Gender-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: a report from the Euro Heart Survey on Atrial Fibrillation

Rate and Rhythm Control Treatment in the Elderly and Very Elderly Patients With Atrial Fibrillation: An Observational Cohort Study of 1497 Patients

Stroke prevention and rate or rhythm control are crucial in the management of atrial fibrillation (AF). There is recent evidence for benefit of early rhythm control, yet rate control is the first choice in elderly patients. However, the efficacy and safety of rate and rhythm control in the elderly population remains largely unexplored. Therefore, we analyzed electronic health record data and investigated prescribing patterns and mortality of both strategies in elderly patients with AF. Data from patients with AF who were aged ≥75 years, used a pharmacological rate or rhythm control strategy, and visited Cardiology Centers of the Netherlands between 2007 and 2018 were extracted. Of the 1497 patients (54% female), 316 (21%) were prescribed rhythm control and 1181 (79%) rate control. Patients aged >85 years (OR: 2.28; 95% CI: 1.51-3.44, P< 0.001) and those with permanent AF (OR: 2.71; 95% CI: 1.67-4.41, P< 0.001) were more likely to receive rate control, whereas those with paroxysmal AF were less likely to receive rate control (OR: 0.42; 95% CI: 0.32-0.56, P< 0.001). After correction for relevant confounders, the mortality risk for patients using rhythm control and patients using rate control was similar (HR: 0.89; 95% CI: 0.70-1.12, P = 0.31). A more liberal approach towards prescribing a rhythm control strategy to the elderly patients with AF may be warranted and seems safe. Our data underscore the need for prospective studies to provide definite answers on efficacy and safety of rhythm control in elderly patients with AF.

A meta-analysis of clinical risk factors for stroke in anticoagulant-naïve patients with atrial fibrillation

AIMS

The aim of this study is to summarize data from prospective cohort studies on clinical predictors of stroke and systemic embolism in anticoagulant-naïve atrial fibrillation (AF) patients.

METHODS AND RESULTS

EMBASE, MEDLINE, Global Index Medicus, and Web of Science were searched to identify all studies published by 28 November 2019. Forty-seven studies reporting data from 1 756 984 participants in 15 countries were included. The pooled incidence of stroke in anticoagulant-naïve AF patients was 23.8 per 1000 person-years (95% CI 19.7-28.2). Older age was associated with incident stroke or systemic embolism, with a pooled hazard ratio (HR) of 2.14 (95% CI 1.85-2.47), 2.83 (95% CI 2.27-3.51), and 6.87 (95% CI 6.33-7.44) for age 65-75, ≥75, and ≥85 years, respectively. Other predictors of stroke or systemic embolism included history of stroke or TIA (HR 2.84, 95% CI 2.19-3.67), hypertension (HR 1.60, 95% CI 1.37-1.86), diabetes (HR 1.28, 95% CI 1.20-1.37), heart failure (HR 1.25, 95% CI 1.11-1.40), peripheral artery disease (pooled HR 1.35, 95% CI 1.04-1.75), vascular disease (pooled HR 1.21, 95% CI 1.06-1.39), and prior myocardial infarction (pooled HR 1.08, 95% CI 1.03-1.14). Female sex was a predictor of thromboembolism in studies outside Asia (HR 1.33, 95% CI 1.15-1.55), but not in those done in Asia (HR 0.95, 95% CI 0.81-1.10).

CONCLUSION

This study confirms age and prior stroke as the strongest predictors of stroke or systemic embolism in anticoagulant-naive AF patients. Other predictors include hypertension, diabetes, heart failure, and vascular disease. Female sex seems not to be universally associated with stroke or systemic embolism.

Sex Differences in Outcomes Following Left Atrial Appendage Closure

OBJECTIVE

To evaluate the effects of female sex on in-hospital outcomes and to provide estimates for sex-specific prediction models of adverse outcomes following left atrial appendage closure (LAAC).

PATIENTS AND METHODS

Cohort-based observational study querying the National Inpatient Sample database between October 1, 2015, and December 31, 2017. Demographics, baseline characteristics, and comorbidities were assessed with the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index score (ECS), and CHA₂DS₂-VASc score. The primary outcome was in-hospital major adverse events (MAEs) defined as the composite of bleeding, vascular, cardiac complications, post-procedural stroke, and acute kidney injury. The associations of the CCI, ECS, and CHA₂DS₂-VASc score with in-hospital MAE were examined using logistic regression models for women and men, respectively.

RESULTS

A total of 3294 hospitalizations were identified, of which 1313 (40%) involved women and 1981 (60%) involved men. Women were older (76.3±7.7 vs 75.2±8.4 years, P<.001), had a higher CHA₂DS₂-VASc score (4.9±1.4 vs 3.9±1.4, P<.001) but showed lower CCI and ECS compared with men (2.1±1.9 vs 2.3±1.9, P=.01; and 9.3±5.9 vs 9.9±5.7, P=.002, respectively). The primary composite outcome occurred in 4.6% of patients and was higher in women compared with men (women 5.6% vs men 4.0%, P=.04), and this was mainly driven by the occurrence of cardiac complications (2.4% vs 1.2%, P=.01). In women, older age, higher median income, and higher CCI (adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.21 to 1.44; P<.001), ECS (aOR, 1.04; 95% CI, 1.02 to 1.07; P=.002), and CHA₂DS₂-VASc score (aOR, 1.24; 95% CI, 1.10 to 1.39; P<.001) were associated with increased risk of in-hospital MAE. In men, non-White race/ethnicity, lower median income, and higher ECS (aOR, 1.06; 95% CI, 1.04 to 1.09; P<.001) were associated with increased risk of in-hospital MAE.

CONCLUSION

Women had higher rates of in-hospital adverse events following LAAC than men did. Women with older age and higher median income, CCI, ECS, and CHA₂DS₂-VASc scores were associated with in-hospital adverse events, whereas men with non-White race/ethnicity, lower median income, and higher ECS were more likely to experience adverse events. Further research is warranted to identify sex-specific, racial/ethnic, and socioeconomic pathways during the patient selection process to minimize complications in patients undergoing LAAC.

GENDER DIFFERENCES IN COMPLICATIONS FOLLOWING CATHETER ABLATION OF ATRIAL FIBRILLATION

AIM

Population studies that provide unbiased estimates of gender differences in risk of complications following catheter ablation of atrial fibrillation (AF) are sparse. We sought to evaluate the association of female gender and risk of complications following AF ablation in a nation-wide cohort.

METHODS AND RESULTS

We identified 35,211 patients (29.5% females) undergoing AF ablations from 2008-17 using national hospitalization data from Australia and New Zealand. The primary outcome was any procedural complication occurring up to 30-days after discharge. Logistic regression was used to adjust for differences in baseline characteristics between sexes. Compared with males, females were older (mean age 64.9 vs. 61.2 years), had higher rates of hypertension (14.0% vs. 11.6%) and hematological disorders (5.3% vs. 3.8%) and experienced a higher rate of procedural complications (6.96% vs. 5.41%) (all p<0.001). This gender disparity remained significant after adjustment (OR 1.25 [95%CI 1.14-1.38], p<0.001) and was driven by an increased risk of vascular injury (OR 1.86 [1.23-2.82], p=0.003), pericarditis (OR 1.86 [1.16-2.67], p=0.008), pericardial effusion (OR 1.71 [1.35-2.17], p< 0.001), and bleeding (OR 1.30 [1.15-1.46], p<0.001). Notably, the gender difference persisted over time (OR for the most recent period 1.19 [1.003-1.422], p=0.046) despite a declining complication rate in both men and women.

CONCLUSION

Females undergoing AF ablations experienced a 25% higher risk of procedural complications compared with males, a disparity that has persisted over time despite a falling complication rate. Efforts to reduce this gender disparity should focus on reducing the incidence of pericardial effusion, pericarditis, vascular injury, and bleeding.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Women and atrial fibrillation

Atrial fibrillation (AF) remains a growing problem in the United States and worldwide, imposing a high individual and health system burden, including increased resource consumption due to repeated hospitalizations, stroke, dementia, heart failure, and death. This comprehensive review summarizes the most recent data on sex-related differences in risks associated with AF. Women with AF have increased risk of stroke and death compared to men, and possible reasons for this disparity are explored. Women also continue to have worse symptoms and quality of life, and poorer outcomes with stroke prevention, as well as with rate and rhythm control management strategies. Many current rhythm control treatment strategies for AF, including cardioversion and ablation, are used less frequently in women as compared to men, whereas women are more likely to be treated with rate control strategies or antiarrhythmic drugs. Sex differences should be considered in treating women with AF to improve outcomes and women and men should be offered the same interventions for AF. We need to improve the evidence base to understand if variation in utilization of rate and rhythm control management between men and women represents health inequities or appropriate clinical judgement.

Predictors of Anticoagulation Use in Indigenous and Non-Indigenous Australians With Atrial Fibrillation

OBJECTIVE

Prior studies have demonstrated that anticoagulation underutilisation for atrial fibrillation (AF) and elevated stroke risk is common. However, there is little data on factors associated with appropriate anticoagulation, particularly in Indigenous Australians who face a disproportionate burden of AF and stroke. We thus sought to determine factors associated with anticoagulation use in Australians with AF.

DESIGN

Administrative, clinical, prescriptive and laboratory data were linked and aggregated over a 12-year period.

SETTING

Single tertiary teaching hospital.

PARTICIPANTS

19,305 (98%) and 308 (2%) consecutive non-Indigenous and Indigenous Australians with AF identified from administrative databases.

MAIN OUTCOME MEASURES

Associations of anticoagulation use according to ethnicity.

RESULTS

Significant independent predictors of anticoagulation use included hypertension (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.17-1.34; p<0.001), diabetes (OR 1.14, 95% CI 1.05-1.24; p=0.002), heart failure (OR 1.54 95% CI 1.43-1.66; p<0.001) and prior stroke or transient ischaemic attack (OR 2.07, 95% CI 1.84-2.33; p<0.001). In contrast, increasing age (OR 0.99, 95% CI 0.98-0.99; p<0.001), female gender (OR 0.88, 95% CI 0.82-0.93; p<0.001), and vascular disease (OR 0.72, 95% CI 0.64-0.80; p<0.001) were significant predictors of no anticoagulation. Hypertension was associated with less anticoagulation use in Indigenous compared to non-Indigenous Australians (p=0.02).

CONCLUSIONS

Anticoagulation for AF was suboptimal in both Indigenous and non-Indigenous Australians. Older age, female gender, and comorbid vascular disease were found to be negatively associated with anticoagulation. Importantly, hypertension may also be under-recognised as a stroke risk factor in Indigenous Australians. Future efforts to encourage anticoagulation use in accordance with guideline recommendations is likely to reduce the burden of AF-related stroke in both Indigenous and non-Indigenous populations.

Perception of atrial fibrillation in dependence of neuroticism

OBJECTIVE

Atrial fibrillation (AF) is associated with a varying symptom burden, which ranges from completely unawareness to disabling conditions. The present cross-sectional study tried to assess if neuroticism is associated with a greater degree of perception of AF related symptoms.

METHODS

162 patients who were considered for catheter ablation of AF were included. AF related symptom burden was quantified according to the European Heart Rhythm Association (EHRA) score. Personality traits were assessed using the Big Five personality traits (5BT).

RESULTS

Female patients reported higher symptom burden. Higher EHRA scores were furthermore associated with treatment with antiarrhythmic agents, digitalis, direct oral anticoagulants (DOAC), and antidepressant treatment, as well as suffering from heart failure or chronic kidney disease. Neuroticism showed a positive correlation to AF related symptom burden with significantly higher neuroticism scores in patients with higher EHRA scores (Rho = 0.41; 95%CI 0.26 to 0.53; p < .001), while no association was demonstrated for the other four personality traits. Multiple linear regression analysis revealed neuroticism as strongest independent predictor for symptomatic AF, followed by treatment with antiarrhythmic agents and DOAC.

CONCLUSIONS

Perception of AF related symptoms is a multifactorial process, which in our cohort was independently associated with neuroticism. Patients with higher symptom burden were also more likely to receive antiarrhythmic agents and DOAC, as well as antidepressants.

TRIAL REGISTRATION

German registry for clinical studies (DRKS), DRKS00019007.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Cardiovascular Diseases in Women: Policies and Practices Around the Globe to Achieve Gender Equity in Cardiac Health

The women's global health agenda has recently been reformulated to address more accurately cardiovascular disease (CVD) prevention, diagnosis, and treatment. The aim of the present work was to review the global and national policies and practices that address sex equality in health with a focus on CVDs in women. Scientific databases and health organizations' websites that presented/discussed policies and initiative targeting to enhance a sex-centered approach regarding general health and/or specifically cardiac health care were reviewed in a systematic way. In total, 61 relevant documents were selected. The selected policies and initiatives included position statements, national action plans, evidence-based guidelines, guidance/recommendations, awareness campaigns, regulations/legislation, and state-of-the art reports by national/international projects and conferences. The target audiences of large stakeholders (eg, American Heart Association, European Society of Cardiology, Centers for Disease Control and Prevention) were female citizens, health professionals, and researchers. Much as policy-makers have recognized the sex/gender gap in the CVD field, there is still much to be done. Thereby, tailor-made strategies should be designed, evaluated, and delivered on a global and most importantly a national basis to achieve gender equity with regard to CVDs.

The Euro Heart Survey and EURObservational Research Programme (EORP) in atrial fibrillation registries: contribution to epidemiology, clinical management and therapy of atrial fibrillation patients over the last 20 years

Management of atrial fibrillation (AF) may be challenging in clinical practice. Given the complexity of AF patients and the continuous advances in AF clinical management, there is a need for standardized programmes aimed at collecting so-called 'real-world clinical practice data' regarding the epidemiology, diagnostic/therapeutic/management practices and assessing adherence to guidelines. Over the past 20 years, the number of registries and surveys based on real-world AF patients has been dramatically increased. In Europe, based on the Euro Heart Survey (EHS) and the EURObservational Research Programme (EORP), a large series of studies based on these prospective, observational, large-scale multicentre registries on AF have been published. This narrative review gives an overview of these two projects on AF led by the European Society of Cardiology, focusing mainly on the contribution that these studies have provided to AF management and patient outcomes. Both the EHS and the EORP registries have collected a large amount of data regarding contemporary clinical practice, and despite some limitations, mainly related to their observational nature, these registries have contributed to our knowledge and clinical management of AF patients.

Psychological aspects of atrial fibrillation: A systematic narrative review : Impact on incidence, cognition, prognosis, and symptom perception

PURPOSE OF THE REVIEW

Atrial fibrillation (AF) is the most frequent arrhythmia in the general population. This review aims to provide a comprehensive overview of the psychological aspects of AF, compiling evidence from epidemiological, clinical, and basic research sources.

RECENT FINDINGS

Findings from large-scale population-based and clinical longitudinal studies reveal an association between negative affectivity (e.g. depression) and the incidence and clinical prognosis of AF. Studies investigating the impact of work stress parameters on AF onset show conflicting results. Researchers have reported the impact of AF on cognitive decline and on health-related quality of life, and have highlighted the role of interoceptive cues in the development of AF symptom burden and gender differences in psychological covariates of AF. Among biological pathways linking psychosocial factors to AF, research on autonomic regulation has yielded the most evidence so far, showing that the onset of AF is associated with simultaneous sympatho-vagal activation rather than an increase in vagal or sympathetic drive alone. Thus, modulation of the autonomic nervous system is likely to be a promising strategy for protecting the myocardium from pro-arrhythmic autonomic influences. In total, the findings show that AF is embedded as a disease condition in a psycho-societal context and is not an isolated medical problem per se. A broader perspective than a focus on the electrophysiology alone is urgently needed.

Acute Stroke During Pregnancy and Puerperium

BACKGROUND

Acute stroke during pregnancy or within 6 weeks of childbirth is devastating for the mother and her family, yet data regarding incidence and contemporary trends are very limited.

OBJECTIVES

This study sought to investigate the incidence and outcomes of acute stroke and transient ischemic attack during pregnancy or within 6 weeks of childbirth in a large database.

METHODS

The National Inpatient Sample was queried to identify women age ≥18 years in the United States with pregnancy-related hospitalizations from January 1, 2007, to September 30, 2015. Temporal trends in acute stroke (ischemic and hemorrhagic)/transient ischemic attack incidence and in-hospital mortality were extracted.

RESULTS

Among 37,360,772 pregnancy-related hospitalizations, 16,694 (0.045%) women had an acute stroke. The rates of acute stroke did not change (42.8 per 100,000 hospitalizations in 2007 vs. 42.2 per 100,000 hospitalizations in 2015; p_trends = 0.10). Among those with acute stroke, there were increases in prevalence of obesity, smoking, hyperlipidemia, migraine, and gestational hypertension. Importantly, in-hospital mortality rates were almost 385-fold higher among those who had a stroke (42.1 per 1,000 pregnancy-related hospitalizations vs. 0.11 per 1,000 pregnancy-related hospitalizations; p < 0.0001). The rates of in-hospital mortality among pregnant women with acute stroke decreased (5.5% in 2007 vs. 2.7% in 2015; p_trends < 0.001).

CONCLUSIONS

In this contemporary analysis of pregnancy-related hospitalizations, acute stroke occurred in 1 of every 2,222 hospitalizations, and these rates did not decrease over approximately 9 years. The prevalence of most stroke risk factors has increased. Acute stroke during pregnancy and puerperium was associated with high maternal mortality, although it appears to be trending downward. Future studies to better identify mechanisms and approaches to prevention and management of acute stroke during pregnancy and puerperium are warranted.

Atrial fibrillation in the elderly: a risk factor beyond stroke

Atrial fibrillation (AF) represents the most common arrhythmia worldwide and its prevalence exponentially increases with age. It is related to increased risk of ischemic stroke or systemic embolism, which determines a significant burden of morbidity and mortality, as widely documented in the literature. AF also constitutes a risk factor for other less investigated conditions, such as heart failure, pulmonary embolism, impairment in physical performance, reduced quality of life, development of disability, mood disorders and cognitive impairment up to dementia. In the elderly population, the management of AF and its complications is particularly complex due to the heterogeneity of the ageing process, the lack of specific evidence-based recommendations, as well as the high grade of comorbidity and disability characterizing the over 65 years aged people. In the present review, we aim to summarize the pieces of the most updated evidence on AF complications beyond stoke, mainly focusing on the elderly population.

Impact of Female Sex on Clinical Presentation and Ablation Outcomes in the CIRCA-DOSE Study

OBJECTIVES

This study sought to evaluate sex-specific differences in atrial fibrillation (AF) presentation and catheter ablation outcomes in the prospective, multicenter, randomized CIRCA-DOSE (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration) study.

BACKGROUND

Similar to other cardiovascular conditions, significant sex-specific differences have been observed in the epidemiology, pathophysiology, presentation, and natural history of AF. Unfortunately, there are major gaps in our understanding of the pathophysiological basis for the observed sex-specific differences and their implications on therapy and prognosis.

METHODS

This study examined sex-specific differences in AF presentation, symptom severity and health-related quality of life, symptomatic and asymptomatic arrhythmia recurrence, AF burden, and health care utilization.

RESULTS

Freedom from any atrial tachyarrhythmia and symptomatic atrial tachyarrhythmia were similar between male (hazard ratio: 1.18; 95% confidence interval: 0.85 to 1.64; p = 0.39) and female patients (hazard ratio: 1.00; 95% confidence interval: 0.62 to 1.59; p = 0.92). Post-ablation, the median AF burden (percentage time in AF) was 0.00% (interquartile range: 0.00% to 0.16%) in male patients and 0.00% (interquartile range: 0.00% to 0.17%) in female patients, with no difference observed between the sexes (p = 0.30). Periprocedural complications occurred twice as frequently in female patients (3.5% vs. 7.0%; p = 0.18). In comparison to male patients, female patients reported a significantly worse symptom score and quality of life at baseline and all follow-up intervals, but they derived similar magnitude of improvement post-ablation. There was no difference between male and female patients with respect to emergency department visits, hospitalization, cardioversion, or repeat ablation.

CONCLUSIONS

When compared with male patients, female patients have significantly worse symptom scores and quality of life at baseline. Despite this, female patients with symptomatic paroxysmal AF derive similar benefit in freedom from recurrent arrhythmia and similar improvements in quality of life following AF ablation. (Cryoballoon vs. Irrigated Radiofrequency Catheter Ablation: Double Short vs. Standard Exposure Duration [CIRCA-DOSE]; NCT01913522).

Sex Differences in Quality of Life in Patients With Atrial Fibrillation: A Systematic Review

Background The goal of this literature review was to assess sex differences in the quality of life (QoL) in patients with atrial fibrillation ( AF ) and, if possible, to determine if these are due to AF . Methods and Results The electronic database PubMed was searched on January 23, 2018, using the search terms "QoL", gender differences, " AF " female, and gender to find potential articles that assessed sex differences in QoL in AF patients. In all, 851 articles were identified, from which 25 original studies were eligible for this systematic review. Female AF patients were found to have poorer QoL and more symptoms than male AF patients. They scored lower, predominantly on the physical component score of the Medical Outcomes Study Short-Form 36 Health Survey. Conclusions The available literature consistently describes poorer QoL in female AF patients but does not clearly address whether this is a reflection of sex differences seen in the general population or is related to AF per se. It is also questionable whether the relatively poorer QoL in women is large enough to be of clinical importance.

Role of Gender and Race in Patient-Reported Outcomes and Satisfaction

The role of gender, race, and socioeconomic status in outcomes and satisfaction are reflected in patient-reported outcomes using measurement tools representing outcome domains. These domains include pain relief, physical and emotional functioning, adverse events, participant disposition, and patient satisfaction. Measurement tools exist for each of the outcomes in both acute and chronic pain. Patients with lower economic status have greater difficulty accessing care, are involved less in shared decision-making process, and are less satisfied with their care. Blacks, Hispanics, and Asians also have increased difficulty in accessing good quality care. Women have inferior outcomes after medical and surgical interventions.

Effectiveness and safety of atrial fibrillation ablation in females

BACKGROUND

Existing data on the effectiveness and safety of atrial fibrillation (AF) ablation in females are limited to studies of small sample size, lacking longer term follow-up or adjustment for potential confounders.

METHODS

A total of 6421 patients (2072 females) undergoing a first AF ablation procedure after enrollment in the Chinese Atrial Fibrillation Registry (China-AF) study between August 2011 and December 2017 were analyzed. We evaluated the effectiveness (recurrence of documented [symptomatic or not] atrial tachyarrhythmia (AT)) and the safety (incidence of procedure-related complications) of AF ablation in female patients compared to male patients. Sensitivity analyses based on routine data were also utilized to avoid potential sex differences in reporting of AF symptoms.

RESULTS

Females were about 5 years older than males at the time of ablation (mean age 63.4 ± 9.5 vs 58.3 ± 10.8, P < .0001). A higher proportion of female patients had paroxysmal AF (74.3% vs 56.7%, P < .0001), hypertension (69.7% vs 61.3%, P < .0001), and hyperlipidemia (57.2% vs 52.9%, P = .001). Female sex was found to be an independent risk factor of AT recurrence in multivariate analyses (HR = 1.26, 95% CI 1.15-1.38, P < .0001). These findings were confirmed in sensitivity analyses using only Holter data. Female sex was also associated with a higher risk of periprocedural complications after adjustment for baseline variables (OR = 1.41, 95% CI 1.03-1.94, P = .03).

CONCLUSIONS

Female sex is an independent risk factor of AT recurrence and periprocedural complications after AF ablation.

Significant association between DHFR promoter methylation and ischemic stroke in a Chinese hypertensive population

Objective

DHFR encodes dihydrofolate reductase, a major enzyme in the metabolism of folate, and is a candidate gene for ischemic stroke (IS). Therefore, we aimed to investigate the association between DHFR promoter methylation and IS in a Chinese population with primary hypertension.

Methods

Quantitative methylation‐specific PCR was used to measure the level of DHFR promoter methylation. A multivariate logistic regression model was used to investigate the association between DHFR promoter methylation and IS. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic value of DHFR promoter methylation for IS.

Results

The level of methylation of the DHFR promoter in the IS group was significantly lower than that in the hypertensive group (median [interquartile range]: 9.11 [2.81‐16.20] vs 24.94 [7.16‐56.45], P < .001). DHFR promoter methylation and homocysteine (Hcy) levels were both related to IS, with an ORs (95% CI) of 0.976 (0.967‐0.984) and 1.057 (1.027‐1.108), respectively. The areas under the curve for the diagnosis of DHFR promoter hypomethylation in IS were 0.603 (95% CI, 0.527‐0.678) in men and 0.754 (95% CI, 0.693‐0.815) in women. A dual‐luciferase reporter assay revealed that the target sequence in the DHFR promoter upregulated gene expression.

Conclusion

There is a significant association between methylation of the DHFR promoter and IS in this Chinese hypertensive population. Hypomethylation of the DHFR promoter may serve as a novel marker for the diagnosis of IS in women.

Risk factors for severe bleeding events during warfarin treatment: the influence of sex, age, comorbidity and co-medication

PURPOSE

To investigate risk factors for severe bleeding during warfarin treatment, including the influence of sex, age, comorbidity and co-medication on bleeding risk.

METHODS

Patients initiating warfarin treatment between 2007 and 2011 were identified in the nationwide Swedish Prescribed Drug Register, and diagnoses of severe bleeding were retrieved from the National Patient Register. Hazard ratios (HR) with 95% confidence intervals (CI) for severe bleeding were estimated using multiple Cox regression adjusting for indications and including covariates age, sex, comorbidities and co-medications. Interactions between sex and other covariates were investigated.

RESULTS

The study cohort included 232,624 patients ≥ 18 years (101,011 women and 131,613 men). The incidence rate of severe bleeding was 37 per 1000 person-years, lower among women than men with an adjusted HR (95% CI) of 0.84 (0.80-0.88). Incidence of bleeding increased with age, HR 2.88 (2.37-3.50) comparing age ≥ 80 to < 40 years, and comorbidities associated with the highest risk of severe bleeding were prior bleeding, HR 1.85 (1.74-1.97); renal failure, HR 1.82 (1.66-2.00); and alcohol dependency diagnosis, HR 1.79 (1.57-2.05). Other comorbidities significantly associated with bleeding events were hypertension, diabetes, peripheral vascular disease, congestive heart failure, liver failure, stroke/TIA, COPD and cancer.

CONCLUSION

Most of the well-established risk factors were found to be significantly associated with bleeding events in our study. We additionally found that women had a lower incidence of bleeding. Potential biases are selection effects, residual confounding and unmeasured frailty.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Atrial Fibrillation in Middle Eastern Arabs and South Asians: Summary of Published Articles in the Arabian Gulf

Seven studies are summarized herein focusing on different aspects of Atrial fibrillation (AF) in two unique ethnicities for which there is very limited literature published before; Middle Eastern Arabs and South Asians, using data from a national registry of cardiovascular diseases in Qatar over a 20-years period (1991-2010). These studies shed light upon important aspects of AF presentations and outcomes in these two ethnicities, thereby enriching the world literature on AF. In the process, several novel observations were reported and new questions were raised that warrant further investigations.

Atrial fibrillation-related stroke in women: Evidence and inequalities in epidemiology, mechanisms, clinical presentation, and management

Background

Atrial fibrillation (AF) is the most common clinical arrhythmia and one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. Despite substantial advances in (interventional) rhythm control treatment during the last decade, anticoagulation for stroke prevention remains a major component of AF treatment.

Hypothesis

There are important sex‐specific differences in AF‐related stroke, resulting from sex‐specific mechanisms and therapeutic differences.

Methods

This review summarizes available data on sex differences in risk assessment and prevention of stroke and highlights current knowledge gaps in AF‐related stroke mechanisms, prevention and management that warrant further research.

Results

Increased thrombotic risk in women is multifactorial, involving hormonal changes after menopause, structural, endocrine and lifestyle/social factors and their interactions. It is clear from randomized studies that women benefit from anticoagulant treatment and that their bleeding risk is similar to men. Women should therefore receive equivalent treatment to men, based on the validated criteria for anticoagulation therapy. However, women are not represented equally in the large randomized studies and sex‐related information in many fields is lacking.

Conclusions

Female sex is an established risk factor for stroke in AF patients. The evidence for sex‐specific differences in stroke risk assessment and stroke prevention is accumulating. However, the underlying biological mechanisms remain incompletely understood and further studies are required in order to decrease AF‐related morbidity and mortality.

Association of sex and atrial fibrillation therapies with patient-reported outcomes

OBJECTIVES

Women report higher atrial fibrillation (AF) symptom severity and receive less AF therapies than their male counterparts. It is understudied if differences in AF therapies received explains sex differences in AF symptom severity. We investigate the impact of sex and AF therapies on patient-reported outcomes.

METHODS

Participants were recruited (n=953) across four academic medical centres with an AF diagnosis and age ≥18 years. Patient-reported outcomes (AF symptom severity, AF-related quality of life, functional status and emotional status) were determined by biannual surveys. We performed multiple linear regressions on propensity-matched cohorts to determine the association of AF therapies and sex on patient-reported outcomes.

RESULTS

Our study population (n=953) was 65% male (n=616), 93% white (n=890) and 72 (±10) years old. Individuals receiving rate control therapy reported comparatively lower AF-related quality of life (-7.22, 95% CI -11.51 to -2.92) and poorer functional status (-3.69, 95% CI -5.27 to -2.12). Individuals receiving rhythm control strategies did not report significantly different patient-reported outcomes. Women were more likely to report poorer functional status (-2.63, 95% CI -3.86 to -1.40) and poorer AF-related quality of life, higher anxiety (2.33, 95% CI 1.07 to 3.59), higher symptoms of depression (1.48, 95% CI 0.31 to 2.65) and AF symptom severity (0.29, 95% CI 0.07 to 0.52).

CONCLUSIONS

Female sex was associated with comparatively poorer AF symptom severity and quality of life, and this association remained after accounting for AF therapies received. Receiving rate control medication alone was associated with comparatively poorer AF-related quality of life and functional status.

Sex Differences in Presentation, Quality of Life, and Treatment in Chinese Atrial Fibrillation Patients: Insights from the China Atrial Fibrillation Registry Study

<strong>BACKGROUND</strong> There is a growing recognition of sex-related disparities in atrial fibrillation (AF). However, limited data is available in Chinese AF patients. <strong>MATERIAL AND METHODS</strong> We compared symptoms, quality of life (QoL), and treatment of AF according to sex from the China AF Registry study. <strong>RESULTS</strong> We studied 14 723 patients with non-valvular AF, of whom 5645 patients (38.3%) were female. Women were older than men (67.5±10.6 vs. 62.2±12.2). Compared to men, women had more comorbidities and a higher proportion of CHA₂DS₂-VASC score ≥2. Women with AF experienced more severe or disabling symptoms than men (33.7% vs. 22.9% in age <75 group; 40.3% vs. 28.7% in age ≥75 group; both P<0.0001). After multivariate analysis, women with AF still had lower QoL (OR 0.69; 95%CI, 0.63-0.76; P<0.0001). Women tended to have lower rates of ablation and rhythm-control drug use in those aged <75 years. Oral anticoagulant use was low and had no sex difference in AF patients with a CHA₂DS₂-VASC score ≥2. <strong>CONCLUSIONS</strong> In Chinese AF patients, women were older and more symptomatic, and had worse QoL. Despite all these differences, women tended to receive less rhythm-control treatment in those aged <75 years. Oral anticoagulant was substantially underused in high stroke risk patients, regardless of sex.

Gender Differences in Arrhythmias: Focused on Atrial Fibrillation

There are significant differences in clinical presentation and treatment of atrial fibrillation (AF) between women and men. The primary goal of AF management is to restore sinus rhythm and to prevent various complications, including stroke and heart failure. In many areas of AF, such as prevalence, clinical manifestations, morbidity, risk factors, pathophysiology, treatment strategies, and complications, gender-specific variability is observed and needs to be further addressed by large-scale population researches or randomized clinical trials, which help to promote the customization of AF treatment programs, hence to maximize the success rate of AF therapy in both sexes. This review highlights our current understanding of these gender differences in AF and how these differences affect treatment decisions on AF.

Gender and age differences in symptoms and health-related quality of life in patients with atrial fibrillation referred for catheter ablation

BACKGROUND

Primary indication for catheter ablation of atrial fibrillation (AF) is to reduce symptoms and improve health-related quality of life (HRQoL). There are data showing differences between the genders and between younger and older patients. To evaluate this, we studied a large Scandinavian cohort of patients referred for catheter ablation of AF.

METHODS

Consecutive patients filled out the ASTA questionnaire, assessing symptoms, HRQoL, and perception of arrhythmia, prior to ablation. Patients were recruited from four Swedish and one Danish tertiary center.

RESULTS

A total of 2493 patients (72% men) filled out the ASTA questionnaire. Women experienced eight of the nine ASTA scale symptoms more often than men. Patients <65 years reported four symptoms more often, only tiredness was more frequent in those ≥65 years (P = .007). Women and patients <65 years experienced more often palpitations and regarding close to fainting and this was more common among women, no age differences were seen. Women and men scored differently in 10 of the 13 HRQoL items. Only negative impact on sexual life was more common in men (P < .001). Older patients reported more negative influence in four of the HRQoL items and the younger in one; ability to concentrate.

CONCLUSIONS

Women experienced a more pronounced symptom burden and were more negatively affected in all HRQoL concerns, except for the negative impact on sexual life, where men reported more influence of AF. Differences between age groups were less pronounced. Disease-specific patient-reported outcomes measures (PROMs) add important information where gender differences should be considered in the care.

Outcomes and Resource Utilization Associated With Readmissions After Atrial Fibrillation Hospitalizations

Background

Atrial fibrillation is the most common arrhythmia worldwide. Data regarding 30‐day readmission rates after discharge for atrial fibrillation remain poorly reported.

Methods and Results

The Nationwide Readmission Database (2010–2014) was queried using the International Classification of Diseases, Ninth Revision (ICD‐9) codes to identify study population. Incidence, etiologies of 30‐day readmission and predictors of 30‐day readmissions, and cost of care were analyzed. Among 1 723 378 patients who survived to discharge, 249 343 (14.4%) patients were readmitted within 30 days. Compared with the readmitted group, the nonreadmitted group had higher utilization of electrical cardioversion and catheter ablation. Atrial fibrillation was the most common cause of readmission (24.1%). Median time to 30‐day readmission was 13 days. Advancing age, female sex, and longer stay during index hospitalization predicted higher 30‐day readmissions, whereas private insurance, electrical cardioversion, catheter ablation, higher income, and elective admissions correlated with lower 30‐day readmission. Comorbidities such as heart failure, neurological disorder, chronic obstructive pulmonary disease, diabetes mellitus, chronic kidney disease, chronic liver failure, coagulopathy, anemia, peripheral vascular disease, and electrolyte disturbance, correlated with increased 30‐day readmissions and cost burden. Trend analysis showed a progressive decline in 30‐day readmission rates from 14.7% in 2010 to 14.3% in 2014 (P trend, <0.001).

Conclusions

Approximately 1 in 7 patients were readmitted within 30 days of discharge, with symptomatic atrial fibrillation being the most common cause. We identified a predictive model for increased risk of readmissions and treatment expense. Electrical cardioversion during index admission was associated with a significant reduction in 30‐day readmissions and service charges. The 30‐day readmissions correlated with a substantial rise in the cost of care.

In-hospital and 12-month follow-up outcome from the ESC-EORP EHRA Atrial Fibrillation Ablation Long-Term registry: sex differences

Aim

The purpose of this study was to compare sex differences of atrial fibrillation (AF) catheter ablation (CA) and to analyse the opportunities for improved outcomes.

Methods and results

All data were collected from the Atrial Fibrillation Ablation Long-Term registry, a prospective, multinational study conducted by the ESC-EORP European Heart Rhythm Association (EHRA) under the EURObservational Research Programme (ESC-EORP). A total of 104 centres in 27 European countries participated. Of 3593 included patients, 1146 (31.9%) were female. Female patients were older (61.0 vs. 56.4 years; P &lt; 0.001), had more comorbidities (hypertension, diabetes, and obesity), more episodes of arrhythmias per month (6.9 vs. 6.2; P &lt; 0.001), and a higher average EHRA score (2.6 vs. 2.4; P &lt; 0.001). The duration of the procedure was shorter in females (160.1 min vs. 167.9 min; P &lt; 0.001), irrespective of additional ablation lesions added to pulmonary vein isolation. Overall cardiovascular complications were more frequent in women than in men (5.7% vs. 3.4%; P &lt; 0.001). Furthermore, cardiac perforations (3.8% vs. 1.3%; P = 0.011) and neurological complications (2.2% vs. 0.3%; P = 0.004) were found in females in less experienced centres than in experienced ones. On a final note, at 12 months, AF recurrence rate was similar in females and males (34.4% vs. 34.2%; P = 0.897), but more females were still on antiarrhythmic drugs (50.6% vs. 44.1%; P &lt; 0.001) when compared with men.

Conclusion

Females underwent CA procedures for AF less frequently than males throughout Europe, despite more recurrent symptoms. With the same success rate, severe acute complications remained considerable in females, especially in less experienced centres.

Sex Differences in Risk Factors for Incident Atrial Fibrillation (from the Reasons for Geographic and Racial Differences in Stroke [REGARDS] Study)

We examined whether the sex differences in atrial fibrillation (AF) is related to difference in risk factors leading to AF or due to a differential impact of the same risk factors in 11,806 participants (55.2 % women) from the REGARDS study. Incident AF was ascertained by electrocardiograms and medical history at a follow-up examination. Backwards elimination logistic regression was used to identify AF risk factors in men and women, separately. Over a median follow-up of 9.0years, 588 (11.1%) men and 428 (6.6%) women (p value <0.001) developed AF. Men had a higher risk of AF than women (age and race adjusted odds ratio [OR] [95% confidence interval (CI)]: 1.61 [1.26, 1.75]). Age, white race, height, weight, use of blood pressure lowering medications and history of cardiovascular disease were identified by backward elimination as AF risk factors shared by both sexes. On the other hand, diabetes was an AF risk factor in women but not in men. Among the shared risk factors between men and women, only age showed a stronger association in women than in men [Interaction p-value = 0.003]. Adjustment for the shared risk factors eliminated the sex difference in AF risk (OR [95% CI]: 0.90 [0.74, 1.09]), which was more noticeable in those younger than the median age (62 years) compared to those who were older (interaction p value 0.003). In conclusion, women and men share several AF risk factors, and these shared risk factors explain the sex differences. However, age association with AF differs by sex, and age modifies the associations between sex and other AF risk factors.

Gender Differences in Atrial Fibrillation: A Review of Epidemiology, Management, and Outcomes

Atrial fibrillation is the most common sustained cardiac arrhythmia. The scope and impact of atrial fibrillation are wide; it can affect cardiac function, functional status, and quality of life, and it confers a stroke risk. There are sex differences in atrial fibrillation across the scope of the disease process, from epidemiology and causative mechanisms to management and outcomes. The approach to management of atrial fibrillation differs between women and men, and there are sex differences in response to medical therapy and catheter ablation. There are many gaps in our knowledge of the gender differences in atrial fibrillation, and many opportunities for future research.

Association of sex, age and education level with patient reported outcomes in atrial fibrillation

BACKGROUND

In atrial fibrillation (AF), there are known sex and sociodemographic disparities in clinical outcomes such as stroke. We investigate whether disparities also exist with respect to patient-reported outcomes. We explored the association of sex, age, and education level with patient-reported outcomes (AF-related quality of life, symptom severity, and emotional and functional status).

METHODS

The PaTH AF cohort study recruited participants (N = 953) with an AF diagnosis and age ≥ 18 years across 4 academic medical centers. We performed longitudinal multiple regression with random effects to determine if individual characteristics were associated with patient-reported outcomes.

RESULTS

Women reported poorer functional status (β - 2.23, 95% CI: -3.52, - 0.94) and AF-related quality of life (β - 4.12, 95% CI: -8.10, - 0.14), and higher symptoms of anxiety (β 2.08, 95% CI: 0.76, 3.40), depression (β 1.44, 95% CI: 0.25, 2.63), and AF (β 0.29, 95% CI: 0.08, 0.50). Individuals < 60 years were significantly (p < 0.05) more likely to report higher symptoms of depression, anxiety, and AF, and poorer AF-related quality of life. Lack of college education was associated with reporting higher symptoms of AF (β 0.42, 95% CI: 0.17, 0.68), anxiety (β 1.86, 95% CI: 0.26, 3.45), and depression (β 1.11, 95% CI: 0.15, 2.38), and lower AF-related quality of life (β - 4.41, 95% CI: -8.25, - 0.57) and functional status.

CONCLUSION

Women, younger adults, and individuals with lower levels of education reported comparatively poor patient-reported outcomes. These findings highlight the importance of understanding why individuals experience AF differently based on certain characteristics.

Established and novel risk factors for atrial fibrillation in women compared with men

BACKGROUND

Atrial fibrillation (AF) is a stronger risk factor for cardiovascular disease in women than men. We assessed whether there are sex differences in the effects of 43 established and novel risk factors and the risk of incident AF.

METHODS

Data were used from the Scottish Heart Health Extended Cohort, a prospective cohort study with over 20 years of follow-up for AF incidence. Cox regression models were used to obtain the adjusted sex-specific HRs and 95% CIs, and the women-to-men ratio of HRs (RHRs), of incident AF associated with personal characteristics, smoking, physical measurements, diabetes mellitus, lipid, inflammatory, cardiac, and diet- and renal-related markers.

RESULTS

Overall, 15 737 participants (52% women) were included. There were sex differences in the relationship between a 1 SD increase in body mass index (BMI), NT-pro-BNP, uric acid, and cystatin-C and the risk of AF. The HRs were 1.17 (95% CI 1.08 to 1.27) in women and 1.36 (95% CI 1.24 to 1.49) in men for BMI (RHR 0.86, 95% CI 0.77 to 0.97); 1.84 (95% CI 1.62 to 2.09) in women and 1.54 (95% CI 1.40 to 1.68) in men for NT-pro-BNP (RHR 1.22, 95% CI1.05 to 1.42); 1.27 (95% CI 1.14 to 1.41) in women and 1.10 (95% CI 1.00 to 1.20) in men for uric acid (RHR 1.17, 95% CI 1.01 to 1.35); and 1.22 (95% CI 1.13 to 1.32) in women and 1.07 (95% CI 0.96 to 1.18) in men for cystatin-C (RHR 1.16, 95% CI 1.05 to1.27).

CONCLUSION

Higher BMI is a stronger risk factor for AF in men whereas elevated NT-pro-BNP, uric acid and cystatin-C were more strongly associated with the risk of AF in women.

The safety of NOACs in atrial fibrillation patient subgroups: A narrative review

AIM

Four non-vitamin K oral anticoagulants (NOACs) have been evaluated in clinical trials for the prevention of stroke in patients with atrial fibrillation (AF). Although each of the NOACs have been shown to be at least non-inferior to warfarin for efficacy and safety outcomes, controversy remains over the relative safety of each NOAC inpatient subgroups. This narrative review provides an overview of phase III data on NOAC trials for the prevention of stroke in AF, with a focus on reporting the safety of each agent in key patient subgroups based on age, gender, accumulated risk factors, and primary or secondary prevention of stroke.

METHODS

A comprehensive literature search was completed and, where data permit, analyses of phase III trials of the NOACs are presented for each patient subgroup.

RESULTS

Analyses of key safety outcomes from NOAC trials were completed using primary trial data, including major bleeding and all-cause mortality. The safety of NOACs was generally consistent and favourable compared with warfarin according to patient age, gender, previous history of stroke, and the presence of risk factors for stroke.

CONCLUSIONS

The safety of the NOACs compared with warfarin was generally favourable across different patient subgroups, including those perceived to be at "high risk" for adverse outcomes. However, certain NOACs may be preferable to warfarin in some subgroups, based on indirect analyses.

Laminar shear stress alters endothelial KCa2.3 expression in H9c2 cells partially via regulating the PI3K/Akt/p300 axis

In cardiac tissues, myoblast atrial myocytes continue to be exposed to mechanical forces including shear stress. However, little is known about the effects of shear stress on atrial myocytes, particularly on ion channel function, in association with disease. The present study demonstrated that the Ca²⁺-activated K⁺ channel (KCa)2.3 serves a vital role in regulating arterial tone. As increased intracellular Ca²⁺ levels and activation of histone acetyltransferase p300 (p300) are early responses to laminar shear stress (LSS) that result in the transcriptional activation of genes, the role of p300 and the phosphoinositide3-kinase (PI3K)/protein kinase B (Akt) pathway, an intracellular pathway that promotes the growth and proliferation rather than the differentiation of adult cells, in the LSS-dependent regulation of KCa2.3 in cardiac myoblasts was examined. In cultured H9c2 cells, exposure to LSS (15 dyn/cm²) for 12 h markedly increased KCa2.3 mRNA expression. Inhibiting PI3K attenuated the LSS-induced increases in the expression and channel activity of KCa2.3, and decreased the phosphorylation levels of p300. The upregulation of these channels was abolished by the inhibition of Akt through decreasing p300 phosphorylation. ChIP assays indicated that p300 was recruited to the promoter region of the KCa2.3 gene. Therefore, the PI3K/Akt/p300 axis serves a crucial role in the LSS-dependent induction of KCa2.3 expression, by regulating cardiac myoblast function and adaptation to hemodynamic changes. The key novel insights gained from the present study are: i) KCa2.3 was upregulated in patients with atrial fibrillation (AF) and in patients with AF combined with mitral value disease; ii) LSS induced a profound upregulation of KCa2.3 mRNA and protein expression in H9c2 cells; iii) PI3K activation was associated with LSS-induced upregulation of the KCa2.3 channel; iv) PI3K activation was mediated by PI3K/Akt-dependent Akt activation; and v) LSS induction of KCa2.3 involved the binding of p300 to transcription factors in the promoter region of the KCa2.3 gene.

Sex-related risks of recurrence of atrial fibrillation after ablation: Insights from the Guangzhou Atrial Fibrillation Ablation Registry

BACKGROUND

Female sex has been linked with worse prognosis in patients with atrial fibrillation (AF). Clinical risk stratification of women with AF may help decision-making before catheter ablation (CA).

AIM

To evaluate arrhythmia outcomes and the predictive value of clinical scores for arrhythmia recurrence in a large cohort of Chinese patients with AF undergoing CA.

METHODS

A total 1410 of patients (68.1% men) who underwent AF ablation with scheduled follow-up were analysed retrospectively. Baseline characteristics and ablation outcome were compared between men and women. The predictive values of risk scoring systems for AF recurrence were assessed in women.

RESULTS

Recurrence, early recurrence and complications after CA were similar in women and men over similar follow-up periods (20.7±8.0 vs 20.7±9.1 months; P>0.05). Compared with men, women with AF recurrence were older and had a larger left atrial diameter (LAD), less paroxysmal AF, lower left ventricular ejection fraction, lower estimated glomerular filtration rate (eGFR) and higher serum concentrations of B-type natriuretic peptide (BNP) and C-reactive protein (CRP) (all P<0.01). Multivariable analysis showed that age, non-paroxysmal AF, body mass index, coronary artery disease, LAD, early recurrence, eGFR, BNP and CRP were independent risk factors with sex differences (all P<0.05) in the whole cohort. In women, only non-paroxysmal AF, early recurrence, BNP, CRP (all P<0.01) and history of stroke/transient ischaemic attack (P=0.016) were independent risk factors. Of the clinical scoring systems tested, MB-LATER, APPLE, CAAP-AF and BASE-AF₂ scores (C-indexes 0.73, 0.72, 0.68 and 0.72, respectively; all P<0.01) had a modest predictive value for AF recurrence after CA in women.

CONCLUSIONS

CA for AF has similar recurrence risks in women and men, but there are sex differences in the clinical characteristics and risk factors associated with AF recurrence.

Female Sex as a Risk Factor for Ischemic Stroke and Systemic Embolism in Chinese Patients With Atrial Fibrillation: A Report From the China-AF Study

Background Previous studies have provided conflicting results as to whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation ( AF ). We investigated whether women with AF were at higher risk of ischemic stroke in the China-AF (China Atrial Fibrillation Registry) Study. Methods and Results A total of 19 515 patients were prospectively enrolled between August 2011 and December 2016 in the China- AF Study. After exclusion of patients receiving anticoagulation or ablation therapy, 6239 patients (2574 women) with results from at least 6 months of follow-up were used for the analysis. Cox proportional hazards models were performed to evaluate whether female sex was an independent risk factor for thromboembolism after multivariate adjustment. The primary outcome was the time to the first occurrence of ischemic stroke or systemic embolism. After a mean follow-up of 2.81±1.46 years, 152 female patients reached the primary outcome, as compared with 172 male patients. Crude incidence rates of thromboembolism between women and men were of borderline statistical significance (2.08 versus 1.68 per 100 patient-years, P=0.058). After multivariable analysis, female sex was not independently associated with an increased thromboembolism risk (hazard ratio 1.09, 95% confidence interval 0.86-1.39). There was no significant difference in thromboembolism risk by sex stratified by age and presence or absence of risk factors ( P for interaction all >0.1). Conclusions Although crude incidence rates of thromboembolism were higher in Chinese female patients with AF compared with male patients, female sex did not emerge as an independent risk factor for thromboembolism on multivariate analysis. Clinical Trial Registration URL : http://www.chictr.org.cn/ . Unique identifier: Chi CTR - OCH -13003729.