Sleep-Disordered Breathing, Hypoxia, and Pulmonary Physiologic Influences in Atrial Fibrillation

BACKGROUND

We leverage a large clinical cohort to elucidate sleep-disordered breathing and sleep-related hypoxia in incident atrial fibrillation (AF) development given the yet unclear contributions of sleep-related hypoxia and pulmonary physiology in sleep-disordered breathing and AF.

METHODS AND RESULTS

Patients who underwent sleep studies at Cleveland Clinic January 2, 2000, to December 30, 2015, comprised this retrospective cohort. Cox proportional hazards models were used to examine apnea hypopnea index, percentage time oxygen saturation <90%, minimum and mean oxygen saturation, and maximum end-tidal carbon dioxide on incident AF adjusted for age, sex, race, body mass index, cardiopulmonary disease and risk factors, antiarrhythmic medications, and positive airway pressure. Those with spirometry were additionally adjusted for forced expiratory volume in 1 second, forced vital capacity, and forced expiratory volume in 1 second/forced vital capacity. This cohort (n=42 057) was 50.7±14.1 years, 51.3% men, 74.1% White individuals, had median body mass index 33.2 kg/m2, and 1947 (4.6%) developed AF over 5 years. A 10-unit apnea hypopnea index increase was associated with 2% higher AF risk (hazard ratio [HR], 1.02 [95% CI, 1.00-1.03]). A 10-unit increase in percentage time oxygen saturation <90% and 10-unit decreases in mean and minimum oxygen saturation were associated with 6% (HR, 1.06 [95% CI, 1.04-1.08]), 30% (HR, 1.30 [95% CI, 1.18-1.42]), and 9% (HR, 1.09 [95% CI, 1.03-1.15]) higher AF risk, respectively. After adjustment for spirometry (n=9683 with available data), only hypoxia remained significantly associated with incident AF, although all coefficients were stable.

CONCLUSIONS

Sleep-related hypoxia was associated with incident AF in this clinical cohort, consistent across 3 measures of hypoxia, persistent after adjustment for pulmonary physiologic impairment. Findings identify a strong role for sleep-related hypoxia in AF development without pulmonary physiologic interdependence.

Effectiveness and safety of edoxaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of observational studies

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia type. Patients with AF are often administered anticoagulants to reduce the risk of ischemic stroke due to an irregular heartbeat. We evaluated the efficacy and safety of edoxaban versus warfarin in patients with nonvalvular AF by conducting an updated meta-analysis of real-world studies. Methods: In this comprehensive meta-analysis, we searched two databases, PubMed and EMBASE, and included retrospective cohort observational studies that compared edoxaban with warfarin in patients with nonvalvular AF from 1 January 2009, to 30 September 2023. The effectiveness and safety outcomes were ischemic stroke and major bleeding, respectively. In the final analysis, six retrospective observational studies involving 87,236 patients treated with warfarin and 40,933 patients treated with edoxaban were included. To analyze the data, we used a random-effects model to calculate the hazard ratio (HR). Results: Patients treated with edoxaban had a significantly lower risk of ischemic stroke [hazard ratio (HR) = 0.66; 95% confidence interval (CI) = 0.61-0.70; p < 0.0001] and major bleeding (HR = 0.58; 95% CI = 0.49-0.69; p < 0.0001) than those treated with warfarin. The sensitivity analysis results for ischemic stroke and major bleeding were as follows: HR = 0.66; 95% CI = 0.61-0.70; p < 0.0001 and HR = 0.58; 95% CI = 0.49-0.69; p < 0.0001, respectively. Conclusion: Our findings revealed that edoxaban performed better than warfarin against major bleeding and ischemic stroke.

lncRNA LENGA sponges miR-378 to promote myocardial fibrosis in atrial fibrillation

miR-378 is known to suppress myocardial fibrosis, while its upstream regulators have not been identified. lncRNA LENGA is a recently identified lncRNA in cancer biology. We observed the altered expression of LENGA in atrial fibrillation (AF) patients and predicted its interaction with miR-378. We then explored the interaction between LENGA and miR-378 in AF. Angiotensin-II (Ang-II)-induced human atrial cardiac fibroblasts and human atrial muscle tissues were collected and the expression of LENGA and miR-378 was determined by RT-qPCR. The interaction between LENGA and miR-378 was analyzed through bioinformatics analysis and confirmed by RNA pulldown assay. Cell proliferation and collagen production were analyzed through in vitro assay to analyze the role of LENGA and miR-378 in MF. AF patients showed increased expression of LENGA and deceased expression of miR-378 compared to the sinus rhythm group. LENGA and miR-378 interacted with each other, while they are not closely correlated with each other. Overexpression assay showed that LENGA and miR-378 overexpression failed to affect each other's expression. LENGA promoted collagen production and proliferation of Ang-II-induced atrial fibroblasts, while miR-378 played opposite roles. Moreover, LENGA suppressed the function of miR-378. Therefore, LENGA may sponge miR-378 to promote MF in AF.

Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care

Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.

Associations of Apixaban Dose With Safety and Effectiveness Outcomes in Patients With Atrial Fibrillation and Severe Chronic Kidney Disease

BACKGROUND

Recommendations for apixaban dosing on the basis of kidney function are inconsistent between the US Food and Drug Administration and European Medicines Agency for patients with atrial fibrillation. Optimal apixaban dosing in chronic kidney disease remains unknown.

METHODS

With the use of deidentified electronic health record data from the Optum Labs Data Warehouse, patients with atrial fibrillation and chronic kidney disease stage 4/5 initiating apixaban between 2013 and 2021 were identified. Risks of bleeding and stroke/systemic embolism were compared by apixaban dose (5 versus 2.5 mg), adjusted for baseline characteristics by the inverse probability of treatment weighting. The Fine-Gray subdistribution hazard model was used to account for the competing risk of death. Cox regression was used to examine risk of death by apixaban dose.

RESULTS

Among 4313 apixaban new users, 1705 (40%) received 5 mg and 2608 (60%) received 2.5 mg. Patients treated with 5 mg apixaban were younger (mean age, 72 versus 80 years), with greater weight (95 versus 80 kg) and higher serum creatinine (2.7 versus 2.5 mg/dL). Mean estimated glomerular filtration rate was not different between the groups (24 versus 24 mL·min-1·1.73 m-2). In inverse probability of treatment weighting analysis, apixaban 5 mg was associated with a higher risk of bleeding (incidence rate 4.9 versus 2.9 events per 100 person-years; incidence rate difference, 2.0 [95% CI, 0.6-3.4] events per 100 person-years; subdistribution hazard ratio, 1.63 [95% CI, 1.04-2.54]). There was no difference between apixaban 5 mg and 2.5 mg groups in the risk of stroke/systemic embolism (3.3 versus 3.0 events per 100 person-years; incidence rate difference, 0.2 [95% CI, -1.0 to 1.4] events per 100 person-years; subdistribution hazard ratio, 1.01 [95% CI, 0.59-1.73]), or death (9.9 versus 9.4 events per 100 person-years; incidence rate difference, 0.5 [95% CI, -1.6 to 2.6] events per 100 person-years; hazard ratio, 1.03 [95% CI, 0.77-1.38]).

CONCLUSIONS

Compared with 2.5 mg, use of 5 mg apixaban was associated with a higher risk of bleeding in patients with atrial fibrillation and severe chronic kidney disease, with no difference in the risk of stroke/systemic embolism or death, supporting the apixaban dosing recommendations on the basis of kidney function by the European Medicines Agency, which differ from those issued by the US Food and Drug Administration.

A proteomic analysis of atrial fibrillation in a prospective longitudinal cohort (AGES-Reykjavik study)

AIMS

Atrial fibrillation (AF) is associated with high risk of comorbidities and mortality. Our aim was to examine causal and predictive relationships between 4137 serum proteins and incident AF in the prospective population-based Age, Gene/Environment Susceptibility-Reykjavik (AGES-Reykjavik) study.

METHODS AND RESULTS

The study included 4765 participants, of whom 1172 developed AF. Cox proportional hazards regression models were fitted for 4137 baseline protein measurements adjusting for known risk factors. Protein associations were tested for replication in the Cardiovascular Health Study (CHS). Causal relationships were examined in a bidirectional, two-sample Mendelian randomization analysis. The time-dependent area under the receiver operating characteristic curve (AUC)-statistic was examined as protein levels and an AF-polygenic risk score (PRS) were added to clinical risk models. The proteomic signature of incident AF consisted of 76 proteins, of which 63 (83%) were novel and 29 (38%) were replicated in CHS. The signature included both N-terminal prohormone of brain natriuretic peptide (NT-proBNP)-dependent (e.g. CHST15, ATP1B1, and SVEP1) and independent components (e.g. ASPN, AKR1B, and LAMA1/LAMB1/LAMC1). Nine causal candidates were identified (TAGLN, WARS, CHST15, CHMP3, COL15A1, DUSP13, MANBA, QSOX2, and SRL). The reverse causal analysis suggested that most AF-associated proteins were affected by the genetic liability to AF. N-terminal prohormone of brain natriuretic peptide improved the prediction of incident AF events close to baseline with further improvements gained by the AF-PRS at all time points.

CONCLUSION

The AF proteomic signature includes biologically relevant proteins, some of which may be causal. It mainly reflects an NT-proBNP-dependent consequence of the genetic liability to AF. N-terminal prohormone of brain natriuretic peptide is a promising marker for incident AF in the short term, but risk assessment incorporating a PRS may improve long-term risk assessment.

Weekend atrial fibrillation hospitalizations are associated with higher short-term mortality

BACKGROUND

Previous investigations have analysed the relationship between weekend (WE) admission and early death in patients with atrial fibrillation (AF) patients without reaching univocal results. We systematically reviewed the available literature and performed a meta-analysis of data from cohort studies to estimate the association between WE admission and short-term mortality in AF patients.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. We searched relevant publications using MEDLINE and Scopus from inception until 15 November 2022. Studies reporting the mortality risk as an adjusted odds ratio (OR), with relative 95% confidence interval (CI) comparing early (in-hospital or 30-day) mortality between patients admitted during the WE (Friday to Sunday) versus weekdays (WD) and having confirmed AF were included into the analysis. Data were pooled using a random-effects models with OR and related 95% CI.

RESULTS

Overall, 5.164.986 AF patients (mean age 69.7 years old, 47.6% males) enrolled in five retrospective investigations were considered for the analysis. A random-effect model evidenced that AF patients admitted during the WE had a higher risk of 30-day or in-hospital death (adjusted OR: 1.57; 95% CI, 1.05-1.27, p = .003, I2 = 64.7%). Sensitivity analysis confirmed yielded results. A meta-regression analysis showed a relationship between mortality and the mean age of the studies included (p = .001) while no associations were identified using sex as moderating variables (p = .15).

CONCLUSIONS

Patients admitted during WE for AF are characterised by an approximately 58% excess in the risk of early death.

Increased small extracellular vesicle levels and decreased miR-126 levels associated with atrial fibrillation and coexisting diabetes mellitus

BACKGROUND

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. Diabetes mellitus (DM) is one of the risk factors for the development of stroke and thromboembolism in patients with AF. Early identification may reduce the incidence of complications and mortality in AF patients.

HYPOTHESIS

AF patients with DM have different pattern of small extracellular vesicle (sEV) levels and sEV-derived microRNA (miRNA) expression compared with those without DM.

METHODS

We compared sEV levels and sEV-miRNA expression in plasma from AF patients with and without DM using nanoparticle tracking analysis and droplet digital polymerase chain reaction, respectively.

RESULTS

We observed a significant increase in total sEV levels (p = .004) and a significant decrease in sEV-miR-126 level (p = .004) in AF patients with DM. Multivariate logistic regression analysis revealed a positive association between total sEV levels and AF with DM (p = .019), and a negative association between sEV-miR-126 level and AF with DM (p = .031). The combination of clinical data, total sEVs, and sEV-miR-126 level had an area under the curve of 0.968 (p < .0001) for discriminating AF with DM, which was shown to be significantly better than clinical data analysis alone (p = .0368).

CONCLUSIONS

These results suggest that an increased level of total sEV and a decreased sEV-miR-126 level may play a potential role in the pathophysiology and complications of AF with DM, especially endothelial dysfunction, and can be considered as an applied biomarker for distinguishing between AF with and without DM.

Safety and Effectiveness of Apixaban Versus Warfarin in Japanese Patients with Nonvalvular Atrial Fibrillation Stratified by Renal Function: A Retrospective Cohort Study

BACKGROUND

We previously conducted a retrospective cohort study using chart review of oral anticoagulant-naïve Japanese patients with nonvalvular atrial fibrillation (NVAF) that assessed the risk of major bleeding and stroke/systemic embolism (SE) events of apixaban versus warfarin.

METHODS

In this subgroup analysis, we compared the risk of major bleeding and stroke/SE events by stratifying patients into four subgroups matched 1:1 using propensity score matching (PSM) according to baseline creatinine clearance (CrCl; mL/min): ≥ 15 to < 30, ≥ 30 to < 50, ≥ 50 to < 80, and ≥ 80.

RESULTS

Of the 7074 patients in the apixaban group and 4998 in the warfarin group eligible for inclusion in the analysis, 4385 were included in each group after PSM. Incidence rates of major bleeding and stroke/SE events were generally lower with apixaban versus warfarin across the CrCl subgroups. When all patients with a CrCl change of < 0 mL/min per year during the study period (apixaban, n = 3871; warfarin, n = 2635) were stratified into four subgroups based on the magnitude of CrCl decline (median CrCl change [mL/min] per year: - 1.09, - 3.48, - 7.54, and - 36.92 for apixaban, and - 1.10, - 3.65, - 7.85, and - 40.40 for warfarin), the incidence rates of major bleeding and stroke/SE events generally increased with an increasing CrCl decline per year in both groups.

CONCLUSIONS

In Japanese patients with NVAF, the safety and effectiveness of apixaban and warfarin were consistent across different renal subgroups, including those with severe renal impairment. Our results highlight the importance of monitoring renal function variations over time in patients with NVAF.

CLINICALTRIALS

GOV IDENTIFIER

NCT03765242.

The Information Needs and Experiences of People Living With Cardiac Implantable Electronic Devices: Qualitative Content Analysis of Reddit Posts

BACKGROUND

Cardiac implantable electronic devices (CIEDs) are used to treat a range of cardiovascular diseases and can lead to substantial clinical improvements. However, studies evaluating patients' experiences of living with these devices are sparse and have focused mainly on implantable cardioverter defibrillators. In addition, there has been limited evaluation of how people living with a CIED use social media to gain insight into their condition.

OBJECTIVE

This study aims to analyze posts from web-based communities called subreddits on the website Reddit, intended for people living with a CIED, to characterize the informational needs and experiences of patients.

METHODS

Reddit was systematically searched for appropriate subreddits, and we found 1 subreddit that could be included in the analysis. A Python-based web scraping script using the Reddit application programming interface was used to extract posts from this subreddit. Each post was individually screened for relevancy, and a register of participants' demographic information was created. Conventional qualitative content analysis was used to inductively classify the qualitative data collected into codes, subcategories, and overarching categories.

RESULTS

Of the 484 posts collected using the script, 186 were excluded, resulting in 298 posts from 196 participants being included in the analysis. The median age of the participants who reported this was 33 (IQR 22.0-39.5; range 17-72) years, and the majority had a permanent pacemaker. The content analysis yielded 5 overarching categories: use of the subreddit by participants, questions and experiences related to the daily challenges of living with a CIED, physical sequelae of CIED implantation, psychological experiences of living with a CIED, and questions and experiences related to health care while living with a CIED. These categories provided insight into the diverse experiences and informational needs of participants living with a CIED. The data predominantly represented the experiences of younger and more physically active participants.

CONCLUSIONS

Social media provides a platform through which people living with a CIED can share information and provide support to their peers. Participants generally sought information about the experiences of others living with a CIED. This was often done to help overcome a range of challenges faced by participants, including the need to adapt to living with a CIED, difficulties with navigating health care, psychological difficulties, and various aversive physical sequelae. These challenges may be particularly difficult for younger and physically active people. Health care professionals may leverage peer support and other aid to help people overcome the challenges they face while living with a CIED.

Obesity-hyperlipidemia, Hypertension, and Left Atrial Enlargement During Stroke in Young Adults

BACKGROUND

This study investigated the association between left atrial enlargement and stroke severity in young adults. We also studied the differences between the normal and left atrial enlargement groups in clinical data.

METHODS

A total of 135 young stroke patients admitted to the Department of Neurology of the Taizhou People's Hospital were recruited from January 2018 to December 2021. The patients were divided into normal and enlarged groups by left atrial size. The relationship between the left atrial diameter and the National Institutes of Health Stroke Scale score was analyzed apart from the differences in clinical variables.

RESULTS

No relationship was observed between the left atrial diameter and the National Institutes of Health Stroke Scale score ( r =-0.045 P =0.603). The univariate analysis of both groups revealed that hypertension ( P =0.004), hyperlipidemia ( P =0.001), body mass index ( P =0.000), obesity ( P =0.015), and not stroke etiologic subtypes were associated with left atrial enlargement. In binary logistic regression analysis models, hyperlipidemia 3.384 (95% CI, 1.536 to 7.452), hypertension 2.661 (95% CI, 1.066 to 6.639), and obesity 2.858 (95% CI, 1.158 to 7.052) were significantly associated with the young stroke of left atrial enlargement.

CONCLUSIONS

In young adults, obesity-hyperlipidemia and hypertension were significantly associated with left atrial enlargement in stroke.

Cardiovascular and Neurological Outcomes in Patients Treated with Edoxaban for Atrial Fibrillation and Characteristics in Patients with Cancer

BACKGROUND

Direct oral anticoagulants (DOACs) outperform warfarin in vascular and bleeding events in atrial fibrillation (AF) patients. Yet, effects of DOACs on congestive heart failure (CHF) and Alzheimer's disease (AD) remain less explored.

METHODS

Using the Taiwan National Health Insurance Research Database, a nationwide retrospective cohort study was conducted. The study matched 5,683 non-valvular atrial fibrillation (NVAF) edoxaban patients with 11,366 warfarin patients, and 703 NVAF with cancer (NVAF-C) edoxaban patients with 1,406 warfarin patients. Vasular and non-vascular outcomes, with focuses on CHF and AD, were compared between the edoxaban and warfarin users.

RESULTS

Edoxaban significantly lowered adjusted hazrad ratio (aHR) of all-cause mortality, hospitalization for gastrointestinal bleeding, and CHF (0.37, 0.74, and 0.26, respectively, in NVAF; 0.39, 0.67, and 0.31, respectively, in NVAF-C, all p < 0.05), compared to warfarin. Edoxaban was associated with significantly lower aHRs of acute myocardial infarction, peripheral artery disease, venous thromboembolism, pulmonary embolism, and AD (0.71, 0.48, 0.55, 0.20, and 0.66, respectively; all p < 0.05) in NVAF patients versus warfarin. However, edoxaban had higher aHR of hospitalized bleeding (1.19, p = 0.002) than warfarin in NVAF patients, but not in NVAF-C patients.

CONCLUSIONS

Edoxaban demonstrated lowered CHF risks in both NVAF and NVAF-C patients, and reduced AD occurrence in NVAF patients versus warfarin. These findings advocate for edoxaban's use in AF cases.

CLINICAL PERSPECTIVE

What Is New?: The study reveals that in patients with atrial fibrillation (AF), edoxaban, a direct oral anticoagulant (DOAC), demonstrates significant advantages over warfarin. Notably, edoxaban is associated with a reduced risk of congestive heart failure (CHF) and Alzheimer's disease (AD) when compared to warfarin.Clinical Implications?: These findings have important clinical implications. Edoxaban appears to be a superior anticoagulant choice for AF patients, as it lowers the risk of CHF and AD. This highlights the potential of edoxaban to improve patient outcomes and underscores its relevance for managing AF cases.

Edoxaban in patients with non-valvular atrial fibrillation after percutaneous coronary intervention: ENCOURAGE-AF design

Approximately one fifth of patients diagnosed with atrial fibrillation (AF) undergo a percutaneous coronary intervention (PCI). Current guidelines recommend different combinations and durations of triple or dual antithrombotic therapy for these patients but data on the implementation of these recommendations in clinical routine are scarce. ENCOURAGE-AF is a prospective, non-interventional, non-comparative, multicentre study. Approximately 720 patients will be consecutively enrolled from 70 participating sites across Germany. Patients with non-valvular AF treated with edoxaban, who have undergone successful PCI, have no planned elective cardiac intervention during the study period, have capability, availability, and willingness for follow-up by telephone interview during the study, are aged ≥ 18 years with life expectancy ≥ 1 year, and provide written informed consent, will be included. Eligible patients will be enrolled between 4- and 72-h after completing a successful PCI. Duration of exposure to and dosing regimens of edoxaban, antiplatelet agents and other concomitant medications of interest will be monitored in line with the clinical practice. Physician- and patient-reported clinical events, adverse drug reactions, patient quality of life (EQ-5D-5L) and health resource utilisation (HRU) parameters will be evaluated at 30 days and 1-year post-PCI. The ENCOURAGE-AF non-interventional study will provide insights into the patterns of edoxaban usage in combination with antiplatelet treatment and other concomitant medications in AF patients with a successful PCI over a 1-year time period during routine clinical practice in Germany. The effectiveness and safety of edoxaban in this patient population, as well as patients' quality of life and HRU will be evaluated.Trial registration: Clinicaltrial.gov NCT04519944, registered on 20 August 2020.

Left atrial appendage angiography for stroke risk prediction in patients with atrial fibrillation

BACKGROUND

The current risk stratification schemes for stroke in patients with atrial fibrillation (AF) are insufficient for an accurate assessment of stroke risk.

AIMS

This study evaluates the association between the mechanical function of the left atrial appendage (LAA), as assessed by angiography, and the risk of stroke.

METHODS

We conducted a cross-sectional study to assess the mechanical function of the LAA by measuring the left atrial appendage ejection fraction (LAAEF) and grading the contrast retention (CR) using angiography.

RESULTS

A total of 746 patients referred for a left atrial appendage occlusion (LAAO) procedure with (n=151; stroke group) or without (n=595; control group) a history of stroke were included in the analysis. LAAEF was significantly lower (14% [9-19] vs 20% [12-33]; p<0.001) and grade 3 CR was more common (66.9% vs 33.9%; p<0.001) in patients with a history of stroke. Multivariable analysis showed that CR was independently associated with stroke in patients with AF (grade 2 vs grade 1=7.29; 95% confidence interval [CI]: 2.84-21.65; p<0.001; grade 3 vs grade 1=16.45; 95% CI: 6.16-51.02; p<0.001). The receiver operating characteristics curve demonstrated that CR identified patients with stroke more accurately than the CHA2D-VASc score (C-statistic 0.712 vs 0.512; p<0.001), and the combination of CR and the CHA2DS2-VASc score provided the best performance (C-statistic 0.871 vs 0.829 [CHA2DS2-VASc score alone]; p=0.048) Conclusions: Impaired mechanical function of the LAA, indicated by a low LAAEF and CR, is associated with a history of stroke in patients with AF. Assessment of CR using LAA angiography helps improve the stratification scheme for stroke risk prediction.

It can be safe to discontinue oral anticoagulants after successful atrial fibrillation ablation: A systematic review and meta-analysis of cohort studies

BACKGROUND

Current guidelines recommended that oral anticoagulants (OACs) should last for a minimum first 2 months after atrial fibrillation (AF) ablation and the long-term decision of anticoagulation after AF ablation should be based on the individual patient's risk of stroke rather than the rhythm status. There is controversy about the safety of discontinuing OACs in patients with atrial fibrillation after the blanking period due to the divergences between consensus recommendations and clinical practice.

METHODS

Electronic bibliographic sources (PubMed, Embase, and Web of Science) were searched until August 2023 to identify cohort studies about the safety of discontinuing OACs in patients with AF after the blanking period. The primary outcome was thromboembolism (TE). The secondary outcome was major bleeding events (MBEs). Two authors extracted articles independently using predefined data fields. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated based on a random-effects model.

RESULTS

A total of 16 studies (11 prospective cohorts and 5 retrospective cohorts) enrolling 23,942 patients (14,382 OFF-OAC and 9560 ON-OAC) were included in our analysis. No significant difference emerged in the risk of TE between OFF-OAC and ON-OAC patients following AF ablation after the banking period (OR = 0.66; 95%CI, 0.43-1.01). Similar results emerged in the patients with a high risk of TE after stratification by the risk level of TE (OR = 0.72; 95%CI, 0.25-2.08). A significant reduction in incidences of major bleeding was found in the OFF-OAC patients compared with the ON-OAC patients (OR = 0.23; 95%CI, 0.12-0.42). Subgroup analyses for TE found a reduction of incidences in the subgroups who switched to antiplatelet drugs and with a follow-up duration <3 years. Subgroup analyses for MBEs found a significant reduction of incidences in all subgroups.

CONCLUSIONS

Our study suggests it can be safe to discontinue OACs after successful AF ablation. Discontinuation of OACs may reduce the risk of MBEs while not increasing the risk of TE.

Gender-Based Clinical, Therapeutic Strategies and Prognosis Differences in Atrial Fibrillation

BACKGROUND

There are limited data on gender-based differences in atrial fibrillation (AF) treatment and prognosis. We aimed to examine gender-related differences in medical attention in an emergency department (ED) and follow-up (FU) among patients diagnosed with an AF episode and to determine whether there are gender-related differences in clinical characteristics, therapeutic strategies, and long-term adverse events in this population.

METHODS

We performed a retrospective observational study of patients who presented to a tertiary hospital ER for AF from 2010 to 2015, with a minimum FU of one year. Data on medical attention received, mortality, and other adverse outcomes were collected and analyzed.

RESULTS

Among the 2013 patients selected, 1232 (60%) were female. Women were less likely than men to be evaluated by a cardiologist during the ED visit (11.5% vs. 16.6%, p = 0.001) and were less likely to be admitted (5.9% vs. 9.5%, p < 0.05). Electrical cardioversion was performed more frequently in men, both during the first episode (3.4% vs. 1.2%, p = 0.001) and during FU (15.9% vs. 10.6%, p < 0.001), despite a lower AF recurrence rate in women (9.9% vs. 18.1%). During FU, women had more hospitalizations for heart failure (26.2% vs. 16.1%, p < 0.001).

CONCLUSIONS

In patients with AF, although there were no gender differences in mortality, there were significant differences in clinical outcomes, medical attention received, and therapeutic strategies. Women underwent fewer attempts at cardioversion, had a lower probability of being evaluated by cardiologists, and showed a higher probability of hospitalization for heart failure. Being alert to these inequities should facilitate the adoption of measures to correct them.

Psychopathology associated with cardiac pacing in Tanzania: A case series

Emotional disarray linked to interventional procedures may potentially aggravate previous psychiatric conditions or even precipitate new psychopathologies. Despite of the well-known deleterious impact of mental health disorders on cardiac outcomes, psychological disturbances are relatively understudied yet of vital importance to the overall health of post-pacing patients. In this case series we present a spectrum of mental illnesses observed in a cohort of patients who underwent permanent pacemaker implantation in Tanzania's national referral cardiac centre. Five individuals of African origin aged between 58 and 81 years presented to Jakaya Kikwete Cardiac Institute with clinical conditions warranting permanent pacemaker implantation. All five denied prior history of mental illness, however, after thorough psychiatric reviews; organic brain syndrome, panic disorder, brief psychotic disorder, adjustment disorder and major depressive disorder diagnoses were reached. All five were successfully channeled for medical psychotherapy. To conclude, this case series illustrates variable consequences of poor psychological adaptation to implantable cardiac devices, and it underscores the importance of continued psychological evaluation to such patients.

Clinical Outcomes of Left Atrial Appendage Occlusion Versus Switch of Direct Oral Antcoagulant in Atrial Fibrillation: A Territory-Wide Retrospective Analysis

Background Left atrial appendage occlusion (LAAO) has emerged as an alternative to oral anticoagulation therapy for stroke prevention in atrial fibrillation, but data comparing LAAO with direct oral anticoagulant (DOAC) are sparse. Methods and Results This cohort study compared LAAO (with or without prior anticoagulation) with a switch of one DOAC to another DOAC by 1:2 propensity score matching. The primary outcome was a composite of all-cause mortality, ischemic stroke, and major bleeding. A total of 2350 patients (874 in the LAAO group and 1476 in the DOAC switch group) were included. After a mean follow-up of 1052±694 days, the primary outcome developed in 215 (24.6%) patients in the LAAO group and in 335 (22.7%) patients in the DOAC switch group (hazard ratio [HR], 0.94 [95% CI, 0.80-1.12]; P=0.516). The LAAO group had a lower all-cause mortality (HR, 0.49 [95% CI, 0.39-0.60]; P<0.001) and cardiovascular mortality (HR, 0.49 [95% CI, 0.32-0.73]; P<0.001) but similar risk of ischemic stroke (HR, 0.83 [95% CI, 0.63-1.10]; P=0.194). The major bleeding risk was similar overall (HR, 1.18 [95% CI, 0.94-1.48], P=0.150) but was lower in the LAAO group after 6 months (HR, 0.71 [95% CI, 0.51-0.97]; P=0.032). Conclusions LAAO conferred a similar risk of composite outcome of all-cause mortality, ischemic stroke, and major bleeding, as compared with DOAC switch. The risks of all-cause mortality and cardiovascular mortality were lower with LAAO.

Clinical Profiles and One-Year Outcome in Middle Eastern Patients With Atrial Fibrillation and Hypertension: Analysis From the Jordan Atrial Fibrillation Study

Studies on the impact of hypertension (HTN) on the outcome of patients with atrial fibrillation (AF) in the Middle East are scarce. The aim of this contemporary multicenter study is to evaluate the effect of the coexisting HTN on the baseline clinical profiles and 1-year prognosis in a cohort of Middle Eastern patients with AF. Consecutive AF patients in 29 hospitals and cardiology clinics were enrolled in the Jordan AF study (May 2019-December 2020). Patients were prospectively followed up for 1 year, and the study had no influence on their treatment, which was at the discretion of the treating physician. We compared clinical features, use of medications, and 1-year prognosis in patients with AF/HTN compared with AF/no HTN. Among 1849 non-valvular AF patients, 76.4% had HTN, with higher prevalence of diabetes, dyslipidemia, coronary heart disease, stroke, and left ventricular hypertrophy in HTN patients. There was a higher thromboembolic and bleeding risk among HTN patients. At 1 year, HTN patients had significantly higher rates of stroke and systemic embolism (SSE) (4.5%), acute coronary syndrome (ACS) (2.4%), rehospitalization (27.9%), and major bleeding events (3.0%) compared with non-HTN patients. In this cohort, the coexistence of HTN was associated with worse baseline clinical profile and 1-year outcomes.

The Impact of Age on the Epidemiology and Cost of Atrial Fibrillation Hospitalizations

Atrial fibrillation (AF) is the most common arrhythmia and increases with age. This rising prevalence of AF is contributing to an increasing public health and economic burden. The 2018 Healthcare Cost and Utilization Project National Inpatient Sample dataset was used. All patients ≥15 years with a principal discharge diagnosis of AF were included. The patient population was divided into an "older" cohort (aged ≥65 years) and a "younger" (aged <65 years). Desired outcomes included hospital length of stay, discharge disposition, hospital charges, and in-hospital mortality. A generalized linear mixed model was used to calculate hospitalization rates for the "younger" and "older" groups. We identified 896,328 AF hospitalizations. Younger patients (18.1%) were more likely to be male (65.5% vs 49.9%), to smoke (21.6% vs 6.1%), and to use alcohol (9.7% vs 2.1%). Older patients were more likely to have heart failure (49.6% vs 43.9%) and hypertension (84.6% vs 76.1%). Hospitalization rates increased with increasing age groups. Older patients had higher in-hospital mortality (4.6% vs 2.9%) and were more likely to be discharged to another facility (31.6% vs 13.2%). AF hospitalization rates vary between hospitals across the United States. Hospital divisions with greater than expected admissions for AF, when compared with the national mean, were driven by higher "older" patient hospitalizations. In conclusion, older patients account for most AF hospitalizations. Older patients have higher AF morbidity and mortality. Hospitalization rates for AF increase with increasing increments of age.

Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study

BACKGROUND

Atrial fibrillation (AF) is a major risk factor for stroke. To enable improvements to AF diagnosis and follow-up care, understanding current patient pathways and barriers to optimal care are essential. We investigated the patient care pathways and their drivers, and the impact of the COVID-19 pandemic on patient pathways in a middle-income country setting, Brazil.

METHODS

This mixed-methods study in São Paulo, included adults (≥18y) with AF from 13 primary/secondary healthcare facilities. Surveys using baseline, follow-up (administered ≥two months after baseline) and COVID-19 questionnaires (quantitative), and three focus group discussions (FGDs) were conducted. Minimum sample size for the quantitative component was 236 and we aimed to reach saturation with at least three FGDs for the qualitative component. Descriptive statistics were used for quantitative data and a content analysis was used for qualitative data to identify themes related to AF diagnosis and follow-up care.

RESULTS

267 participants completed the baseline questionnaire: 25% were diagnosed in primary care, 65% in an emergency or inpatient department. At follow-up (n = 259), 31% visited more than one facility for AF care, and 7% had no follow-up. Intervals between international normalised ratio (INR) tests were increased during the pandemic, and the number of healthcare visits and availability of medication were reduced. Seventeen patients participated in three FGDs and revealed that AF diagnosis often occurred following a medical emergency and patients often delay care-seeking due to misconceptions about AF symptoms. Long waiting times, doctor/patient interactions and health system factors, such as doctor availability and the referral system, influence where participants visited for follow-up care.

CONCLUSIONS

Lack of public awareness and underdeveloped primary healthcare lead to delayed diagnosis, which impacts clinical outcomes and excess patient and healthcare system costs. Health system, care-provider, and pandemic factors disrupt timely and effective continuity of care.

Left atrium 4D-flow segmentation with high-resolution contrast-enhanced magnetic resonance angiography

Background

Atrial fibrillation (AF) leads to intracardiac thrombus and an associated risk of stroke. Phase-contrast cardiovascular magnetic resonance (CMR) with flow-encoding in all three spatial directions (4D-flow) provides a time-resolved 3D volume image with 3D blood velocity, which brings individual hemodynamic information affecting thrombus formation. As the resolution and contrast of 4D-flow are limited, we proposed a semi-automated 4D-flow segmentation method for the left atrium (LA) using a standard-of-care contrast-enhanced magnetic resonance angiography (CE-MRA) and registration technique.

Methods

LA of 54 patients with AF were segmented from 4D-flow taken in sinus rhythm using two segmentation methods. (1) Phase-contrast magnetic resonance angiography (PC-MRA) was calculated from 4D-flow, and LA was segmented slice-by-slice manually. (2) LA and other structures were segmented from CE-MRA and transformed into 4D-flow coordinates by registration with the mutual information method. Overlap of volume was tested by the Dice similarity coefficient (DSC) and the average symmetric surface distance (ASSD). Mean velocity and stasis were calculated to compare the functional property of LA from two segmentation methods.

Results

LA volumes from segmentation on CE-MRA were strongly correlated with PC-MRA volume, although mean CE-MRA volumes were about 10% larger. The proposed registration scheme resulted in visually successful registration in 76% of cases after two rounds of registration. The mean of DSC of the registered cases was 0.770 ± 0.045, and the mean of ASSD was 2.704 mm ± 0.668 mm. Mean velocity had no significant difference between the two segmentation methods, and mean stasis had a 3.3% difference.

Conclusion

The proposed CE-MRA segmentation and registration method can generate segmentation for 4D-flow images. This method will facilitate 4D-flow analysis for AF patients by making segmentation easier and overcoming the limit of resolution.

Left atrial appendage doppler velocity as a predictor of recurrence of atrial fibrillation after transesophageal echocardiogram guided electrical cardioversion

Background

There is a paucity of data on average left atrial appendage emptying velocity (LAAV) measured by doppler during transesophageal echocardiogram (TEE) being able to predict the risk of AF recurrence after electrical cardioversion (ECV).

Methods

Using electronic medical records from a community hospital, retrospective study was conducted after identifying all patients that received TEE-guided ECV. Data pertaining to LAAV, AF recurrence, and variables were obtained and analyzed.

Results

Out of 625 patients receiving TEE-guided ECV, 94 were excluded, and 51 did not convert to sinus rhythm. 480 patients had a successful ECV; out of these, 201 (41.87%) and 243 (50.62%) had a recurrence of atrial fibrillation at the end of 1 month and 3 months, respectively. Low LAAV (<=30 cm/s) was independently associated with an increased risk of AF recurrence at the end of 1 month (aOR 2.37, 95CI 1.5-3.73; p < 0.001) and 3 months (aOR 2.51, 95CI 1.59-3.96; p < 0.001) after TEE-guided ECV.

Conclusions

Low LAAV is associated with a high risk of AF recurrence. Identifying a specific subgroup of individuals at high risk of AF recurrence with the help of pre-ECV LAAV will facilitate the early institution of alternate treatment strategies and the plan for additional therapies.

Few-shot transfer learning for personalized atrial fibrillation detection using patient-based siamese network with single-lead ECG records

The proliferation of wearable devices has allowed the collection of electrocardiogram (ECG) recordings daily to monitor heart rhythm and rate. For example, 24-hour Holter monitors, cardiac patches, and smartwatches are widely used for ECG gathering and application. An automatic atrial fibrillation (AF) detector is required for timely ECG interpretation. Deep learning models can accurately identify AFs if large amounts of annotated data are available for model training. However, it is impractical to request sufficient labels for ECG recordings for an individual patient to train a personalized model. We propose a Siamese-network-based approach for transfer learning to address this issue. A pre-trained Siamese convolutional neural network is created by comparing two labeled ECG segments from the same patient. We sampled 30-second ECG segments with a 50% overlapping window from the ECG recordings of patients in the MIT-BIH Atrial Fibrillation Database. Subsequently, we independently detected the occurrence of AF in each patient in the Long-Term AF Database. By fine-tuning the model with the 1, 3, 5, 7, 9, or 11 ECG segments ranging from 30 to 180 s, our method achieved macro-F1 scores of 96.84%, 96.91%, 96.97%, 97.02%, 97.05%, and 97.07%, respectively.

The neutrophil-to-lymphocyte ratio is a potential biomarker for the occurrence of atrial fibrillation in patients with obstructive sleep apnea: A BIOMARKER OF AF IN OSA PATIENTS

BACKGROUND

Obstructive sleep apnea (OSA) affects the occurrence of atrial fibrillation (AF) and usually coexists with AF. Chronic inflammation has been identified as an important factor in the development of AF, and the neutrophil-to-lymphocyte ratio (NLR) has been identified as a biomarker that positively correlates with the degree of inflammation. However, little information regarding how NLR correlates with AF in OSA patients.

METHODS

Our study enrolled 368 patients with OSA between September 2018 and April 2023. All data were collected after admission. Independently associated factors were assessed by multivariate logistic regression and then constructed a nomogram to predict AF risk. Nomogram's calculation model was evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). The correlation between CHA2DS2-VASc scores and NLR was assessed using Spearman correlation.

RESULTS

Multivariate logistic regression showed that high level log-transformed NLR (OR, 1.664; 95% CI, 1.026-2.699; P = 0.039) was independently associated with the presence of AF in patients with OSA. The concordance index (0.817, 95% CI, 0.770-0.864), ROC curve, calibration curve, and DCA of the nomogram indicated this model had well clinical utility. Also, the nomogram's calculation model could identify patients who are at a higher risk of developing AF, and the CHA2DS2-VASc score was positively correlated with NLR in patients with AF (P < 0.05).

CONCLUSION

The elevated NLR may serve as a promising biomarker for assessing the risk of AF in individuals with OSA. The nomogram's calculation model may be utilized as a tool to estimate the probability of AF occurrence in OSA patients.

Prescription of DOACs in Patients with Atrial Fibrillation at Different Stages of Renal Insufficiency

Atrial fibrillation (AF) and renal insufficiency often coexist and are increasingly prevalent with advancing age. Both the risk of thromboembolic events and bleeding propensity are higher in patients with AF and impaired renal function versus those with good renal health. Direct oral anticoagulants (DOACs) are being increasingly preferred over vitamin K antagonists (VKAs) in the treatment of patients with AF and impaired renal function as VKAs may accelerate progression of chronic kidney disease. DOACs, however, are eliminated by the kidneys to varying degrees, and their dosages must be adapted in accordance with renal function. Since creatinine clearance (CrCl) monitoring is recommended in patients with AF receiving DOAC therapy, CrCl must be routinely monitored in patients at the start and during the course of anticoagulation to avoid deviation from Summary of Product Characteristics dosage specifications. This review article provides an overview of current knowledge on the selection and dose of DOACs including apixaban, dabigatran, edoxaban and rivaroxaban in AF patients at different stages of renal insufficiency, with a special focus on elderly patients with comorbidities and receiving multiple medications. The groups discussed in this review include patients with varying levels of CrCl including hyperfiltration or CrCl > 90 ml/min, CrCl < 90-50 ml/min, CrCl < 50-30 ml/min, CrCl < 30-15 ml/min and end-stage renal disease or on dialysis.

Adjunct posterior wall isolation reduces the recurrence of atrial fibrillation in patients undergoing cryoballoon ablation: A systematic review and meta-analysis

BACKGROUND

Recurrence rates of atrial fibrillation (AF) remain high even after complete wide area circumferential pulmonary vein isolation (PVI). In recent years adjunct posterior wall isolation (PWI) has been performed in patients with more persistent forms of AF but the benefits remain unclear.

AIM

The objective of this meta-analysis was to evaluate the efficacy of adjunct posterior wall isolation in reducing recurrence rates of AF using cryoballoon ablation (CBA).

METHODS

We searched PubMed, Google Scholar, Clinicaltrials.gov and Cochrane CENTRAL. We included studies comparing PVI to PVI + PWI in patients with either persistent or paroxysmal AF (PAF) undergoing CBA. After data extraction and quality assessment of the studies, we assessed recurrence rates of atrial tachy-arrhythmias (AF, atrial flutter, and atrial tachycardia) as well as total ablation time and procedural adverse events. Risk ratio (RR), mean difference (MD), and 95% confidence interval (CI) were calculated using Review Manager.

RESULTS

Concomitant PWI exhibited a substantial reduction in the risk of AF recurrence (RR: 0.51; 95% CI: 0.42-0.63, p < .00001), as well as all atrial arrhythmias (RR: 0.58; 95% CI: 0.49-0.68, p < .00001). On subgroup analysis, in patients with only PAF, adjunct PWI resulted in significant reduction in recurrence risk of AF (RR: 0.56; 95% CI: 0.41-0.76, p = .0002) as well. There was no significant difference in adverse events between both groups (RR: 0.90; 95% CI: 0.44-1.86; p = .78), whereas total ablation time was significantly increased in PVI + PWI group (MD: 21.75; 95% CI: 11.13-32.37, p < .0001).

CONCLUSION

Adjunct PWI when compared to PVI alone decreases recurrence rates of atrial fibrillation after CBA of patients with persistent as well as paroxysmal atrial fibrillation.

Selection of patients for hybrid ablation procedure

Catheter ablation for treatment of symptomatic non-paroxysmal atrial fibrillation remains challenging. Clinical failure and need for continued medical therapy or repeat ablation is common, especially in more advanced forms of atrial fibrillation. Hybrid ablation has emerged as a more effective and safe therapy than endocardial-only ablation particularly for longstanding persistent atrial fibrillation as demonstrated by the randomized controlled CONVERGE trial. Hybrid ablation requires collaboration of electrophysiologists and cardiac surgeons to develop specific workflows. This review describes the Hybrid Convergent approach in the context of available ablation options and offers guidance for workflow development and patient selection.

Lifestyle changes in atrial fibrillation management and intervention

Atrial fibrillation (AF) is one of the most common arrhythmias in adults, and its continued rise in the United States is complicated by the increased incidence and prevalence of several AF risk factors, such as obesity, physical inactivity, hypertension, obstructive sleep apnea, diabetes mellitus, coronary artery disease, and alcohol, tobacco, or caffeine use. Lifestyle and risk factor modification has been proposed as an additional pillar of AF therapy, added to rhythm control, rate control, and anticoagulation, to reduce AF burden and risk. Although emerging evidence largely supports the integration of lifestyle and risk factor management in clinical practice, randomized clinical trials investigating the long-term sustainability and reproducibility of these benefits remain sparse. The purpose of this review is to discuss potentially reversible risk factors on AF, share evidence for the impact on AF by modification of these risk factors, and then provide an overview of the effects of reversing or managing these risk factors on the success of various AF management strategies, such as antithrombotic, rate control, and rhythm control therapies.

Detecting atrial fibrillation in the polysomnography-derived electrocardiogram: a software validation study

PURPOSE

The present study validated a software-based electrocardiogram (ECG) analysis tool for detection of atrial fibrillation (AF) and risk for AF using polysomnography (PSG)-derived ECG recordings.

METHODS

The Stroke Risk Analysis® (SRA®) software was applied to 3-channel ECG tracings from diagnostic PSG performed in enrolled subjects including a subgroup of subjects with previously documented AF. No subjects used positive airway pressure therapy. All ECG recordings were visually analyzed by a blinded cardiologist.

RESULTS

Of subjects enrolled in the study, 93 had previously documented AF and 178 of 186 had an ECG that could be analyzed by either method. In subjects with known history of AF, automated analysis using SRA® classified 47 out of 87 ECG as either manifest AF or showing increased risk for paroxysmal AF (PAF) by SRA® (sensitivity 0.54, specificity 0.86). On visual analysis, 36/87 ECG showed manifest AF and 51/87 showed sinus rhythm. Among the latter subgroup, an increased risk for PAF was ascribed by SRA® in 11 cases (sensitivity 0.22, specificity 0.78) and by expert visual analysis in 5 cases (sensitivity 0.1, specificity 0.90). Among 36/178 ECG with manifest AF on visual analysis, 33 were correctly identified by the SRA® software (sensitivity and specificity 0.92).

CONCLUSION

Sleep studies provide a valuable source of ECG recordings that can be easily subjected to software-based analysis in order to identify manifest AF and automatically assess the risk of PAF. For optimal evaluability of data, multiple channel ECG tracings are desirable. For assessment of PAF risk, the SRA® analysis probably excels visual analysis, but sensitivity of both methods is low, reflecting that repeated ECG recording remains essential.

Platelet Receptor Glycoprotein VI-Dimer Is Overexpressed in Patients with Atrial Fibrillation at High Risk of Ischemic Stroke

Introduction  Atrial fibrillation (AF) increases the risk of ischemic stroke (IS). We hypothesized that the functional form of platelet receptor glycoprotein (GP) VI, GPVI-dimer, which binds to collagen and fibrin causing platelet activation, is overexpressed in patients with AF who have not had a stroke. Methods  A total of 75 inpatients with AF were recruited. None were admitted with or had previously had thrombotic events, including IS or myocardial infarction. Platelet surface expression of total GPVI, GPVI-dimer, and the platelet activation marker P-selectin were quantitated by whole blood flow cytometry. Serum biomarkers were collected in AF patients. Results were compared against patients contemporaneously admitted to hospital with similar age and vascular risk-factor profiles without AF (noAF, n  = 30). Results  Patients with AF have similar total GPVI surface expression ( p  = 0.58) and P-selectin exposure ( p  = 0.73) on their platelets compared with noAF patients but demonstrate significantly higher GPVI-dimer expression ( p  = 0.02 ). Patients with paroxysmal AF express similar GPVI-dimer levels compared with permanent AF and GPVI-dimer levels were not different between anticoagulated groups. Serum N-terminal pro b-type natriuretic peptide ( p  < 0.0001 ) and high sensitivity C-reactive protein ( p  < 0.0001 ) were significantly correlated with GPVI-dimer expression in AF platelets. AF was the only vascular risk factor that was independently associated with higher GPVI-dimer expression in the whole population ( p  = 0.02 ) . Conclusion  GPVI inhibition is being explored in clinical trials as a novel target for IS treatment. As GPVI-dimer is elevated in AF patients' platelets, the exploration of targeted GPVI-dimer inhibition for stroke prevention in patients at high risk of IS due to AF is supported.

Comparison of left atrial and left atrial appendage mechanics in the recurrence of atrial fibrillation after radiofrequency catheter ablation

OBJECTIVES

Although radiofrequency catheter ablation (RFCA) has become an important treatment strategy for paroxysmal or persistent atrial fibrillation (AF), AF recurrence after RFCA remains an important issue that plagues clinicians and patients. This study aimed to investigate the association of left atrial (LA) and left atrial appendage (LAA) mechanics with AF recurrence after RFCA and to compare their prognostic values in patients with AF undergoing RFCA.

METHODS

A total of 160 patients with non-valvular AF who underwent RFCA for the first time were included in this study. All patients underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) before the procedure. All patients were followed up for one year after RFCA, and AF recurrence was recorded. Speckle-tracking echocardiography was used to measure LA and LAA global longitudinal strain (GLS). LA and LAA mechanical dispersion (MD) were defined as the standard deviation of time to peak strain at each segment standardized by the R-R interval. Logistic regression analysis was used to analyze independent contributors for AF recurrence after RFCA. The prediction efficiency of factors associated with the presence of AF recurrence was evaluated by the receiver operating characteristic (ROC) curve with area under curve (AUC).

RESULTS

During 1-year follow-up, 45 (28%) patients had recurrence, and 115 (72%) patients had no recurrence. The age, CHA2 DS2 -VASc score, NT-proBNP, LA volume index (LAVI), LA MD, and LAA MD of patients in recurrence group were significantly higher than those in no recurrent group (p < .05). The LAA emptying fraction (LAAEF), LA GLS, and LAA GLS in recurrence group were significantly lower than those in no recurrent group (p < .05). Logistic regression analysis showed that LA and LAA GLS were independent contributors for AF recurrence (p < .05), providing incremental values. The AUCs of LA and LAA GLS in predicting AF recurrence were higher than that of other factors, and the LA GLS+LAA GLS joint model had higher prediction efficiency.

CONCLUSION

This study demonstrated the LA and LAA GLS were independent contributors for AF recurrence after RFCA and provided incremental values. LA and LAA GLS can be used as the predictor of AF recurrence after RFCA, and they may be beneficial for the risk stratification of AF recurrence.

Evaluation of the safety, efficacy, effectiveness and cost-effectiveness of implantable Holter for prolonged monitoring in patients with previous stroke: a systematic review

Background

Atrial fibrillation (AF), which is associated with cryptogenic stroke, is the most common sustained arrhythmia in the general population. Because AF is asymptomatic and intermittent, its detection rate increases with the duration of monitoring. The objective of this study is to review the available evidence on the safety, efficacy, effectiveness and cost-effectiveness of AF diagnosis by prolonged monitoring with an implantable Holter monitor in adult patients with idiopathic or cryptogenic stroke of suspected cardioembolic origin, compared to conventional monitoring.

Methods

Two independent reviewers performed a systematic review of the literature, identifying relevant studies through a structured search of Medline (Ovid), EMBASE, Web of Science and Cochrane Library and the databases of national and international health technology assessment agencies. The quality of the included studies was assessed with AGREE-II, AMSTAR-2 and CHEC. GRADE criteria were used to summarise the evidence.

Results

Four of the 211 papers identified were included: 1 clinical practice guideline, 2 systematic reviews, and 1 economic evaluation. The quality of the evidence reviewed was low. An implantable Holter monitor might be more effective in detecting AF than conventional monitoring. Serious adverse events were similar in both groups. The economic evaluation suggests that the technology is cost-effective.

Conclusions

The available evidence suggests the diagnostic superiority of the implantable Holter monitor over the traditional Holter monitor. Due to the low quality of the evidence, further and higher quality studies on these technologies are needed before solid conclusions can be drawn.

Beyond the Rhythm: In Silico Identification of Key Genes and Therapeutic Targets in Atrial Fibrillation

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia worldwide and is characterized by a high risk of thromboembolism, ischemic stroke, and fatality. The precise molecular mechanisms of AF pathogenesis remain unclear. The purpose of this study was to use bioinformatics tools to identify novel key genes in AF, provide deeper insights into the molecular pathogenesis of AF, and uncover potential therapeutic targets. Four publicly available raw RNA-Seq datasets obtained through the ENA Browser, as well as proteomic analysis results, both derived from atrial tissues, were used in this analysis. Differential gene expression analysis was performed and cross-validated with proteomics results to identify common genes/proteins between them. A functional enrichment pathway analysis was performed. Cross-validation analysis revealed five differentially expressed genes, namely FGL2, IGFBP5, NNMT, PLA2G2A, and TNC, in patients with AF compared with those with sinus rhythm (SR). These genes play crucial roles in various cardiovascular functions and may be part of the molecular signature of AF. Furthermore, functional enrichment analysis revealed several pathways related to the extracellular matrix, inflammation, and structural remodeling. This study highlighted five key genes that constitute promising candidates for further experimental exploration as biomarkers as well as therapeutic targets for AF.

Influence of body mass index on recurrence of atrial fibrillation after electrical cardioversion

BACKGROUND

Several studies have shown an independent relationship between body mass index (BMI) and the incidence of atrial fibrillation (AF). However, little is known about the influence of BMI on AF recurrence after electrical cardioversion (ECV).

METHODS

We selected 1121 patients who reverted to sinus rhythm after scheduled ECV and were included in three prospective Spanish registries of ECV in persistent AF. The patients were classified according to baseline BMI into three categories (normal weight, overweight, obesity). We assessed the influence of BMI on the rate of AF recurrence at 3 months.

RESULTS

We identified 538 patients (48%) who had AF recurrence in the first 3 months after successful ECV. The patients who suffered AF recurrence had a higher BMI than those who remained in sinus rhythm (29.66±4.57 vs. 28.87±4.64 Kg/m2, respectively; p = 0.004). We observed a higher incidence of AF recurrence in the overweight and obese patients (BMI ≥25 kg/m2) than in those classified as normal weight (50.5% vs. 35.6%, respectively; p<0,001). BMI≥25 Kg/m2 was shown to be independently related to of AF recurrence in the multivariate analysis (OR = 1.75, 95% confidence interval = 1.20-2.58; p = 0.004).

CONCLUSIONS

Increased BMI is independently related to AF recurrence after ECV. BMI should also be taken into account when making decisions about the indication for ECV in persistent AF.

Appropriateness of rivaroxaban and apixaban dosing in hospitalized patients with a newly diagnosed nonvalvular atrial fibrillation at a single tertiary hospital

Possible challenges in dosing non-vitamin K antagonist oral anticoagulants in nonvalvular atrial fibrillation (NVAF) and limited evidence in Saudi Arabia make it difficult to assess their appropriateness. This study aimed to assess the appropriateness of prescribing rivaroxaban and apixaban in hospitalized patients with newly diagnosed NVAF. This single-center, descriptive, retrospective study was conducted at a tertiary hospital in Saudi Arabia between December 2018 and December 2019. The included patients were aged 18 years and older with newly diagnosed NVAF who received either rivaroxaban or apixaban during hospitalization. The primary outcome was the dosing appropriateness of rivaroxaban and apixaban in NVAF based on recent food and drug administration prescribing guidelines. Descriptive statistics including frequencies and percentages as well as mean ± standard deviation was used to summarize the data. Pearson Chi-square was used to test for significant difference in proportions of appropriate and inappropriate dosing. Pearson Correlation was used to test for associations between underdosing and overdosing with other patients characteristics. A priori P value < .05 was considered significant throughout. A total of 203 patients were included in our analysis. Majority of the patients {125 (61.6%), P = .001} received rivaroxaban. Overall, the dosing appropriateness observed in 143 (70.5%) of the patients who received the rivaroxaban and apixaban was significantly higher than the dosing inappropriateness observed in 60 (29.5%) of the patients who received the same drugs, P < .001. Apixaban had the highest proportion of patients, 45 (57.7%) with dosing inappropriateness. Overall, underdosing was the most common dosing inappropriateness observed in 53 (26.1%) of the patients. There was a significant negative correlation between the drugs underdosing and creatinine clearance, r = -0.223, P = .001. The findings in our present study showed that majority of the patients received appropriate dosing of rivaroxaban and apixaban in hospitalized patients with NVAF. Healthcare providers should update themselves with the recent dosing recommendations for the non-vitamin K-antagonist oral anticoagulants in NVAF to further improve the dosing appropriateness in hospitalized patients with NVAF.

Early experiences with edoxaban for stroke prevention in atrial fibrillation in the Southeast Asia region

Edoxaban, a once-daily, direct-acting oral anticoagulant, is approved to prevent stroke or systemic embolism in non-valvular atrial fibrillation (NVAF) and treat venous thromboembolism. The clinical benefit of edoxaban for stroke prevention in Asian patients with NVAF has been demonstrated in clinical and real-world studies. We share early clinical experiences with once-daily edoxaban and discuss its evidence-based use in patients with NVAF in Southeast Asia through several cases of patients at high risk, including frail patients, elderly patients with multiple comorbidities and patients with increased bleeding risk. These cases demonstrate the effectiveness and safety of once-daily edoxaban in patients with NVAF in Southeast Asia.

A cardiologist-like computer-aided interpretation framework to improve arrhythmia diagnosis from imbalanced training datasets

Arrhythmias can pose a significant threat to cardiac health, potentially leading to serious consequences such as stroke, heart failure, cardiac arrest, shock, and sudden death. In computer-aided electrocardiogram interpretation systems, the inclusion of certain classes of arrhythmias, which we term "aggressive" or "bullying," can lead to the underdiagnosis of other "vulnerable" classes. To address this issue, a method for arrhythmia diagnosis is proposed in this study. This method combines morphological-characteristic-based waveform clustering with Bayesian theory, drawing inspiration from the diagnostic reasoning of experienced cardiologists. The proposed method achieved optimal performance in macro-recall and macro-precision through hyperparameter optimization, including spliced heartbeats and clusters. In addition, with increasing bullying by aggressive arrhythmias, our model obtained the highest average recall and the lowest average drop in recall on the nine vulnerable arrhythmias. Furthermore, the maximum cluster characteristics were found to be consistent with established arrhythmia diagnostic criteria, lending interpretability to the proposed method.

Global Burden of Atrial Fibrillation and Flutter by National Income: Results From the Global Burden of Disease 2019 Database

Background Atrial fibrillation (AF) and atrial flutter (AFL) are common conditions that can lead to significant morbidity and death. We aimed to understand the distribution and disparities of the global burden of AF/AFL as well as the underlying risk factors. Methods and Results Data on the AF/AFL burden from the Global Burden of Disease data set were analyzed for the years 1990 to 2019, with countries grouped into low, lower-middle, upper-middle, and high national income classes according to World Bank categories. Data were supplemented with World Health Organization and World Bank information. The prevalence of AF/AFL has more than doubled (+120.7%) since 1990 in all income groups, though with a larger increment in middle-income countries (+146.6% in lower-middle- and +145.2% in upper-middle-income countries). In absolute numbers, 63.4% of AF/AFL cases originate from upper-middle-income countries, although the relative prevalence is highest in high-income countries. Prevalence of AF/AFL appears to be correlated with medical doctor rate and life expectancy. The most relevant AF/AFL risk factors are unevenly distributed among income classes, with elevated blood pressure as the only risk factor that becomes less common with increasing income. The development of these risk factors differed over time. Conclusions The global burden of AF/AFL is increasing in all income groups and is more pronounced in middle-income countries, with further growth to be expected. Underdiagnosis of AF/AFL in low- and middle-income countries may contribute to lower reported prevalence. The risk factor distribution varies between income groups.

Management and Prognosis of Acute Stroke in Atrial Fibrillation

Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and mortality compared to non-AF strokes. The management of patients with AF-related strokes is challenging, and it involves weighing individual risks and benefits in the acute treatment and preventive strategies of these patients. This review summarizes the current knowledge of the acute management of ischemic and hemorrhagic stroke in patients with AF, and the prognosis and potential implications for management both in the acute and long-term setting.

Three Ablation Techniques for Atrial Fibrillation during Concomitant Cardiac Surgery: A Systematic Review and Network Meta-Analysis

Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94-1.23); PVI: OR = 1.36 (CI 1.08-1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37-0.71); PVI: OR = 0.52 (CI 0.31-0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28-1.45); PVI: OR = 0.31 (CI 0.1-0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time.

Assessment of Beat-To-Beat Variability in Left Atrial Hemodynamics Using Real Time Phase Contrast MRI in Patients With Atrial Fibrillation

BACKGROUND

Hemodynamic assessment of left atrial (LA) flow using phase contrast MRI provides insight into thromboembolic risk in atrial fibrillation (AF). However, conventional flow imaging techniques are averaged over many heartbeats.

PURPOSE

To evaluate beat-to-beat variability and LA hemodynamics in patients with AF using real time phase contrast (RTPC) MRI.

STUDY TYPE

Prospective.

SUBJECTS

Thirty-five patients with history of AF (68 ± 10 years, nine female), 10 healthy controls (57 ± 19 years, four female).

FIELD STRENGTH/SEQUENCE

5T, 2D RTPC with through-plane velocity-encoded gradient echo sequence and 4D flow MRI with three-directional velocity-encoded gradient echo sequence.

ASSESSMENT

RTPC was continuously acquired for a mid-LA slice in all subjects. 4D flow data were interpolated at the RTPC location and normally projected for comparison with RTPC. RR intervals extracted from RTPC were used to calculate heart rate variability (HRV = interquartile range over median × 100%). Patients were classified into low (<9.7%) and high (>9.7%) HRV groups. LA peak/mean velocity and stasis (%velocities < 5.8 cm/sec) were calculated from segmented 2D images. Variability in RTPC flow metrics was quantified by coefficient of variation (CV) over all cycles.

STATISTICAL TESTS

Pearson's correlation coefficient (r), Bland-Altman analysis, Kruskal-Wallis test. A P value < 0.05 was considered statistically significant.

RESULTS

RTPC and 4D flow measurements were strongly/significantly correlated for all hemodynamic parameters (R2  = 0.75-0.83) in controls. Twenty-four patients had low HRV (mean = 4 ± 2%) and 11 patients had high HRV (27 ± 9%). In patients, increased HRV was significantly correlated with CV of peak velocity (r = 0.67), mean velocity (r = 0.51), and stasis (r = 0.41). A stepwise decrease in peak/mean velocity and increase in stasis was observed when comparing controls vs. low HRV vs. high HRV groups. Mean velocity and stasis differences were significant for control vs. high HRV groups.

CONCLUSIONS

RTPC may be suitable for assessing the impact of HRV on hemodynamics and provide insight for AF management in highly arrhythmic patients.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Fractal complexity alternations in paroxysmal atrial fibrillation patients with and without recurrence after pulmonary vein isolation

BACKGROUND

Pulmonary vein isolation (PVI) is a cornerstone therapy for paroxysmal atrial fibrillation (PAF). The variations in nonlinear heart rate variability (HRV) between patients with and without recurrences remain unclear. We aimed to characterize the nonlinear HRV before and after PVI in patients with and without recurrence.

METHODS

Twenty-five drug-refractory PAF patients (56.0 ± 9.1 years old, 20 males) who received PVI were enrolled. Holter electrocardiography were performed before, 1-3, and 6-12 months after PVI. After 8.2 ± 2.5 months of follow-ups after PVI, patients were divided into two groups: the recurrence (n = 8) and non-recurrence (n = 17) groups. Linear and nonlinear HRV variables were analyzed, including the Poincaré Plot analysis and the Detrended Fluctuation Analysis (DFA).

RESULTS

The non-recurrence group, but not the recurrence group, had decreased high-frequency component (HF), the root mean square of successive RR interval differences (RMSSD), and the Poincaré Plot index SD1 1-3 months after PVI and increased DFAslope2 6-12 months after PVI. The non-recurrence group's LF/HF ratio and DFAslope1 decreased significantly 1-3 and 6-12 months after PVI, respectively, whereas there was no significant change in the recurrence group after PVI.

CONCLUSIONS

Significantly reduced vagal tone 1-3 months after PVI, increased long-term fractal complexity 6-12 months after PVI, and decreased sympathetic tone as well as short-term fractal complexity 1-3 and 6-12 months after PVI led to a better AF-free survival after PVI. These findings suggest that neuromodulation and heart rate dynamics play crucial roles in AF recurrence following PVI.

Gut microbiome relationship with arrhythmias and conduction blocks: A two-sample Mendelian randomization study

INTRODUCTION

Past research based on observations has suggested that the gut microbiome (GM) could play a role in developing arrhythmias and conduction blocks. Nonetheless, the nature of this association remains uncertain due to the potential for reverse causation and confounding factors in observational research. The aim of this investigation is to elucidate the causal relationship between GM and the development of arrhythmias as well as conduction blocks.

METHODS

This study collected summary statistics regarding GM, arrhythmias, and conduction blocks. Two-sample Mendelian randomization (MR) analysis was carried out employing various methods, with inverse variance weighted being the primary approach, followed by weighted median, simple mode, MR-Egger, and MR-PRESSO. Moreover, the MR findings were corroborated through multiple sensitivity analyses.

RESULTS

Among them, for atrial fibrillation and flutter (AF), phylum_Actinobacteria and genus_RuminococcaceaeUCG004 demonstrated a negative correlation, while order_Pasteurellales, family_Pasteurellaceae, and genus_Turicibacter were associated with an increased risk. In the case of paroxysmal tachycardia (PT), genus_Holdemania and genus_Roseburia were found to reduce risk. For atrioventricular block (AVB), order_Bifidobacteriales, family_Bifidobacteriaceae, and genus_Alistipes exhibited a negative correlation, whereas genus_CandidatusSoleaferrea showed a positive correlation. Concerning the left bundle-branch block (LBBB), family_Peptococcaceae appeared to decrease the risk, while genus_Flavonifractor was linked to an increased risk. Lastly, no causative GM was identified in the right bundle-branch block (RBBB) context.

CONCLUSION

We have uncovered potential causal links between some GM, arrhythmias, and conduction blocks. This insight may aid in designing microbiome-based interventions for these conditions and their risk factors in future trials. Additionally, it could facilitate the discovery of novel biomarkers for targeted prevention strategies.

Visit-to-Visit Heart Rate Variability in the Prediction of Clinical Outcomes of Patients with Atrial Fibrillation

BACKGROUND

 Visit-to-visit heart rate variability (VVV-HR) has been associated with adverse cardiovascular outcomes. We aimed to determine the predictive value of VVV-HR for adverse clinical outcomes in patients with nonvalvular atrial fibrillation (AF).

METHODS

 We used data from a prospective multicenter AF registry of 27 hospitals in Thailand during 2014 to 2017. After the baseline visit, patients were followed up every 6 months until 3 years. VVV-HR was calculated from the standard deviation of heart rate data from baseline visit and every follow-up visit. VVV-HR was categorized into four groups according to the quartiles. Clinical outcomes were all-cause death, ischemic stroke/systemic embolism (SE), and heart failure. Cox proportional hazard models were used for multivariable analysis.

RESULTS

 There were a total of 3,174 patients (mean age: 67.7 years; 41.8% female). The incidence rates of all-cause death, ischemic stroke/SE, and heart failure were 3.10 (2.74-3.49), 1.42 (1.18-1.69), and 2.09 (1.80-2.42) per 100 person-years respectively. The average heart rate was 77.8 ± 11.0 bpm and the average of standard deviation of heart rate was 11.0 ± 5.9 bpm. VVV-HR Q4 was an independent predictor of all-cause death, ischemic stroke/SE, and heart failure with adjusted hazard ratios of 1.45 (95% confidence interval: 1.07-1.98), 2.02 (1.24-3.29), and 2.63 (1.75-3.96), respectively. VVV-HR still remained a significant predictor of clinical outcomes when analyzed based on coefficient of variation and variability independent of mean.

CONCLUSION

 VVV-HR is an independent predictor for adverse clinical outcomes in patients with AF. A J-curve appearance was demonstrated for the effect of VVV-HR on all-cause death.

Evaluation of Atrial Fibrillation Detection in Short-Term Photoplethysmography (PPG) Signals Using Artificial Intelligence

Background Atrial fibrillation (AFIB) is a common atrial arrhythmia that affects millions of people worldwide. However, most of the time, AFIB is paroxysmal and can pass unnoticed in medical exams; therefore, regular screening is required. This paper proposes machine learning (ML) methods to detect AFIB from short-term electrocardiogram (ECG) and photoplethysmography (PPG) signals. Aim Several experiments were conducted across five different databases, with three of them containing ECG signals and the other two consisting of only PPG signals. Experiments were conducted to investigate the hypothesis that an ML model trained to predict AFIB from ECG segments could be used to predict AFIB from PPG segments. Materials and methods A random forest (RF) ML algorithm achieved the best accuracy and achieved a 90% accuracy rate on the University of Mississippi Medical Center (UMMC) dataset (216 samples) and a 97% accuracy rate on the Medical Information Mart for Intensive Care (MIMIC)-III datasets (2,134 samples). Results A total of 269,842 signal segments were analyzed across all datasets (212,266 were of normal sinus rhythm (NSR) and 57,576 corresponded to AFIB segments). Conclusions The ability to detect AFIB with significant accuracy using ML algorithms from PPG signals, which can be acquired via non-invasive contact or contactless, is a promising step forward toward the goal of achieving large-scale screening for AFIB.

Prevalence and prognostic value of atrial fibrillation in patients with cardiac sarcoidosis

Aims

The prognostic value of the presence of atrial fibrillation (AF) in patients at the time of cardiac sarcoidosis (CS) diagnosis is unknown. This study aimed to investigate the association between AF at the time of CS diagnosis and patient prognosis.

Methods and results

This study is a post-hoc analysis of Illustration of the Management and Prognosis of Japanese Patients with CS, a multicentre, retrospective observational study that evaluated the clinical characteristics and prognosis of patients with CS. The primary endpoint was the combined endpoint of all-cause death and hospitalization due to heart failure. After excluding patients with missing data about AF status, 445 patients (62 ± 11 years, 36% males) diagnosed with CS according to the Japanese current diagnostic guideline were analysed. Compared to patients without AF, patients with AF (n = 46, 10%) had higher levels of brain natriuretic peptide and a higher prevalence of heart failure hospitalizations. During a median follow-up period of 3.2 years (interquartile range, 1.7-5.8 years), 80 primary endpoints were observed. Kaplan-Meier curve analysis indicated that concomitant AF at the time of diagnosis was significantly associated with a high incidence of primary endpoints (log-rank P = 0.002). This association was retained after adjusting for known risk factors including log-transformed brain natriuretic peptide levels and left ventricular ejection fractions [hazard ratio, 1.96 (95% confidence interval, 1.05-3.65); P = 0.035].

Conclusion

The presence of AF at the time of CS diagnosis is associated with higher incidence of all-cause death and heart failure hospitalization.

One-year Aerobic Interval Training Improves Endothelial Dysfunction in Patients with Atrial Fibrillation: A Randomized Trial

Objective To evaluate the effects of one-year aerobic interval training on endothelial dysfunction in patients with atrial fibrillation. Methods Seventy-four patients with atrial fibrillation (53 men, 21 women; mean age 63±6 years old) were randomized into a 1-year continuous aerobic interval training (CT), 6-month detraining after 6 months of aerobic interval training (DT), or medical treatment only (MT) group. Aerobic interval training was performed 3 times a week for 1 year or 6 months, with an exercise intensity of 85-95% of the peak heart rate. The primary outcome was a change in biomarkers of endothelial dysfunction from baseline at six months or at the one-year follow-up. Results Six-month aerobic interval training reduced von Willebrand factor (CT: 103.7±30.7 IU/dL and DT: 106±31.2 IU/dL vs. MT: 145±47.7 IU/dL, p=0.044). Improvements were maintained with continuous aerobic interval training; however, the values increased again to the baseline levels upon detraining (CT: 84.3±39.1 IU/dL vs. DT: 122.2±27.5 IU/dL and MT: 135.9±50.4 IU/dL, p=0.002). Interleukin 1 beta levels decreased after 6 months of aerobic interval training (CT: 0.59±0.1 pg/mL and DT: 0.63±0.09 pg/mL vs. MT: 0.82±0.28 pg/mL, p=0.031), and the improvement was maintained with continuous aerobic interval training and even after detraining (CT: 0.58±0.08 pg/mL and DT: 0.62±0.09 pg/mL vs. MT: 0.86±0.28 pg/mL, p=0.015). Conclusion One-year aerobic interval training improves endothelial dysfunction in patients with atrial fibrillation and is primarily associated with the reduction in circulating thrombogenic and pro-inflammatory factors. A definitive way to sustain these improvements is the long-term continuation of aerobic training.

An economic evaluation of first-line cryoballoon ablation vs antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from a U.S. Medicare perspective

Background

Three recent randomized controlled trials have demonstrated that, as an initial rhythm control strategy, first-line cryoballoon ablation (cryoablation) reduces atrial arrhythmia recurrence compared with antiarrhythmic drugs (AADs) in patients with symptomatic paroxysmal atrial fibrillation (PAF).

Objective

The study sought to evaluate the cost-effectiveness of first-line cryoablation compared with first-line AADs for treating symptomatic PAF from a U.S. Medicare payer perspective.

Methods

Individual patient-level data from 703 participants with PAF enrolled into the Cryo-FIRST (NCT01803438), STOP AF First (NCT03118518), and EARLY-AF (NCT02825979) trials were used to derive parameters for the cost-effectiveness model. The cost-effectiveness model used a hybrid decision tree and Markov structure. The decision tree had a 1-year time horizon and was used to inform the initial health state allocation in the first cycle of the Markov model. The Markov model used a 40-year time horizon (3-month cycle length). Health benefits were expressed in quality-adjusted life years (QALYs). Costs and benefits were discounted at 3% per year.

Results

Cryoablation was estimated to yield higher QALYs (+0.17) and higher costs (+$4274) per patient over a 40-year time horizon than AADs. Ultimately, this produced an average incremental cost-effectiveness ratio of $24,637 per QALY gained. Independent of initial treatment, individuals were expected to receive ∼1.2 ablations over a lifetime. There was a 45% relative reduction in time spent in atrial fibrillation health states for those initially treated with cryoablation compared with AADs.

Conclusion

Initial rhythm control with first-line cryoballoon ablation is highly cost-effective compared with first-line AADs from a U.S. Medicare payer perspective.

Association between polymorphisms in connexin 40 gene (Cx40) and risk of atrial fibrillation: a meta-analysis based on 3,452 subjects

INTRODUCTION

Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with heart failure and stroke, leading sometimes to death. But the pathogenesis of AF remains unclear. Numerous studies have investigated whether the connexin 40 (Cx40) polymorphisms influences the risk of AF, but the results are controversial.

METHODS

We searched English and Chinese databases and calculated the odds ratio (OR) and 95% confidence interval (CI) to examine the existence of genetic associations between the Cx40 polymorphisms and the risk of AF. All relevant studies were screened and meta-analyzed using Review Manager 5.0.

RESULTS

A total of 12 studies, including 10 studies for -44 polymorphism (rs35594137) and 4 studies for -26 polymorphism (rs10465885), were identified for the meta-analysis. For -44 polymorphism, the results showed a significantly increased risk of AF in the five genetic models in the overall analysis. Furthermore, in subgroup analysis, increased AF risks were also observed in Asian and non-Asian populations. For -26 polymorphism, the overall OR revealed an increased risk of AF in dominant model. In subgroup analysis, increased AF risk was only found in recessive genetic model of the Asian population.

CONCLUSIONS

The Cx40 polymorphisms were positively associated with AF in both populations, especially on -44 polymorphism.