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.

Diagnostic Blind Spot: Physicians Overlook Atrial Fibrillation in Pacemaker-Dependent Patients

BACKGROUND

Pacemaker recipients demonstrate a higher prevalence of atrial fibrillation (AF), yet the regular ventricular activation in pacemaker-dependent patients with AF presents a substantial diagnostic challenge.

METHODS

A total of 310 medical practitioners completed a brief, validated survey consisting of three electrocardiograms displaying AF with ventricular pacing. Participants were instructed to identify the underlying rhythm.

RESULTS

Cardiologists outperformed all other groups with 69% correct responses, followed by emergency physicians (33%) and internists (24%). The poorest performance was observed among primary care physicians (14%) and medical interns (12%) (p < 0.0001). The comparison between groups revealed a statistically significant difference between cardiologists and non-cardiologists (p < 0.001).

CONCLUSION

The detection of AF in patients with ventricular-paced rhythm remains a significant diagnostic challenge, with notable gaps even among cardiologists. It is imperative to educate physicians that AF in this context may not present with the typical irregular rhythm. Routine interrogation of cardiac devices in cases where the rhythm is unclear can facilitate a timely and accurate diagnosis of this concealed arrhythmia.

Predictors of atrial fibrillation recurrence after pulmonary vein ablation: Clinical and radiological risk factors

BACKGROUND AND OBJECTIVE

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. Previous studies have described that certain clinical characteristics such as age, obesity, the type of AF, and imaging-based factors, such as left atrial (LA) volume, mean density (calculated as the average of Hounsfield Units values in a certain región of interest), and volume of cardiac adipose tissue, may increase the risk of recurrence following pulmonary vein ablation. However, there have been contradictory results regarding radiological variables in previous studies. The objective of this study was to evaluate these clinical and radiological risk factors obtained from computed tomography (CT) studies.

MATERIALS AND METHODS

This retrospective case-control study included all patients with AF who underwent initial radiofrequency or cryoablation of pulmonary veins after undergoing contrast-enhanced CT between 2017 and 2021. Clinical variables such as age, gender, comorbidities, medications used after ablation, type of AF, and radiological variables obtained from volumetric segmentation of CT studies were collected. Radiological variables included LA volume, mean density, and volume of epicardial, periatrial, and interatrial adipose tissue. The occurrence or absence of AF recurrence within 12 months after ablation was also recorded. These variables were subjected to univariate and multivariate analysis to evaluate the risk of recurrence.

RESULTS

Among the total number of included patients, 40 had paroxysmal AF and 12 had persistent AF. During the follow-up period, 12 patients (23.1%) experienced AF recurrence, while 40 patients (76.9%) remained in sinus rhythm. There were statistically significant differences in LA volume based on the type of AF, with higher volumes observed in patients with persistent AF (119.16 +/- 32.38 cc) compared to the rest (90.99 +/- 28.34 cc). Regarding the differences between patients with and without recurrence after ablation, only LA volume (p < 0.05) and periatrial adipose tissue volume (p < 0.01) were significantly higher in patients with recurrence.

CONCLUSION

The type of atrial fibrillation, increased left atrial volume, and increased periatrial adipose tissue volume are risk factors for recurrence in patients with atrial fibrillation undergoing pulmonary vein ablation using cryoablation or radiofrequency.

The COOL-AF Phase 2 Registry: COhort of Antithrombotic Use and Clinical Outcomes in Atrial Fibrillation Patients

Background

Atrial fibrillation (AF) is a common condition leading to an increased risk of death and complications such as stroke. Even though direct oral anticoagulants (DOACs) can reduce the risk of ICH, the rate of DOAC use remains low in many Asian countries because of cost concerns.

Objectives

The purpose of this protocol paper of the COOL-AF (COhort of antithrOmbotic use and cLinical outcomes in patients with Atrial Fibrillation) Phase 2 registry is to determine the rate of clinical outcome, changes in antithrombotic patterns, and their impact on clinical outcomes, and to develop a prediction model for clinical outcomes.

Methods

The COOL-AF Phase 2 study is a prospective observational multicenter study of patients with known or newly diagnosed nonvalvular AF in Thailand. The aim is to achieve a sample size of 3,667 patients from 33 centers. Patients will be followed up every 6 months for up to 3 years. Data collection on and doses of oral anticoagulants (warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban) and antiplatelets are collected. The study outcomes include death, ischemic stroke/systemic embolism, major bleeding, myocardial infarction, heart failure, and quality of life. All events will be adjudicated.

Results

Enrollment started in June 2024. The results of the COOL-AF phase 2 registry will be reported when enrollment is complete and one year of follow-up data is available.

Conclusions

The COOL-AF Phase 2 trial will provide valuable information about the real-world practice of AF management and outcomes in Asia, which should be able to improve AF outcomes in the future. (COhort of antithrOmbotic Use and cLinical Outcomes in Patients With Atrial Fibrillation [COOL-AF] Phase 2; NCT06396299).

Proactive esophageal cooling during radiofrequency cardiac ablation: data update including applications in very high-power short duration ablation

INTRODUCTION

Proactive esophageal cooling reduces injury during radiofrequency (RF) ablation of the left atrium (LA) for the treatment of atrial fibrillation (AF). New catheters are capable of higher wattage settings up to 90 W (very high-power short duration, vHPSD) for 4 s. Varying power and duration, however, does not eliminate the risk of thermal injury. Furthermore, alternative energy sources such as pulsed field ablation (PFA) also exhibit thermal effects, with clinical data showing esophageal temperatures up to 40.3°C. The ensoETM esophageal cooling device (Attune Medical, now a part of Haemonetics, Boston, MA, U.S.A.) is commercially available and FDA-cleared to reduce thermal injury to the esophagus during RF ablation for AF and is recommended in the 2024 expert consensus statement on catheter and surgical ablation of AF.

AREAS COVERED

This review summarizes growing evidence of esophageal cooling during high power RF ablation for AF treatment, including data relating to procedural efficacy, safety, and efficiency, and techniques to enhance operator success while providing directions for further research.

EXPERT OPINION

Proactive esophageal cooling reduces injury to the esophagus during high power RF ablation, and utilizing this approach may result in increased success in first-pass isolation, procedural efficiency, and long-term efficacy.

Clinical practices for defining, detecting, and diagnosing postoperative atrial fibrillation after coronary revascularization surgery - A scoping review

OBJECTIVES

This scoping review was undertaken to understand the degree of variation in clinical practices associated with postoperative atrial fibrillation (POAF), following coronary revascularization surgery by collating and synthesising key concepts from current published literature.

REVIEW METHODS AND DATA SOURCES

This scoping review was conducted following the framework outlined by Askey and O'Malley. Reporting of this scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Initial searches were completed in September 2020 and updated in January 2023. Comprehensive searches to identify relevant published literature were carried out within CINAHL, MEDLINE, and ProQuest databases. All searches were limited to full-text papers published in English with human adult participants. Deductive content analysis using NVivo software was performed to synthesise the data.

RESULTS

A total of 692 studies were identified during the database searches. After the deletion of duplicates and the application of the inclusion and exclusion criteria, 73 studies were included in the scoping review. The included studies were published between 2001 and 2022 and included a total of 24,833 participants. Forty-six studies included a definition of POAF, with four of these citing a peak-body definition. A total of 24 included studies reported on electrocardiogram diagnostic criteria for POAF, with 13/24 [54%] describing these characteristics within their definition. The time-based diagnostic criteria ranged from a minimum duration of greater than 30 seconds to greater than 1 hour. The most frequently reported minimum-time thresholds were ≥30 seconds, reported in 12 of 51 (24%) studies and ≥5 min, reported in 13 of 51 (25%) studies.

CONCLUSIONS

There is a lack of consistency in clinical practice for defining, detecting, and diagnosing POAF, following coronary revascularization surgery. Consensus and standardisation of clinical practices are urgently needed.

The Value of P-Wave Parameters Changes in Predicting Catheter Ablation Outcomes for Paroxysmal Atrial Fibrillation

BACKGROUND

Pulmonary vein isolation (PVI) is the most promising management method for paroxysmal atrial fibrillation (PAF). The P wave in the electrocardiogram (ECG) represents atrial depolarization. This study aims to correlate P-wave parameters after PVI with outcomes.

METHODS

This single-center retrospective study included consecutive patients with first-time PVI for PAF between 2018 and 2019 and targeted pulmonary veins (PVs). Procedure success was defined by freedom of ECG-documented AF at 12 months. Digital 12 leads ECGs with 1-50 hertz bandpass filter were monitored before the procedure. P-wave amplitude (PWA) and P-wave terminal force in V1 (PTFV1) Corrected P-wave duration (PWDc), and P-wave dispersion (PWDisp), were measured before and after ablation.

RESULTS

The final analysis included 180 patients, of which 130 (72%) had successful ablations and 53 (30%) had radiofrequency ablation (RF). Males comprised 71% of the patients; the mean age was 60. Demographics were similar between both arms p < 0.001. Patients with failed PVI had increased PWDc after PVI (139-146 ms, p < 0.001) compared to patients with successful PVI. PWA increased significantly after failed PVI (1.6-2 mV, p < 0.001) and successful PVI (1.6-1.8 mV, p = 0.008). PWD (hazard ratio [HR]: 2.5, 95% confidence interval [CI]: 1.4-4.2, p < 0.001) and PWA (HR: 1.7, 95% CI: 1.2-2.9, p = 0.03) were independently associated with PVI failure at 12 months. PWdisp and PTFV1 were not correlated with outcomes.

CONCLUSION

Increased PWDc and PWA after PVI were independently associated with failed ablation for PAF, supporting the role of P-wave parameters in predicting outcomes.

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.

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/m 2 (men) and greater than 95 g/m 2 (women), and LAE was defined as LA volume index greater than 42 ml/m 2 . 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.

Atrial Fibrillation Recurrence Risk After Catheter Ablation in Patients With Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

BACKGROUND

The association between rheumatoid arthritis (RA) and the risk of developing atrial fibrillation (AF) is well-established. However, data on the impact of RA on AF recurrence postcatheter ablation (CA) remain unclear. This current study aimed to assess the impact of RA on AF recurrence after catheter-based pulmonary vein isolation.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to December 20, 2023. Eligible study must consist of two cohorts of patients with and without RA who underwent catheter ablation for AF. Pooled risk ratio (RR) and 95% CI were calculated using Dersimonian and Laird's random-effect, generic inverse variance approach.

RESULTS

The meta-analysis includes three retrospective cohort studies with a total of 700 patients. The pooled analysis found a significantly increased risk of AF recurrence after CA among patients with RA compared to patients without RA with the pooled RR of 1.59 (95% CI, 1.10-2.29, I2 14%). Increased risk of early recurrence (within 90 days) was also observed with the pooled RR of 2.70 (95% CI, 1.74-4.19, I2 0%).

CONCLUSIONS

The current study found that patients with RA have a higher risk of AF recurrence after CA for AF, including the risk of early recurrence.

Joint effects of atrial fibrillation and prothrombotic genotypes on the risk of ischemic stroke

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Whether prothrombotic single nucleotide polymorphisms (SNPs) impact stroke risk in AF is not well known.

OBJECTIVES

To investigate the joint effects of 5 prothrombotic SNPs and AF on ischemic stroke risk.

METHODS

A subcohort (n = 14 583) was randomly sampled from the Tromsø (1994-2012) and the Trøndelag Health (1995-2008) studies. DNA was genotyped for rs8176719 (ABO blood type), rs6025 (factor [F]V Leiden), rs1799963 (prothrombin G20210A), rs2066865 (fibrinogen-γ), and rs2036914 (F11). Hazard ratios (HRs) with 95% CIs for incident ischemic stroke were estimated by AF status for individual SNPs and by categories of a genetic risk score.

RESULTS

A total of 1091 participants developed AF during follow-up, of whom 169 (15.5%) subsequently had a stroke. Having ≥1 risk allele in prothrombin, FV Leiden, F11, or fibrinogen-γ was not associated with excess stroke risk in AF. In the absence of AF, ≥1 risk allele(s) in ABO was not associated with stroke (HR, 1.03; 95% CI, 0.85-1.25), whereas those with AF and ≥1 risk allele(s) in ABO had a 1.4-fold increased stroke risk compared with those with AF and no risk allele (HR, 1.42; 95% CI, 0.99-2.04). There was no linear increase in stroke risk across categories of the genetic risk score in participants either with or without AF.

CONCLUSION

Most prothrombotic SNPs were not associated with ischemic stroke risk, regardless of AF status. The ABO SNP was associated with ischemic stroke risk in those with AF only.

Appropriateness of antithrombotics in geriatric inpatients with atrial fibrillation: a retrospective, cross-sectional study

BACKGROUND

Atrial fibrillation occurs in nearly half of geriatric inpatients and is a major cause of morbidity and mortality. Suboptimal anticoagulation use is an important concern in this population. This study aimed to evaluate the appropriateness of antithrombotic therapies in this patient cohort.

METHODS

A retrospective analysis was conducted on the geriatric wards of a teaching hospital in Belgium, on a background of clinical pharmacy services. The first 90 atrial fibrillation patients from 2020 to 2022 were included if they received an oral anticoagulant. We assessed utilisation and appropriateness of antithrombotics at discharge, examined reasons for guideline deviations, and explored factors associated with underdosing. Temporal associations for appropriateness and type of anticoagulant (vitamin K antagonist (VKA) vs direct oral anticoagulant (DOAC)) were assessed.

RESULTS

The mean age of patients was 86.5 (±5.3) years and the median CHA2DS2-VASc score was 5 (interquartile range (IQR) 4-6). At discharge, 256 (94.8%) patients used a DOAC; nine (3.3%) used a VKA; one (0.4%) a DOAC-antiplatelet combination, and in four patients (1.5%) all antithrombotics were discontinued. The majority (64.4%) of patients received reduced DOAC doses with apixaban prescribed in 40.7%. In 39 (14.4%) patients, antithrombotic use was considered inappropriate, mostly without a rationale (23/39). Year 2022 (odds ratio (OR) 0.104; 95% confidence interval (CI), 0.012-0.878) was the sole determinant for underdosing. No significant differences were found with respect to appropriateness (p=0.533) or anticoagulant class (p=0.479) over time.

CONCLUSION

Most geriatric inpatients received a justified reduced DOAC dose. A significant proportion was managed inappropriately with underdosing (= unjustified reduced dose) being most common. Frequently no rationale was provided for deviating from trial-tested doses.

Developing technologies to assess vascular ageing: a roadmap from VascAgeNet

Vascular ageing (vascular ageing) is the deterioration of arterial structure and function which occurs naturally with age, and which can be accelerated with disease. Measurements of vascular ageing are emerging as markers of cardiovascular risk, with potential applications in disease diagnosis and prognosis, and for guiding treatments. However, vascular ageing is not yet routinely assessed in clinical practice. A key step towards this is the development of technologies to assess vascular ageing. In this Roadmap, experts discuss several aspects of this process, including: measurement technologies; the development pipeline; clinical applications; and future research directions. The Roadmap summarises the state of the art, outlines the major challenges to overcome, and identifies potential future research directions to address these challenges.

Steerable Delivery Sheath for Optimized LAA Closure: First Experience and Procedural Outcomes

BACKGROUND

The new Amplatzer Steerable Delivery Sheath is a delivery system designed to improve ease-of-use and procedural results of left atrial appendage closure (LAAC). We aimed to compare procedural results after switching our LAAC program at a tertiary care center with the Amulet device to the Steerable Delivery Sheath, with a control group of LAAC employing the standard sheath.

METHODS

The first n = 32 consecutively treated patients at our site using the Amulet device with the Steerable Delivery Sheath were included in this retrospective analysis. As a control-group, n = 39 consecutive patients treated with the Amulet device before the switch to the new sheath were used.

RESULTS

LAAC was successful in all patients in both groups (100%). Contrast use and fluoroscopy time were numerically higher in the steerable sheath group (steerable sheath vs. control group: contrast use 70 ± 23 vs. 55 ± 50 mL, p = 0.09, fluoroscopy time 12.7 ± 4.6 vs. 10.2 ± 6.6 min, p = 0.3). Fluoroscopy time and dose decreased after 3 months while contrast use remained unchanged. Complete sealing rate was high in both groups (steerable sheath vs. control group 97% vs. 95%, p > 0.9) and periprocedural complication rate was low, without any periprocedural stroke, vascular complications, or death in both cohorts.

CONCLUSIONS

LAAC with the Amplatzer Amulet steerable delivery sheath is feasible and safe. Fluoroscopy time and dose suggest a learning curve with the new sheath.

Real-world evaluation of intracardiac echocardiography guided radio-frequency catheter ablation for atrial fibrillation: a retrospective cohort study

Intracardiac echocardiography (ICE) has been used to guide radio-frequency catheter ablation (RFCA) for better catheter navigation and less radiation exposure in treating atrial fibrillation (AF). This retrospective cohort study enrolled 227 AF patients undergoing ICE- or traditional fluoroscopy (TF)-guided RFCA for AF in a tertiary hospital. ICE was used more often in patients with atrial tachycardia [odds ratio (OR) 3.692, p = 0.062], a higher score of Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol concomitantly (OR 1.541, p = 0.050), or heart failure (OR 2.098, p = 0.156). Based on the comparisons of 47 propensity score-matched pairs from 156 patients only undergoing pulmonary vein isolation (PVI), patients using ICE exhibited a significantly higher success rate in the first transseptal puncture (100% vs. 87.2%, p = 0.041) and less radiation exposure [utilization of radiographic contrast agent (2.7 ml vs. 6.0 ml, p < 0.001), fluoroscopy time (5.7 min vs. 7.6 min, p = 0.026), and fluoroscopy dose (208.4 mGy vs. 332.3 mGy, p = 0.024)] than patients using TF. Other perioperative efficacy outcomes (PVI success, free from AF after RFCA and complications) showed no difference between the matched pairs. ICE can enhance procedural safety and efficiency of RFCA, particularly for more complex patient profiles, in real-world setting.

Pre-procedural TMAO as a predictor for recurrence of atrial fibrillation after catheter ablation

BACKGROUND

Numerous studies have demonstrated the significance of trimethylamine-N-oxide (TMAO) in the progression of atrial fibrillation (AF). However, the association between TMAO and AF recurrence (RAF) post-catheter ablation is not yet fully understood. This study aims to elucidate the predictive capability of pre-procedural TMAO levels in determining RAF following catheter ablation (CA).

METHODS

This study was conducted as a prospective, single-center observational study. Between June 2021 and June 2022, 152 patients from the Department of Cardiology at The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University were enrolled. Baseline characteristics and serum TMAO levels were assessed for all participants. Patients with AF who underwent CA were monitored for recurrences of AF using electrocardiography (ECG) or 24-hour Holter monitoring during the follow-up period.

RESULTS

The study found that serum TMAO levels were significantly higher in persistent AF (PeAF) patients compared to those in sinus rhythm (SR) and paroxysmal AF (PaAF) patients (3.96 ± 1.69 vs. 1.81 ± 0.59, 3.02 ± 1.50 µM, P < 0.001 and P < 0.01, respectively). After a one-year follow-up, 29 (21.2%) AF patients experienced recurrence after CA. Multivariate Cox proportional hazards regression analysis revealed that pre-procedural serum TMAO was an independent predictor of recurrent AF (HR = 1.78, 95% CI = 1.43-2.21, P < 0.001). The receiver operating characteristic (ROC) curve analysis identified a cut-off value of 4.3µM for serum TMAO levels in predicting recurrent AF (area under the curve: 0.835, P < 0.001). The Kaplan-Meier plot demonstrated that patients with TMAO levels greater than 4.3µM had a significantly higher rate of recurrent AF (HR = 13.53, 95% CI = 6.19-29.56, P < 0.001).

CONCLUSION

Patients with AF exhibited elevated levels of circulating TMAO compared to patients with SR. The findings suggest a potential role of TMAO in the development of AF, with pre-procedural serum TMAO levels serving as a reliable predictor of recurrence of AF CA.

LA PULSE: Evaluating Left Atrial Function Pre- and Post-Atrial Fibrillation Ablation Using PULSEd Field Ablation

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia associated with left atrial dysfunction. The impact of pulmonary vein isolation (PVI) using pulsed field ablation (PFA) on left atrial function has not been previously quantified. This study aims to evaluate the effects of PVI using PFA on left atrial function in patients with AF. Methods: Thirty-four patients undergoing PVI with PFA between July 2022 and November 2023 were included. The left atrial function was assessed using echocardiography pre-procedure and at 6 months post-procedure. Results: The mean age of the patients was 66.5 ± 9.76 years, with 70.6% being male. The cohort included 44% of patients with paroxysmal AF. PVI was successfully achieved in all patients, with a significant improvement in all aspects of left atrial strain at an average of six-month follow-up. The left atrial strain reservoir (LASr) increased from 12.5 ± 5.8% to 21.7 ± 8.1% (p < 0.001). Notably, patients with paroxysmal AF exhibited a greater increase in LASr compared to those with persistent AF. Additionally, pre-procedural sinus rhythm was a significant predictor of better LASr outcomes. Conclusions: PFA is associated with significant improvement in left atrial reservoir strain, suggesting a positive impact on atrial function. These findings have important implications for the therapeutic management of AF and warrant further research.

Catheter ablation using pulsed-field energy: Do we finally have the magic wand to defeat atrial fibrillation?

Clinical outcomes of catheter ablation remain suboptimal in patients with atrial fibrillation (AF), particularly in those with persistent AF, despite decades of research, clinical trials, and technological advancements. Recently, pulsed-field ablation (PFA), a promising non-thermal technology, has been introduced to improve procedural outcomes. Its unique feature of myocardial selectivity offers safety advantages by avoiding potential harm to vulnerable adjacent structures during AF ablation. However, despite the global enthusiasm within the electrophysiology community, recent data indicate that PFA is still far from being a "magic wand" for addressing such a complex and challenging arrhythmia as AF. More progress is needed in mapping processes rather than in ablation technology. This editorial reviews relevant available data and explores future research directions for PFA.

Epidemiology, risk factors and mechanism of breast cancer and atrial fibrillation

Cancer and cardiovascular diseases are leading causes of death worldwide. Among them, breast cancer is one of the most common malignancies in women, while atrial fibrillation is one of the most extensively studied arrhythmias, with significant public health implications. As the global population ages and advancements in cancer treatments continue, the survival rates of breast cancer patients have significantly improved, leading to an increasing coexistence of breast cancer and atrial fibrillation. However, the mechanisms underlying this coexistence remain insufficiently studied, and there is no consensus on the optimal treatment strategies for these patients. This review consolidates existing research to systematically explore the epidemiological characteristics, risk factors, and pathophysiological mechanisms of both breast cancer and atrial fibrillation. It focuses on the unique signaling pathways associated with different molecular subtypes of breast cancer and their potential impact on the mechanisms of atrial fibrillation. Additionally, the relationship between atrial fibrillation treatment medications and breast cancer is discussed. These insights not only provide essential evidence for the precise prevention and management of atrial fibrillation in breast cancer patients but also lay a solid theoretical foundation for interdisciplinary clinical management practices.

Advances in Atrial Fibrillation Management: A Guide for General Internists

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, impacting approximately 6.1 million adults in the United States, with projections to increase two-fold by 2030. AF significantly increases the risk of stroke and other adverse cardiovascular events, leading to increased morbidity and mortality. The 2023 ACC/AHA/ACCP/HRS guidelines present a paradigm shift in AF management, moving from a duration-based classification to a more comprehensive, patient-centered approach. This includes a novel AF classification system that emphasizes early detection and intervention, including risk factors and lifestyle modification tailored to each patient's risk profile. Moreover, the recommendations advocate for a multidisciplinary care model, ensuring coordinated management involving primary care providers and specialists. Primary care providers play a crucial role in initiating risk factor management and lifestyle interventions, even before the development of AF. This review aims to thoroughly examine the guidelines for the diagnosis and management of AF and equip general internists with the necessary insights to navigate the evolving landscape of AF care effectively.

Accurate Arrhythmia Classification with Multi-Branch, Multi-Head Attention Temporal Convolutional Networks

Electrocardiogram (ECG) signals contain complex and diverse features, serving as a crucial basis for arrhythmia diagnosis. The subtle differences in characteristics among various types of arrhythmias, coupled with class imbalance issues in datasets, often hinder existing models from effectively capturing key information within these complex signals, leading to a bias towards normal classes. To address these challenges, this paper proposes a method for arrhythmia classification based on a multi-branch, multi-head attention temporal convolutional network (MB-MHA-TCN). The model integrates three convolutional branch layers with different kernel sizes and dilation rates to capture features across varying temporal scales. A multi-head self-attention mechanism dynamically allocates weights, integrating features and correlations from different branches to enhance the recognition capability for difficult-to-classify samples. Additionally, the temporal convolutional network employs multi-layer dilated convolutions to progressively expand the receptive field for extracting long-term dependencies. To tackle data imbalance, a novel data augmentation strategy is implemented, and focal loss is utilized to increase the weight of minority classes, while Bayesian optimization is employed to fine-tune the model's hyperparameters. The results from five-fold cross-validation on the MIT-BIH Arrhythmia Database demonstrate that the proposed method achieves an overall accuracy of 98.75%, precision of 96.60%, sensitivity of 97.21%, and F1 score of 96.89% across five categories of ECG signals. Compared to other studies, this method exhibits superior performance in arrhythmia classification, significantly improving the recognition rate of minority classes.

Right atrial volume index and right atrial volume predict atrial fibrillation recurrence: A meta-analysis

BACKGROUND

Atrial volume index and atrial volume have recently been identified as predictors of atrial fibrillation (AF) recurrence following electrical cardioversion or radiofrequency ablation. However, most studies have reported the relationship between LAVI/LAV and AF recurrence, whereas there is little information on the relationship between RAVI/RAV and AF recurrence. Therefore, we performed a meta-analysis to assess the relationship between the risk of AF recurrence and RAVI/RAV in patients with AF who underwent electrical cardioversion or radiofrequency ablation.

METHODS

CNKI, Wanfang Database, Pubmed, Embase, Cochrane Library, and Web of Science were searched up to October 01, 2024. A meta-analysis of relative risk data from prospective and retrospective cohort studies that reported on the relationship between the risk of AF recurrence and RAVI/RAV in patients with AF after electrical cardioversion or radiofrequency ablation was performed.

RESULTS

The results showed that patients with AF recurrence had a higher mean right atrial volume index (RAVI) compared to patients with no recurrence. After electrical cardioversion or radiofrequency ablation, RAVI can independently predict the recurrence of AF (OR = 1.06, 95%CI (1.02, 1.11)). The average right atrial volume (RAV) of patients with AF recurrence was higher than that of patients without AF recurrence. After electrical cardioversion or radiofrequency ablation, RAV can independently predict the recurrence of AF (OR = 1.02, 95%CI (1.00, 1.05)).

CONCLUSION

Patients with AF recurrence after electrical cardioversion or radio frequency ablation had higher mean RAVI and RAV compared to patients with no recurrence. After electrical cardioversion or radiofrequency ablation in patients with AF, higher levels of RAVI and RAV increase the chance of recurrence of AF.

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.

Late Enhancement Computed Tomography for Left Atrial Fibrosis Imaging: A Pilot "Proof-of-Concept" Study

Background/Objective: Left atrial (LA) fibrosis imaging improves the guidance of LA catheter ablation. Cardiac computed tomography (CT) may be a reasonable alternative to CMR. The aim was to evaluate late enhancement (LE) fibrosis mapping by CT, and to correlate the results with low-voltage areas on electroanatomical mapping (EAM). Methods: In patients with atrial fibrillation who underwent 128-slice dual-source CT angiography (CTA) prior to LA catheter ablation, an additional LE-CT scan was performed 7 min after CTA. (1) Left atrial wall thickness (LAWT) was measured at three sites along the LA ridge. (2) Late enhancement (LE) was quantified co-axially aligned to LAWT and compared with low-voltage areas (LVA) on EAM. Results: Of 137 patients (age: 59.8 years; 27.7% females), 108 were included. The prevalence of LE was higher in patients with LAWT > 2 mm compared with 1.5 mm, with 78 (91.7%) vs. 77 (80.2%) (p = 0.022). Of 78 patients with LE, 60 (77.1%) had focal, 13 (16.5%) had diffuse, and 5 (6.3%) had mixed LE patterns. The CT density of focal LE was not different from that of diffuse patterns (104.2 +/- 21 HU vs. 98.9 +/- 18 HU; p = 0.360). Increasing LAWT and LE-HU were weakly correlated (r = 0.229; p = 0.041). LA wall artifacts had higher CT density compared with LE (154.1 HU vs. 114.2 HU; p = 0.002). The effective radiation dose was 0.95 mSv (range, 0.52-1.2 mSv) for LE-CT. The agreement of LE-CT was 80% for LVA < 0.5 mV and 86.6% for LVA < 0.7 mV in a subset of 30 patients. Conclusions: Left atrial fibrosis mapping by LE-CT is feasible. Late enhancement was found more frequently in LAWTs of more than 2 mm, and LE was correlated with increasing LA remodeling and low-voltage areas.

The association of the triglyceride-glucose index with the risk of atrial fibrillation: Analysis of the UK Biobank

BACKGROUND AND AIMS

The relationship between the triglyceride-glucose (TyG) index and the incidence of atrial fibrillation (AF) remains insufficiently explored. This investigation aims to elucidate the association between the TyG index and the long-term risk of developing AF.

METHODS AND RESULTS

This cohort study analyzed data from 409,705 participants sourced from the UK Biobank database. Participants were stratified into three groups based on TyG index tertiles. The association between the TyG index and AF was evaluated using Cox proportional hazards models. Restricted cubic spline (RCS) analysis was employed to investigate potential linear or nonlinear relationships. During a mean follow-up period of 13.9 years, 26,092 AF cases were recorded. Compared with the T2 group, participants in the T1 group and T3 group presented a significantly higher risk of AF (T1: HR: 1.22, 95%CI: 1.17-1.27; T3: HR: 1.09, 95%CI: 1.05-1.14). RCS analysis documented a U-shaped relationship between the TyG index and the risk of AF (P for non-linearity <0.001). In non-type 2 diabetes (T2D) participants, TyG levels were associated with AF risk in a U-shaped relationship. Among T2D participants, only the T3 group had an increased risk of AF (reverse "L" pattern). The U-shaped relationship between TyG levels and AF risk remained consistent across heart valve disease (HVD) and non-HVD patients, as well as different strata of genetic susceptibility to AF.

CONCLUSIONS

This study demonstrates a U-shaped association between the TyG index and the risks of AF, underscoring the index's potential utility in identifying individuals at elevated risk for these conditions.

Temporal Trends of Ischemic Stroke Risk in Patients With Incident Atrial Fibrillation Before Anticoagulation

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS), but whether the magnitude of this risk has changed over time is unknown.

OBJECTIVES

This study sought to investigate temporal trends in IS rates in patients with incident AF before oral anticoagulant agent (OAC) therapy.

METHODS

The nationwide FinACAF (Finnish Anticoagulation in Atrial Fibrillation) study covers patients with AF at all levels of care in Finland from 2007 to 2018. A 4-week quarantine period from AF diagnosis was applied, and only follow-up time without OAC therapy was included. Incidence rates of IS were computed in 4-year intervals in relation to sex and non-sex CHA2DS2-VASc (ie, CHA2DS2-VA) score values.

RESULTS

In total, 129,789 patients with new-onset AF were identified (49.2% women; mean age: 71.4 ± 14.5 years). Between the calendar year intervals of 2007-2010 and 2015-2018, the patients' mean CHA2DS2-VA score increased from 2.5 to 3.0, and concurrently the overall IS rate decreased by 25% from 36.7 to 27.6 events per 1,000 patient-years. This trend was driven by a 32% decrease of IS rate in women, particularly among those with higher age and CHA2DS2-VA scores. The IS rate in patients with a CHA2DS2-VA score of 1 was 8.2 events per 1,000 patient-years and remained stable across the study period.

CONCLUSIONS

The initial IS risk in AF patients, before the initiation of OAC therapy, has decreased by 25% between 2007 and 2018 despite an increase in both age and stroke risk scores. The decrease has been most pronounced in older women with high stroke risk scores.

Predictive value of cardiac electrophysiological balance index for recurrent atrial fibrillation after ablation

OBJECTIVE

This study aimed to evaluate the prognostic significance of the cardiac electrophysiological balance index in predicting the recurrence of atrial fibrillation following radiofrequency ablation.

METHODS

Patients with paroxysmal atrial fibrillation undergoing radiofrequency ablation were enrolled from July 2021 to March 2023 and categorized into recurrence and non-recurrence groups based on postoperative atrial fibrillation recurrence during a 6- to 12-month follow-up. Clinical and electrocardiogram data at admission were collected, and cardiac electrophysiological balance index was calculated. Multivariate logistic regression analysis identified independent factors contributing to atrial fibrillation recurrence. Receiver operating characteristic curves assessed predictive values.

RESULTS

Among 127 subjects, 36 experienced postoperative recurrence (22 paroxysmal atrial fibrillation, 10 atrial flutter, and 4 atrial tachycardia). Significant differences in hypersensitive C-reactive protein levels, QT, QRS, and cardiac electrophysiological balance index were observed between recurrent and non-recurrent groups. Multivariate analysis revealed cardiac electrophysiological balance index as an independent risk factor for recurrence (OR 1.766, 95%CI 1.415-2.204, p<0.001). Receiver operating characteristic curve analysis showed cardiac electrophysiological balance index's predictive value with an area under the curve of 0.865 (95%CI 0.807-0.923, p<0.001), and a cutoff value of 4.3 demonstrated a sensitivity of 87.67% and a specificity of 71.23%.

CONCLUSIONS

The cardiac electrophysiological balance index emerges as a non-invasive tool with substantial predictive value for estimating the likelihood of paroxysmal AF recurrence post-ablation.

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.

Validation, bias assessment, and optimization of the UNAFIED 2-year risk prediction model for undiagnosed atrial fibrillation using national electronic health data

Background

Prediction models for atrial fibrillation (AF) may enable earlier detection and guideline-directed treatment decisions. However, model bias may lead to inaccurate predictions and unintended consequences.

Objective

The purpose of this study was to validate, assess bias, and improve generalizability of "UNAFIED-10," a 2-year, 10-variable predictive model of undiagnosed AF in a national data set (originally developed using the Indiana Network for Patient Care regional data).

Methods

UNAFIED-10 was validated and optimized using Optum de-identified electronic health record data set. AF diagnoses were recorded in the January 2018-December 2019 period (outcome period), with January 2016-December 2017 as the baseline period. Validation cohorts (patients with AF and non-AF controls, aged ≥40 years) comprised the full imbalanced and randomly sampled balanced data sets. Model performance and bias in patient subpopulations based on sex, insurance, race, and region were evaluated.

Results

Of the 6,058,657 eligible patients (mean age 60 ± 12 years), 4.1% (n = 246,975) had their first AF diagnosis within the outcome period. The validated UNAFIED-10 model achieved a higher C-statistic (0.85 [95% confidence interval 0.85-0.86] vs 0.81 [0.80-0.81]) and sensitivity (86% vs 74%) but lower specificity (66% vs 74%) than the original UNAFIED-10 model. During retraining and optimization, the variables insurance, shock, and albumin were excluded to address bias and improve generalizability. This generated an 8-variable model (UNAFIED-8) with consistent performance.

Conclusion

UNAFIED-10, developed using regional patient data, displayed consistent performance in a large national data set. UNAFIED-8 is more parsimonious and generalizable for using advanced analytics for AF detection. Future directions include validation on additional data sets.

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.

Multiphysics simulations reveal haemodynamic 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 ischaemic 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 multiphysics simulations of left atrial (LA) myocardial motion and haemodynamics 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 multifactorial behaviour is observed. This work illustrates how high-fidelity, multiphysics models can be used to study thrombogenesis mechanisms in patient-specific anatomies, shedding light onto the links between atrial fibrosis and ischaemic stroke. KEY POINTS: Left atrial (LA) fibrosis is associated with arrhythmogenesis and increased risk of ischaemic 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 such as fibrotic maps and haemodynamic patterns. We present the first electro-mechano-fluidic multiphysics 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.

Targeting the NLRP3 inflammasome signalling for the management of atrial fibrillation

Inflammatory signalling via the nod-like receptor (NLR) family pyrin domain-containing protein-3 (NLRP3) inflammasome has recently been implicated in the pathophysiology of atrial fibrillation (AF). However, the precise role of the NLRP3 inflammasome in various cardiac cell types is poorly understood. Targeting components or products of the inflammasome and preventing their proinflammatory consequences may constitute novel therapeutic treatment strategies for AF. In this review, we summarise the current understanding of the role of the inflammasome in AF pathogenesis. We first review the NLRP3 inflammasome pathway and inflammatory signalling in cardiomyocytes, (myo)fibroblasts and immune cells, such as neutrophils, macrophages and monocytes. Because numerous compounds targeting NLRP3 signalling are currently in preclinical development, or undergoing clinical evaluation for other indications than AF, we subsequently review known therapeutics, such as colchicine and canakinumab, targeting the NLRP3 inflammasome and evaluate their potential for treating AF.

Global Health Inequities in Electrophysiology Care: A State-of-the-Art Review

This state-of-the-art review examines disparities in the diagnosis, management, and outcomes of cardiac arrhythmias globally. These arrhythmias include atrial fibrillation, ventricular tachyarrhythmias underlying sudden cardiac death, and bradyarrhythmias associated with sinus node and atrioventricular node disease. Arrhythmias in low- and middle-income countries often result in higher mortality rates due to complex and poorly documented risk factors, lack of clinical expertise among health care personnel, lack of sufficient infrastructure, and challenges in access to care. Innovative approaches like repurposing pacemakers, mobile clinics, use of digital technology, and training initiatives are being explored to address these issues. This article highlights the importance of diagnosis of arrhythmias in varying resource settings, access to care in those settings, and ongoing efforts to expand access to care.

Possible Risk Factors Contributing to Atrial Fibrillation Occurrence in Heart Failure With Mildly Reduced Ejection Fraction

Background

Heart failure (HF) is often accompanied by atrial fibrillation (AF), which significantly worsens the outcome of both diseases. Half of individuals with HF has AF, and HF occurs in more than one-third of individuals with AF. Thus, HF and AF are commonly encountered together and are closely interrelated with similar risk factors. The aim of this study was to investigate the impact of potential risk factors on the occurrence of paroxysmal/persistent AF in patients with heart failure with moderately reduced ejection fraction (HFmrEF).

Methods

The study included 193 patients with HFmrEF and nonvalvular paroxysmal/persistent AF after successful cardioversion. As a control group the similar 76 patients without AF were examined. All patients underwent the examination, including electrocardiography (ECG), echocardiography, ambulatory blood pressure monitoring and Holter ECG monitoring. Levels of inflammatory markers, such as high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and the fibrotic marker transforming growth factor-β1 (TGF-β1) were measured using the enzyme-linked immunosorbent assay (ELISA) method. The obtained results were modeled using binary logistic regression using the odds ratio (OR).

Results

It was shown that frequent episodes of hypertensive crisis (HC) and increased body mass index (BMI) were possible risk factors for paroxysmal/persistent AF. An increased OR of diastolic and systolic parameters of the left ventricle was associated with significant atrial and ventricular remodeling. Statistically, higher OR of inflammatory markers levels, such as hs-CRP, IL-6 and TNF-α were associated with an increased risk of paroxysmal/persistent AF occurrence in HFmrEF patients compared to similar patients without AF. An increase of the fibrosis marker TGF-β1 OR was statistically significant in patients with persistent AF.

Conclusions

It could be considered that frequency of HC, BMI, atrial and ventricular remodeling, as well as an increase of inflammation markers were possible risk factors for the occurrence of paroxysmal/persistent AF in HFmrEF patients. Moreover, fibrosis factor level significantly increased the likelihood of persistent AF in these patients.

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.

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.

Atrial Fibrillation in Young Patients: Insights From the National Inpatient Sample

BACKGROUND

The burden of atrial fibrillation (AF) hospitalizations in young patients is not well characterized. We aimed to study the burden, comorbidities, outcomes, and resource utilization of AF hospitalizations in young patients.

METHODS

We conducted a retrospective analysis of all primary AF hospitalizations in patients 18-45 years of age using the National Inpatient Sample data from January 1, 2008 to December 31, 2019. We collected data on various clinical and socioeconomic features including demographics and clinical outcomes.

RESULTS

AF hospitalizations decreased over time from 18.7 per 100,000 in 2008 to 13.0 per 100,000 in 2019 (p < 0.001). AF hospitalizations were higher amongst males compared to females (24.0 vs. 7.5 per 100,000), and higher in Black patients compared to other ethnicities (20.4 for Black vs. 15.6 for White vs. 8.5 Hispanic per 100,000). The utilization of electrical cardioversion increased from 17.6% in 2008 to 21.9% in 2019 (p < 0.001), and catheter ablation decreased from 7.1% in 2008 to 4.3% in 2019 (p < 0.001). Men were more likely to undergo electrical cardioversion than women (20.1% vs. 14.8%, p < 0.001). White patients were more likely to undergo electrical cardioversion (20.8% vs. 14.3% vs. 15.5%, p < 0.001) and catheter ablation (6.1% vs. 3.3% vs. 4.2%, p < 0.001) compared to Black and Hispanic patients, respectively. Patients in the highest income residence quartile were more likely to undergo electrical cardioversion (21.9% vs. 16.4%, p < 0.001) and catheter ablation (8.0% vs. 3.7%, p < 0.001) compared to patients in the lowest income residence quartile.

CONCLUSIONS

We found significant differences in inpatient AF management based on sex, ethnicity, and SES.

[Everyone over the age of 65 years should wear a smartwatch : Pro and contra]

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias and has far-reaching consequences not only for patients, but also for our healthcare system. The prevalence of this condition is expected to double in the coming decades. On the one hand, this is due to our aging population, the increasing number of comorbidities, and the improved technical possibilities for detection. A major complication of AF is stroke, whereby at-risk patients can be protected by oral anticoagulation if AF is diagnosed. The extent to which continuous screening for AF in patients with an increased risk of thromboembolic events should be carried out using wearables remains an important point in the current debate.

Fair prediction of 2-year stroke risk in patients with atrial fibrillation

OBJECTIVE

This study aims to develop machine learning models that provide both accurate and equitable predictions of 2-year stroke risk for patients with atrial fibrillation across diverse racial groups.

MATERIALS AND METHODS

Our study utilized structured electronic health records (EHR) data from the All of Us Research Program. Machine learning models (LightGBM) were utilized to capture the relations between stroke risks and the predictors used by the widely recognized CHADS2 and CHA2DS2-VASc scores. We mitigated the racial disparity by creating a representative tuning set, customizing tuning criteria, and setting binary thresholds separately for subgroups. We constructed a hold-out test set that not only supports temporal validation but also includes a larger proportion of Black/African Americans for fairness validation.

RESULTS

Compared to the original CHADS2 and CHA2DS2-VASc scores, significant improvements were achieved by modeling their predictors using machine learning models (Area Under the Receiver Operating Characteristic curve from near 0.70 to above 0.80). Furthermore, applying our disparity mitigation strategies can effectively enhance model fairness compared to the conventional cross-validation approach.

DISCUSSION

Modeling CHADS2 and CHA2DS2-VASc risk factors with LightGBM and our disparity mitigation strategies achieved decent discriminative performance and excellent fairness performance. In addition, this approach can provide a complete interpretation of each predictor. These highlight its potential utility in clinical practice.

CONCLUSIONS

Our research presents a practical example of addressing clinical challenges through the All of Us Research Program data. The disparity mitigation framework we proposed is adaptable across various models and data modalities, demonstrating broad potential in clinical informatics.

Tricuspid regurgitation: a contemporary review

Tricuspid regurgitation (TR), an underrecognized disease, overlooked by clinicians for many years due to its assumed benign nature. Recent epidemiological studies suggest significant TR may be seen in up to 6% of elderly patients. An increase in prevalence is expected due to the higher incidence of various clinical predictors of TR progression. Increasing severity of TR is associated with worse outcomes with a novel morphologic classification providing a more refined prediction of outcomes. Advances in cardiac imaging, particularly echocardiography, are integral to the diagnosis of disease severity which not only includes quantitation of TR, but also an assessment of the right atrium, right ventricle and pulmonary arterial circulation. Once identified and quantified, TR management requires a multi-disciplinary heart team management including structural imagers, heart failure specialists, electrophysiologist, cardiac surgeons and interventionalists. Data to support medical therapies are lacking although guidelines support the management of congestive signs and symptoms, as well as comorbidities such as left heart failure and rhythm management. The risks of surgical interventions are slowly improving, however, transcatheter therapies are now available to treat patients with high surgical risk. This manuscript will provide a state-of-art review of this fast-moving field, including current scientific evidences, but also upcoming perspectives with multiple ongoing clinical studies.

An economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from a German healthcare payer perspective

BACKGROUND

Three recent randomized controlled trials demonstrated that, in patients with symptomatic paroxysmal atrial fibrillation (PAF), first-line pulmonary vein isolation with cryoballoon catheter ablation reduces atrial arrhythmia recurrence compared to initial antiarrhythmic drug (AAD) therapy. This study aimed to evaluate the cost-effectiveness of first-line cryoablation compared to first-line AADs from a German healthcare payer perspective.

METHODS

Individual patient-level data from 703 participants with untreated PAF enrolled into three randomized clinical trials (Cryo-FIRST, STOP AF First and EARLY-AF) were used to derive parameters for the cost-effectiveness model (CEM). The CEM structure consisted of a hybrid decision tree and Markov model. The decision tree (one-year time horizon) informed initial health state allocation in the first cycle of the Markov model (40-year time horizon; three-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Cost inputs were sourced from German diagnosis-related groups and the Institute for the Hospital Remuneration System (InEK). Costs and benefits were discounted at 3% per annum.

RESULTS

Cryoablation was cost-effective, incurring ~ €200 per patient while offering an increase in QALYs (~ 0.18) over a lifetime. This produced an average incremental cost-effectiveness ratio of ~ €1,000 per QALY gained. Individuals were expected to receive ~ 1.2 ablations over a lifetime, regardless of initial treatment. However, those initially treated with cryoablation as opposed to AADs experience 0.9 fewer re-ablations and a 45% reduction in time spent in AF health states.

CONCLUSION

Initial rhythm control with cryoballoon ablation in symptomatic PAF is a cost-effective treatment option in a German healthcare setting.

Associations between cardiac arrhythmias and cardiovascular disease incidence and all-cause mortality: the Kailuan study

AIMS

Cardiac arrhythmia is a rising public health issue. The aim of this study was to determine the associations of atrial fibrillation (AF) and heart block with cardiovascular disease (CVD) incidence and all-cause mortality.

METHODS AND RESULTS

We included 141,362 participants (mean age [49.3], 80.9% men) from the Kailuan study. Arrhythmias were diagnosed through a 12-lead electrocardiograph (ECG). Mortality and CVD events were ascertained through multiple sources, including a municipal social insurance institution, hospital records, death certificates, and regular active follow-ups. During a median follow-up of 12.5 years, 18,301 total deaths and 13,208 cases of CVD were documented. The multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) comparing participants with AF to those without arrhythmia were 1.76 (1.61-1.93) for all-cause mortality, 2.11 (1.86-2.39) for CVD, 3.99 (3.33-4.79) for heart failure, and 1.56 (1.30-1.90) for stroke. Further, comparing participants with heart block to those without arrhythmia, the multivariable-adjusted HRs (95% CIs) were 1.31 (1.24-1.38) for all-cause mortality, 1.26 (1.18-1.35) for CVD, 1.40 (1.23-1.59) for heart failure, and 1.25 (1.15-1.37) for stroke. Additionally, there were generally stronger associations for AF and heart block with all-cause mortality and CVD in younger participants compared with their older counterparts (Ps-interaction ≤ 0.02) and a stronger association between AF and CVD in women compared with men (Ps-interaction ≤ 0.006).

CONCLUSION

AF and heart block were associated with a higher risk of subsequent adverse CVD events and mortality. Our findings highlight the importance of strategies for preventing cardiac arrhythmias to reduce the risk of CVD and mortality.

Complexity AF score as a novel marker of atrial fibrillation instability

Atrial fibrillation (AF) is a heart disease affecting millions of Americans. Clinicians evaluate AF-related risk by assessing the temporal pattern, variation, and severity of AF episodes through AF burden (AFB). However, existing prognostic tools based on these metrics are suboptimal, as they do not account for electrical complexity of AF signals. This study introduced Electrical Burden (EB) as a new marker to assess electrical instability and complexity of AF. We also developed a Complexity AF score that incorporates AFB, EB, and Poincaré analysis to assess the severity of AF. Electrocardiogram (ECG) from 50 AF patients in the Long-term AF database were analyzed. EB was calculated using four metrics and combined with AFB and Poincaré metrics to derive the Complexity AF score for each patient. Our results show that AFB, EB, and Poincaré metrics are independent markers, each describing different aspects of AF complexity. The Complexity AF score effectively distinguished between terminated (2.82 ± 1.29, 17 patients) and non-terminated AF groups (4 ± 1.46, 33 patients) (p-value < 0.05). This study emphasizes the importance of EB and Poincaré analysis as an indicator of electrical complexity of AF and highlights the utility of the Complexity AF score in accurately characterizing and stratifying AF to guide management.

Pulsed Field Ablation in Atrial Fibrillation: Initial Experience of the Efficacy and Safety in Pulmonary Vein Isolation and Beyond

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p < 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p > 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3-97.3] and 82.8% [95% CI, 68.1-97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications.

Hospitalizations of Patients with Atrial Fibrillation (AF) in Poland: A Nationwide Study Based on over One Million AF Hospitalizations in 2017-2021

Background/Objectives: Atrial fibrillation (AF) is one of the most common forms of persistent arrhythmia in adults worldwide. The aim of this study was to present recent data on the epidemiology of patients hospitalized with AF in Poland. Methods: This is a retrospective, population-based study conducted using hospital discharge records. The data covered 1,225,424 cases of AF hospitalization reported in 2017-2021. Results: The study group consisted of 51.36% men and 48.64% women. The mean and median ages were 73.6 and 74 years, respectively. Women were older than men (77 vs. 70 years, p < 0.001). The mean and median lengths of hospitalization were 6.9 and 4 days. The mean annual hospitalization rate was 640.0 per 100,000 person-years. In the group of patients aged ≥65 years, the hospitalization rate was 2870.4 per 100,000 person-years. Men were hospitalized more frequently than women (p < 0.001). The total in-hospital mortality rate was 37.7 per 100,000 person-years, and it was higher in women than in men (p < 0.001). There was a significant downward trend in first-time hospitalizations during the analyzed period and a significant downward trend in mortality rates with a marked increase in the years 2020-2021. Conclusions: Although women are less frequently hospitalized for AF, they show a higher risk of fatal hospitalizations. The pandemic may have reduced new AF diagnoses and increased mortality in this group of patients. The results of this study may be helpful in making comparative analyses in the European and global contexts and taking actions aimed at improving the health condition of the Polish population.

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.