parameters in Predicting Pulmonary Vein Isolation Outcomes for Paroxysmal Atrial Fibrillation: An Observational Cohort Study

BACKGROUND

Pulmonary vein isolation (PVI) is an effective management method for paroxysmal atrial fibrillation (PAF). The P wave in the 12-lead electrocardiogram (ECG) represents atrial depolarisation. This study aims to utilise the P wave to predict PVI outcomes for PAF.

METHODS

This single-centre retrospective study aimed to predict PVI outcomes using P wave parameters. It included 211 consecutive patients with first PVI for PAF between 2018 and 2019 and targeted the pulmonary veins (PVs). Procedure success was defined by freedom of ECG-documented AF at 12 months. Digital 12-lead ECGs with 1-50 hertz bandpass filters were monitored before the procedure. Corrected P wave duration (PWDc), P wave amplitude (PWV), P wave dispersion (PWDisp), intra-atrial block (IAB), P wave area (PWA), and P wave terminal force in V1 (PTFV1) were measured before ablation and correlated with the outcomes.

RESULTS

Successful PVI occurred in 154 patients (73%). Demographics were similar between both arms. P wave parameters correlated with PVI failure included increased PWDc in all leads except for lead III, aVR, and V3, decreased PWV in lead I (hazard ratio [HR]: 0.7, 95% confidence interval [CI]: 0.53-0.95), lead II (HR: 0.45, 95% CI: 0.22-0.65), aVL (HR: 0.58, 95% CI: 0.22-0.98), and aVF (HR: 0.67, 95% CI: 0.58-0.87), decreased PWA in lead I (HR: 0.55, 95% CI: 0.21-0.76), lead II (HR: 0.48, 95% CI: 0.34-0.87), aVL (HR: 0.65, 95% CI: 0.45-0.96), and aVF (HR: 0.61, 95% CI: 0.32-0.89), and the presence of IAB (HR: 2, 95% CI: 1.4-4.2, p = 0.02). PWDisp and PTFV1 were not correlated with PVI outcome.

CONCLUSIONS

PWDc, PWA, PWV, and IAB are valuable predictors for PVI outcome for PAF at 12 months.

Effects of mineralocorticoid receptor antagonists on new-onset or recurrent atrial fibrillation: a Bayesian and frequentist network meta-analysis of randomized trials

Background Clinical and translational research suggests that mineralocorticoid receptor antagonists (MRAs) may prevent atrial fibrosis and electrical remodeling associated with atrial fibrillation (AF). This study aimed to consolidate existing evidence from randomized controlled trials (RCTs) evaluating the effect of MRAs on incident or recurrent AF. Methods Medline, Cochrane Library and Scopus were searched until February 12, 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using both pairwise and Bayesian and frequentist network meta-analyses. Results Twenty-three RCTs (13,358 participants) were identified. Based on the pairwise random effects meta-analysis, MRAs were associated with a significant reduction in AF events compared to placebo or usual care (risk ratio {RR}= 0.75; 95% confidence interval {CI}= [0.66, 0.87]; P< 0.001; I2= 3%). This protective effect was robust both for new-onset and recurrent AF episodes (subgroup p-value= 0.69), while the baseline HF status was not a significant effect modifier (subgroup p-value= 0.58). MRAs demonstrated a significantly higher reduction in AF events for patients with chronic renal disease compared to placebo (RR= 0.78; 95% CI= [0.62, 0.98]; P= 0.03; I2= 0%). The network meta-analyses revealed that only spironolactone was associated with a significant reduction in AF events (Bayesian RR= 0.76; 95% CI= [0.65, 0.89]; P< 0.001; level of evidence moderate; SUCRA 0.731), while eplerenone and finerenone showed a neutral effect. Conclusion MRAs confer a significant benefit in terms of reducing incident or recurrent AF episodes, irrespective of HF status. In this context, spironolactone may be preferable compared to eplerenone or finerenone.

Adherence to oral anticoagulants in patients with non-valvular atrial fibrillation: the role of patients' characteristics and out-of-pocket payments

BACKGROUND

Recent practice guidelines favor direct oral anticoagulants (DOACs) over warfarin for primary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). However, challenges persist in Iraq's private pharmaceutical sector. DOACs have been sold at high and inconsistent retail prices and lack insurance coverage, leading to significant out-of-pocket (OOP) costs. The objective of this study is to investigate the impact of OOP costs on oral anticoagulants (OAC) adherence among NVAF patients.

RESEARCH DESIGN AND METHODS

This multicenter cross-sectional study interviewed 359 eligible patients attending three private cardiology clinics within Iraq's southern region from December 2022 to February 2023. The 8-item Morisky Adherence Scale evaluated patient adherence. Statistical analyses, including descriptive analysis, ANOVA, and chi-square. p < 0.05 was considered statistically significant.

RESULTS

The most frequently prescribed OAC were DOACs (62.8%). Patient adherence level to OAC was chiefly medium (54.6%) with no significant difference in adherence based on OAC type. Patient adherence was significantly associated with monthly income (p = 0.001), number of daily pills (p = 0.006), and OACs' average monthly cost (p = 0.011).

CONCLUSION

Addressing the issue of cost-related non-adherence to OACs requires multiple actions. These include ensuring comprehensive health insurance coverage for OACs, increasing the use of affordable generic alternatives, and establishing effective cost-related discussions between healthcare providers and patients.

Risk Factor Management for Patients with Atrial Fibrillation in Home Healthcare

Atrial fibrillation (AF) is a common and persistent cardiac arrhythmia that impacts morbidity, mortality, disability, quality of life, and healthcare costs. Typically, AF is managed using a three-pillar approach of rate control, rhythm control, and anticoagulation. However, these interventions fail to address the underlying pathophysiological factors that contribute to AF. A compelling body of research expands traditional management by focusing on lifestyle modification to lower the risk of AF incidence, prevalence, progression, and severity. Home healthcare clinicians possess the knowledge and skills to examine and treat a wide range of risk factors that lead to AF, and therefore can substantially reduce incident and persistent AF and facilitate optimal outcomes. This perspective paper presents a clinical paradigm shift by proposing a five-factor Partner, Quantify, Recommend, Support, and Teach (PQRST) framework to support AF risk factor modification in home healthcare. The PQRST framework incorporates a greater focus on patient self-management through education and exercise to reduce incidence, prevalence, progression, and severity of AF.

Risk factors for MACE and bleeding in atrial fibrillation patients undergoing surgery: Insights from the bridge trial

INTRODUCTION

Patients with atrial fibrillation (AF) undergoing elective procedures are at risk for Major Adverse Cardiovascular Events (MACE) and symptomatic bleeding. We aimed to identify risk factors to guide perioperative risk stratification.

METHODS

We conducted a post-hoc analysis of the "Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Invasive Procedure or Surgery" randomized trial. The primary outcomes were MACE and symptomatic bleeding. Our statistical approach encompassed standard univariate analysis, logistic stepwise regression, and Cox regression models. Additional interaction analyses evaluated the interplay between low-molecular-weight heparin bridge therapy and other identified risk factors.

RESULTS

Among a total of 1,813 participants (mean age 71.6 ± 8.8, 73.3 % male), MACE occurred in 25 (1.4 %) individuals, with pre-procedure clopidogrel use (adjusted hazard ratio [aHR] 7.73, 95 % CI 2.63-22.72, p < 0.001) and CHA2DS2-VASc score ≥ 5 (aHR 2.89, 95 % CI 1.26-6.63, p = 0.012) identified as risk factors. Symptomatic bleeding occurred in 57 (3.1 %) individuals, with bridge therapy (aHR 1.84, 95 % CI 1.07-3.19, p = 0.029), renal disease (aHR 2.50, 95 % CI 1.34-4.67, p = 0.004), post-procedure aspirin use (aHR 2.86, 95 % CI 1.66-4.91, p < 0.001), post-procedure nonsteroidal anti-inflammatory drug use excluding aspirin (aHR 3.40, 95 % CI 1.22-9.43, p = 0.019), and major surgery (aHR 3.94, 95 % CI 2.26-6.85, p < 0.001) identified as risk factors. The interactions between risk factors and bridging therapy on MACE and symptomatic bleeding outcomes were not significant (p > 0.05).

CONCLUSION

We identified predictors for MACE and symptomatic bleeding in AF patients undergoing elective procedures. These insights may help guide perioperative decisions to reduce the risk of adverse outcomes.

The association of exhaled carbon monoxide with atrial fibrillation and left atrial size in the Framingham Heart Study

Background

Exhaled carbon monoxide (eCO) is associated with subclinical and overt cardiovascular disease and stroke. The association between eCO with left atrial size, prevalent, or incident atrial fibrillation (AF) are uncertain.

Methods

eCO was measured using an Ecolyzer instrument among Framingham Heart Study Offspring and Omni participants who attended an examination from 1994 to 1998. We analyzed multivariable-adjusted (current smoking, and other covariates including age, race, sex, height, weight, systolic blood pressure, diastolic blood pressure, diabetes, hypertension treatment, prevalent myocardial infarction [MI], and prevalent heart failure [HF]). Cox and logistic regression models assessed the relations between eCO and incident AF (primary model), and prevalent AF and left atrial (LA) size (pre-specified secondary analyses). We also conducted secondary analyses adjusting for biomarkers, and interim MI and interim HF.

Results

Our study sample included 3814 participants (mean age 58 ± 10 years; 54.4 % women, 88.4 % White). During an average of 18.8 ± 6.5 years follow-up, 683 participants were diagnosed with AF. eCO was associated with incident AF after adjusting for established AF risk factors (HR, 1.31 [95 % CI, 1.09-1.58]). In secondary analyses the association remained significant after additionally adjusting for C-reactive protein and B-type natriuretic peptide, and interim MI and CHF, and in analyses excluding individuals who currently smoked. eCO was not significantly associated with LA size and prevalent AF.

Conclusion

In our community-based sample of individuals without AF, higher mean eCO concentrations were associated with incident AF. Further investigation is needed to explore the biological mechanisms linking eCO with AF.

Artificial intelligence-based electrocardiogram analysis improves atrial arrhythmia detection from a smartwatch electrocardiogram

Aims

Smartwatch electrocardiograms (SW ECGs) have been identified as a non-invasive solution to assess abnormal heart rhythm, especially atrial arrhythmias (AAs) that are related to stroke risk. However, the performance of these tools is limited and could be improved with the use of deep neural network (DNN) algorithms, particularly for specific populations encountered in clinical cardiology practice.

Methods and results

A total of 400 patients from the electrophysiology department of one tertiary care hospital were included in two similar clinical trials (respectively, 200 patients per study). Simultaneous ECGs were recorded with the watch and a 12-lead recording system during consultation or before and after an electrophysiology procedure if any. The SW ECGs were processed by using the DNN and with the Apple watch ECG software (Apple app). Corresponding 12-lead ECGs (12L ECGs) were adjudicated by an expert electrophysiologist. The performance of the DNN was assessed vs. the expert interpretation of the 12L ECG, and inconclusive rates were reported. Overall, the DNN and the Apple app presented, respectively, a sensitivity of 91% [95% confidence interval (CI) 85-95%] and 61% (95% CI 44-75%) with a specificity of 95% (95% CI 91-97%) and 97% (95% CI 93-99%) when compared with the physician 12L ECG interpretation. The DNN was able to provide a diagnosis on 99% of ECGs, while the Apple app was able to classify only 78% of strips (22% of inconclusive diagnosis).

Conclusion

In this study, by including patients from a cardiology department, a DNN-based algorithm applied to an SW ECG provided an accurate diagnosis for AA detection on virtually all tracings, outperforming the SW algorithm.

A Predictive Nomogram of In-Hospital Mortality After 48 h for Atrial Fibrillation Patients in the Coronary Care Unit

BACKGROUND

Patients with atrial fibrillation (AF) suffer a higher risk of death, and it is necessary to develop prediction tools for mortality risk in critically ill patients with AF. This study aimed to develop a novel predictive nomogram of in-hospital mortality after 48 h in the coronary care unit (CCU) for patients with AF.

METHODS

We collected information on CCU patients with AF from the "Medical Information Mart for Intensive Care-III" database and developed a nomogram model for predicting the all-cause mortality risk after 48 h in the hospital. Key variables were selected by univariate logistic and least absolute shrinkage and selection operator regression. The independent predictors with p < 0.05 were screened out by multivariate logistic regression. A predictive nomogram was constructed using these independent predictors, and the model calibration and discrimination were evaluated.

RESULTS

This study finally enrolled 1248 CCU patients with AF, and the in-hospital mortality was 17% (209/1248). The predictive nomogram was constructed by 13 selected independent predictors, including age, smoking status, acute kidney injury, chronic obstructive pulmonary disease, ventricular arrhythmia, shock, urea, red cell distribution width, leucocytosis, continuous renal replacement therapy, continuous positive airway pressure, anticoagulation, and heart rate. The area under the curve of the nomogram was 0.803 (95% confidence interval 0.771-0.835). The nomogram was verified to have good accuracy and calibration.

CONCLUSIONS

This study developed a novel nomogram containing age, acute kidney injury, and heart rate that can be a good predictor of potential in-hospital mortality after 48 h in CCU patients with AF.

Effectiveness of antazoline versus amiodarone, flecainide and propafenone in restoring sinus rhythm at the emergency department

PURPOSE

Little is known about the effectiveness of pharmacological cardioversion (PCV) with antazoline in comparison to flecainide. The aim of this study was to compare the effectiveness of antazoline in restoring sinus rhythm (SR) versus amiodarone, flecainide and propafenone in a group of emergency department (ED) patients.

MATERIALS/METHODS

This was a single-centre retrospective analysis of patient records from an ED in a large hospital in Poland. We analysed a total of 1878 patient records, divided based on the anti-arrhythmic drug (AAD) administered during PCV: antazoline (n ​= ​1080), antazoline ​+ ​β-blocker (n ​= ​479), amiodarone (n ​= ​129), flecainide (n ​= ​102), propafenone (n ​= ​88). Of the patients, 63.5 ​% were female (median 65 years, [19-100]).

RESULTS

The percentage of successful PCV was significantly higher in the antazoline group (84.3 ​%) than in the antazoline ​+ ​β-blocker (75.8 ​%, p ​= ​0.0001), propafenone (75.6 ​%, p ​= ​0.0364) and amiodarone (68.8 ​%, p ​< ​0.0001) groups. Post-hoc analysis revealed that patients who received PCV with antazoline, antazoline ​+ ​β-blocker, flecainide and propafenone had significantly shorter time to SR than those who received amiodarone (p ​< ​0.0001). Univariate regression analysis revealed that patients who underwent PCV with antazoline were almost twice as likely to return to SR compared to the other groups (p ​< ​0.0001, OR 1.81, 95 ​% CI 1.44-2.27).

CONCLUSIONS

This is the first study comparing the effectiveness of antazoline in PCV versus flecainide in addition to the previously studied amiodarone and propafenone. Our results indicate that antazoline is more effective in restoring SR than amiodarone, flecainide and propafenone. In addition, antazoline restored SR significantly faster than amiodarone or propafenone.

Development and validation of the Atri-Risk Conduction Index risk score to predict risk of atrial fibrillation after typical atrial flutter ablation

BACKGROUND

Identification of patients at risk for atrial fibrillation (AF) after typical atrial flutter (tAFL) ablation is important to guide monitoring and treatment.

OBJECTIVE

The purpose of this study was to create and validate a risk score to predict AF after tAFL ablation METHODS: We identified patients who underwent tAFL ablation with no AF history between 2017 and 2022 and randomly allocated to derivation and validation cohorts. We collected clinical variables and measured conduction parameters in sinus rhythm on an electrophysiology recording system (CardioLab, GE Healthcare). Univariate and multivariate logistic regressions (LogR) were used to evaluate association with AF development.

RESULTS

A total of 242 consecutive patients (81% male; mean age 66 ± 11 years) were divided into derivation (n =142) and validation (n = 100) cohorts. Forty-two percent developed AF over median follow-up of 330 days. In multivariate LogR (derivation cohort), proximal to distal coronary sinus time (pCS-dCS) ≥70 ms (odds ratio [OR] 16.7; 95% confidence interval [CI] 5.6-49), pCS time ≥36 ms (OR 4.5; 95% CI 1.5-13), and CHADS2-VASc score ≥3 (OR 4.3; 95% CI 1.6-11.8) were independently associated with new AF during follow-up. The Atri-Risk Conduction Index (ARCI) score was created with 0 as minimal and 4 as high-risk using pCS-dCS ≥70 ms = 2 points; pCS ≥36 ms = 1 point; and CHADS2-VASc score ≥3 = 1 point. In the validation cohort, 0% of patients with ARCI score = 0 developed AF, whereas 89% of patients with ARCI score = 4 developed AF.

CONCLUSION

We developed and validated a risk score using atrial conduction parameters and clinical risk factors to predict AF after tAFL ablation. It stratifies low-, moderate-, and high-risk patients and may be helpful in individualizing approaches to AF monitoring and anticoagulation.