Atrial fibrillation incidence and risk factors in relation to race-ethnicity and the population attributable fraction of atrial fibrillation risk factors: the Multi-Ethnic Study of Atherosclerosis

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD: CRD42024581661.

Smart watch applications in atrial fibrillation detection: Current state and future directions

INTRODUCTION

Atrial fibrillation (Afib) is a prevalent chronic arrhythmia associated with severe complications, including stroke, heart failure, and increased mortality. This review explores the use of smartwatches for Afib detection, addressing the limitations of current monitoring methods and emphasizing the potential of wearable technology in revolutionizing healthcare.

RESULTS/OBSERVATION

Current Afib detection methods, such as electrocardiography, have limitations in sensitivity and specificity. Smartwatches with advanced sensors offer continuous monitoring, improving the chances of detecting asymptomatic and paroxysmal Afib. The review meticulously examines major clinical trials studying Afib detection using smartwatches, including the landmark Apple Heart Study and ongoing trials such as the Heart Watch, Heartline, and Fitbit Heart Study. Detailed summaries of participant numbers, smartwatch devices used, and key findings are presented. It also comments on the cost-effectiveness and scalability of smartwatch-based screening, highlighting the potential to reduce healthcare costs and improve patient outcomes.

CONCLUSION/RELEVANCE

The integration of wearable technology into healthcare can lead to earlier diagnosis, improved patient engagement, and enhanced cardiac health monitoring. Despite ethical considerations and disparities, the potential benefits outweigh the challenges. This review calls for increased awareness, collaboration with insurance companies, and ongoing research efforts to optimize smartwatch accuracy and encourage widespread adoption of Afib detection. With insights from major trials, this review serves as a comprehensive reference for healthcare professionals and policymakers, guiding future strategies in the early diagnosis and management of atrial fibrillation.

Latent profiles of global electrical heterogeneity: the Hispanic Community Health Study/Study of Latinos

Aims

Despite the highest prevalence of stroke, obesity, and diabetes across races/ethnicities, paradoxically, Hispanic/Latino populations have the lowest prevalence of atrial fibrillation and major Minnesota code-defined ECG abnormalities. We aimed to use Latent Profile Analysis in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) population to obtain insight into epidemiological discrepancies.

Methods and results

We conducted a cross-sectional analysis of baseline HCHS/SOL visit. Global electrical heterogeneity (GEH) was measured as spatial QRS-T angle (QRSTa), spatial ventricular gradient azimuth (SVGaz), elevation (SVGel), magnitude (SVGmag), and sum absolute QRST integral (SAIQRST). Statistical analysis accounted for the stratified two-stage area probability sample design. We fitted a multivariate latent profile generalized structural equation model adjusted for age, sex, ethnic background, education, hypertension, diabetes, smoking, dyslipidaemia, obesity, chronic kidney disease, physical activity, diet quality, average RR' interval, median beat type, and cardiovascular disease (CVD) to gain insight into the GEH profiles. Among 15 684 participants (age 41 years; 53% females; 6% known CVD), 17% had an increased probability of likely abnormal GEH profile (QRSTa 80 ± 27°, SVGaz -4 ± 21°, SVGel 72 ± 12°, SVGmag 45 ± 12 mVms, and SAIQRST 120 ± 23 mVms). There was a 23% probability for a participant of being in Class 1 with a narrow QRSTa (40.0 ± 10.2°) and large SVG (SVGmag 108.3 ± 22.6 mVms; SAIQRST 203.4 ± 39.1 mVms) and a 60% probability of being in intermediate Class 2.

Conclusion

A substantial proportion (17%) in the Hispanic/Latino population had an increased probability of altered, likely abnormal GEH profile, whereas 83% of the population was resilient to harmful risk factors exposures.

Advances in the medical treatment and diagnosis of intracranial hemorrhage associated with oral anticoagulation

INTRODUCTION

With the increasing prevalence of atrial fibrillation (AF), it entails expanding oral anticoagulants (OACs) use, carrying a higher risk of associated hemorrhagic events, including intracranial hemorrhage (ICH). Despite advances in OACs development with a better safety profile and reversal agent for these anticoagulants, there is still no consensus on the optimal management of patients with OACs-associated ICH.

AREAS COVERED

In this review, the authors have carried out an exhaustive search on the advances in recent years. The authors provide an update on the management of ICH in anticoagulated patients, as well as an update on the latest evidence on anticoagulation resumption, recent therapeutic strategies, and investigational drugs that could play a role in the future.

EXPERT OPINION

Following an ICH event in an anticoagulated patient, a comprehensive clinical evaluation is imperative. Anticoagulation should be promptly withdrawn and reversed. Once the patient is stabilized, a reintroduction of anticoagulation should be considered, typically within a timeframe of 4-8 weeks, if feasible. If re-anticoagulation is not possible, alternative options such as Left Atrial Appendage Occlusion are available.

A nomogram for individualized prediction of new-onset postoperative atrial fibrillation in acute type A aortic dissection patients: a retrospective study

Objective

The objective of this study is to explore the risk factors associated with new-onset postoperative atrial fibrillation (POAF) following Sun's surgery(total arch replacement using a tetrafurcate graft with stented elephant trunk implantation) for acute type A aortic dissection(AAAD) and to develop a predictive model for assessing the likelihood of new-onset POAF in patients undergoing Sun's surgery for AAAD.

Methods

We reviewed the clinical parameters of patients diagnosed with AAAD who underwent Sun's surgery at Qilu Hospital between December 1, 2017 and December 31, 2022. The data was analyzed through univariable and multivariable logistic regression analysis. Variance inflation factor was used to investigate for variable collinearity. A nomogram for predicting new-onset POAF was developed and verified by bootstrap resampling. In addition, the calibration of our model was evaluated by the calibration curve and Hosmer-Lemeshow test. Furthermore, the clinical utility of our model was evaluated using the net benefit curve.

Results

This study focused on a cohort of 242 patients with AAAD, among whom 42 experienced new-onset POAF, indicating an incidence rate of 17.36%. Age, left atrial diameter (LA), right atrial diameter (RA), preoperative red blood cells (RBC), and previous acute coronary syndrome (preACS) emerged as independent influences on new-onset POAF following Sun's surgery, as identified by univariable and multivariable logistic regression analysis. Collinearity analysis with demonstrated no collinearity among the variables. A user-friendly prediction nomogram for new onset POAF following Sun's surgery was formulated. The model demonstrated commendable diagnostic accuracy with an area under the curve (AUC) of 0.7852. Validation of the model through bootstrapping (1,000 repetitions) yielded an AUC of 0.8080 (95% CI: 0.8056-0.8104). affirming its robustness. Additionally, the model exhibited favorable fit, calibration, and positive net benefits in decision curve analysis.

Conclusions

Drawing upon these findings, we have developed a predictive model for the occurrence of new-onset POAF. These results suggest the potential efficacy of this prediction model for identifying patients at risk of developing POAF. The visualization of this model empowers healthcare professionals to conveniently and promptly assess the risk of AF in patients, thereby facilitating the timely intervention implementation.

Uncovering the Role of Direct Oral Anticoagulants in Stroke Prevention for Atrial Fibrillation: A Review of the Literature

Atrial fibrillation (AF) is a predominant contributor to morbidity and mortality, and stroke prevention remains the mainstay for the management of AF. The precise mechanism involved in thrombus formation remains unknown. However, factors such as stretch-induced fibrosis, endothelial dysfunction, disordered atrial contractions, and pro-thrombotic states have been postulated for the development of AF. Various risk assessment strategies have been acknowledged for determining the risk of stroke in AF, of which the congestive heart failure, hypertension, age ≥75, diabetes, stroke, vascular disease, age between 65-74, and female sex (CHA2DS2-VASc) score remains the ultimate risk stratification tool. For the longest time, vitamin K antagonists (VKA) were the only oral anticoagulants available but were associated with an increased risk of bleeding. Recently, direct oral anticoagulants (DOACs) were approved and considered more efficient and safer than or as secure as warfarin in stroke prevention and lowering intra-cranial bleeding events. The pharmacodynamics and pharmacokinetics of DOACs were also clarified in this article. This review article compiles current evidence-based data on the role of DOACs, uncovering their underlying mechanisms, and comparing their efficacy with warfarin in stroke prevention in AF.

Racial and Gender Differences in Cardiorespiratory Fitness and Atrial Fibrillation

The expanding field of cardiorespiratory fitness (CRF) in individuals with and without atrial fibrillation (AF) presents a complex landscape, demanding careful interpretation of the existing research. AF, characterized by significant mortality and morbidity, prompts the exploration of strategies to mitigate its impact. Increasing physical activity (PA) levels emerges as a promising avenue to address AF risk factors, such as obesity, hypertension, and diabetes mellitus, through mechanisms of reduced vasoconstriction, endothelin-1 modulation, and improved insulin sensitivity. However, caution is warranted, as recent investigations suggest a heightened incidence of AF, particularly in athletes engaged in high-intensity exercise, due to the formation of ectopic foci and changes in cardiac anatomy. Accordingly, patients should adhere to guideline-recommended amounts of low-to-moderate PA to balance benefits and minimize adverse effects. When looking closer at the current evidence, gender-specific differences have been observed and challenged conventional understanding, with women demonstrating decreased AF risk even at extreme exercise levels. This phenomenon may be rooted in divergent hemodynamic and structural responses to exercise between men and women. Existing research is predominantly observational and limited to racially homogenous populations, which underscores the need for comprehensive studies encompassing diverse, non-White ethnic groups in athlete and non-athlete populations. These individuals exhibit a disproportionately high burden of AF risk factors that could be addressed through improved CRF. Despite the limitations, randomized control trials offer promising evidence for the efficacy of CRF interventions in patients with preexisting AF, showcasing improvements in clinically significant AF outcomes and patient quality of life. The potential of CRF as a countermeasure to the consequences of AF remains an area of great promise, urging future research to delve deeper to explore its role within specific racial and gender contexts. This comprehensive understanding will contribute to the development of tailored strategies for optimizing cardiovascular health and AF prevention in all those who are affected.

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

High Prevalence of Atrial Fibrillation Found in the Capital of Greenland When Using Continuous Electrocardiogram Monitoring: A Cross-Sectional Study

Background

Atrial fibrillation (AF) increases the risk of conditions such as ischemic stroke, dementia, and heart failure, and early detection is crucial. In Greenland, ischemic strokes are common, and the prevalences of AF risk factors are increasing. Studies based on 30-second electrocardiograms (ECGs) and diagnosis codes so far have indicated either a low prevalence of AF or a prevalence comparable to that in other Western countries, such as Denmark. However, using short, single-point ECGs may underestimate the true prevalence, as especially paroxysmal AF can be missed. With this study, we aim to estimate the prevalence of AF using 3-5-day continuous Holter recordings among people in Nuuk, the capital of Greenland.

Methods

In this cross-sectional study, we estimated the prevalence of AF among the population aged ≥ 50 years in Greenland's capital, Nuuk. We used an ePatch to record continuous ECGs for 3-5 days, and questionnaires to assess demographic data, comorbidities, medication, symptoms, and risk factors for AF.

Results

Of 226 participants (62% women), 21 (33% women) had either self-reported AF, AF on the recording, or both, equivalent to a prevalence of 9.3% (confidence interval [CI] 5.8-13.9). The age-stratified prevalence was 7.2% (CI 2.7-15.1) among those aged 50-59 years; 8.8% (CI 4.1-16.1) among those aged 60-69 years; and 18.2% (CI 7.0-35.5) among those aged ≥ 70 years.

Conclusions

This study provides a novel insight into AF prevalence in Nuuk, emphasizing the potential underestimation in previous studies. Continuous ECG monitoring revealed a higher prevalence, especially among the younger age groups, urging a reevaluation of diagnostic practices in this unique population.

Left ventricular hypertrophy phenotype to predict incident atrial fibrillation: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIM

Left ventricular hypertrophy (LVH) has been shown to be associated with the occurrence of atrial fibrillation (AF). However, the predictive value of the LVH phenotype for incident AF remains uncertain. This study aimed to investigate the predictive value of LVH phenotype for incident AF.

METHODS AND RESULTS

This study utilized the Multi-Ethnic Study of Atherosclerosis (MESA) data. LVH was defined by cardiac magnetic resonance measured LV mass index. Isolated LVH was determined as LVH without elevated cardiac biomarker and malignant LVH was determined as LVH with at least 1 elevated biomarker. Receiver-operating characteristic (ROC) analysis was performed to calculate areas under the curves (AUC) for predicting AF. A total of 4983 community-dwelling participants were included, with a mean age of 61.5 years. 279 (5.6 %) had isolated LVH, and 222 (4.5 %) had malignant LVH. During a median follow-up of 8.5 years, 272 incident AF was observed. Compared to participants without LVH and elevated cardiac biomarkers, those with isolated LVH (HR, 1.82; 95 % CI, 1.03-3.20) and malignant LVH (HR, 4.13; 95 % CI, 2.77-6.16) had a higher risk of incident AF. Malignant LVH carried a 1.5-fold increased risk of AF compared to isolated LVH (HR: 2.48, 95 % CI: 1.30-4.73). Including the LVH phenotype in the CHARGE-AF model improved model discrimination (AUC increase: 0.03, p < 0.001).

CONCLUSIONS

The risks of AF incidence varied across LVH phenotypes. Malignant LVH carried the highest risk among LVH phenotypes. LVH phenotype provides incremental predictive value over the variables included in the CHARGE-AF model.

Racial disparities among patients with cardiac sarcoidosis and arrhythmias in the United States: A propensity matched-analysis from the national inpatient sample database 2016-2020

BACKGROUND

Cardiac sarcoidosis (CS) is frequently associated with conduction abnormalities and arrhythmias. In this study, we aim to evaluate racial disparities in the frequency of arrhythmias, and associated co-morbidities, among patients with CS.

METHODS

White and African American (AA) patients diagnosed with CS were identified and compared from the 2016-2020 National Inpatient Sample (NIS) database whilst adjusting for confounders via logistic regression models.

RESULTS

A total of 7,935 patients with CS were included in the study. The propensity-matched sample comprised of 5,570 patients, of whom 2,785 were White and 2,785 were AA. AA patients had a longer mean length of hospital stay (LOS) (7.84 vs. 6.94, p<0.01), a higher mean Charlson Comorbidity Index (CCI) score (3.10 vs. 2.84, p<0.01), and significantly higher incidences of cardiogenic shock [(9.2% vs 6.3%, p<0.01), aOR 1.45 (95% CI 1.17-1.78), p<0.01] and acute kidney injury (AKI) [(34.3% vs. 26.9%, p<0.01), aOR 1.41 (95% CI 1.24-1.61), p<0.01]. From an arrhythmia perspective, AA CS patients were shown to have a lower frequency of: (1) ventricular tachycardia (32.5% vs. 37.9%, p<0.01), (2) ventricular fibrillation (5.4% vs.7.2%, p<0.01), (3) first-degree AV block (1.8% vs. 4.1%, p<0.01), (4) complete AV block (6.3% vs. 14.2%, p<0.01), and (5) atrial fibrillation (31.8% vs. 34.8%, p=0.016) when compared to Whites with CS. Mortality remained higher for AAs (3.8% vs. 2.7%, p=0.024).

CONCLUSION

Our study demonstrates a higher incidence of cardiac arrhythmias among White patients but a higher incidence of cardiogenic shock, AKI, mean LOS, and mortality among AA patients with cardiac sarcoidosis.

Unveiling the Role of Endothelial Dysfunction: A Possible Key to Enhancing Catheter Ablation Success in Atrial Fibrillation

Atrial fibrillation, a prevalent type of arrhythmia, is increasingly contributing to the economic burden on healthcare systems. The development of innovative treatments, notably catheter ablation, has demonstrated both impressive and promising outcomes. However, these treatments have not yet fully replaced pharmaceutical approaches, primarily due to the relatively high incidence of atrial fibrillation recurrence post-procedure. Recent insights into endothelial dysfunction have shed light on its role in both the onset and progression of atrial fibrillation. This emerging understanding suggests that endothelial function might significantly influence the effectiveness of catheter ablation. Consequently, a deeper exploration into endothelial dynamics could potentially elevate the status of catheter ablation, positioning it as a primary treatment option for atrial fibrillation.

Atrial fibrillation: pathophysiology, genetic and epigenetic mechanisms

Atrial fibrillation (AF) is the most common supraventricular arrhythmia affecting up to 1% of the general population. Its prevalence dramatically increases with age and could reach up to ∼10% in the elderly. The management of AF is a complex issue that is object of extensive ongoing basic and clinical research, it depends on its genetic and epigenetic causes, and it varies considerably geographically and also according to the ethnicity. Mechanistically, over the last decade, Genome Wide Association Studies have uncovered over 100 genetic loci associated with AF, and have shown that European ancestry is associated with elevated risk of AF. These AF-associated loci revolve around different types of disturbances, including inflammation, electrical abnormalities, and structural remodeling. Moreover, the discovery of epigenetic regulatory mechanisms, involving non-coding RNAs, DNA methylation and histone modification, has allowed unravelling what modifications reshape the processes leading to arrhythmias. Our review provides a current state of the field regarding the identification and functional characterization of AF-related genetic and epigenetic regulatory networks, including ethnic differences. We discuss clear and emerging connections between genetic regulation and pathophysiological mechanisms of AF.

Atrial fibrillation: comorbidities, lifestyle, and patient factors

Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.

Incidence of atrial fibrillation and flutter in Denmark in relation to country of origin: a nationwide register-based study

BACKGROUND

Atrial fibrillation and flutter (AF) is the most common sustained arrhythmia with an increasing prevalence in Western countries. However, little is known about AF among immigrants compared to non-immigrants.

AIM

To examine the incidence of hospital-diagnosed AF according to country of origin.

METHOD

Immigrants were defined as individuals born outside Denmark by parents born outside Denmark. AF was defined as first-time diagnosis of AF. All individuals were followed from the age of 45 years from 1998 to 2017. The analyses were adjusted for sex, age, comorbidity, contact with the general practitioner and socioeconomic variables. Adjustment was conducted using standardised morbidity ratio weights, standardised to the Danish population in a marginal structural model.

RESULTS

The study population consisted of 3,489,730 Danish individuals free of AF and 108,914 immigrants free of AF who had emigrated from the 10 most represented countries. A total of 323,005 individuals of Danish origin had an incident hospital diagnosis of AF, among the immigrants 7,300 developed AF. Adjusted hazard rate ratios (HRRs) of AF for immigrants from Iran (0.48 [95%CI:0.35;0.64]), Turkey (0.74 [95%CI:0.67;0.82]) and Bosnia-Herzegovina (0.42 [95%CI:0.22;0.79]) were low compared with Danish individuals. Immigrants from Sweden, Germany and Norway had an adjusted HRR of 1.13 [95%CI:1.03;1.23], 1.12 [95%CI:1.05;1.18] and 1.11 [95%CI:1.03;1.21], respectively (Danish individuals as reference).

CONCLUSIONS

Substantial variation in the incidence of hospital-diagnosed AF according to country of origin was observed. The results may reflect true biological differences but could also reflect barriers to AF diagnosis for immigrants. Further efforts are warranted to determine the underlying mechanisms.

Association between Obesity and Heart Failure and Related Atrial Fibrillation: Patient-Level Data Comparisons of Two Cohort Studies

PURPOSE

Heart failure (HF) and atrial fibrillation (AF) frequently coexist, with over 50% patients with HF having AF, while one-third of those with AF develop HF. Differences in obesity-mediated association between HF and HF-related AF among Asians and Europeans were evaluated.

MATERIALS AND METHODS

Using the Korean National Health Insurance Service-Health Screening (K-NHIS-HealS) cohort and the UK Biobank, we included 394801 Korean and 476883 UK adults, respectively aged 40-70 years. The incidence and risk of HF were evaluated based on body mass index (BMI).

RESULTS

The proportion of obese individuals was significantly higher in the UK Biobank cohort than in the K-NHIS-HealS cohort (24.2% vs. 2.7%, p<0.001). The incidence of HF and HF-related AF was higher among the obese in the UK than in Korea. The risk of HF was higher among the British than in Koreans, with adjusted hazard ratios of 1.82 [95% confidence interval (CI), 1.30-2.55] in K-NHIS-HealS and 2.00 (95% CI, 1.69-2.37) in UK Biobank in obese participants (p for interaction <0.001). A 5-unit increase in BMI was associated with a 44% greater risk of HF-related AF in the UK Biobank cohort (p<0.001) but not in the K-NHIS-HealS cohort (p=0.277).

CONCLUSION

Obesity was associated with an increased risk of HF and HF-related AF in both Korean and UK populations. The higher incidence in the UK population was likely due to the higher proportion of obese individuals.

Acquired risk factors and incident atrial fibrillation according to age and genetic predisposition

BACKGROUND AND AIMS

Atrial fibrillation (AF) is the most common sustained arrhythmia in adults. Investigations of risk factor profiles for AF according to age and genetic risk groups are essential to promote individualized strategies for the prevention and control of AF.

METHODS

A total of 409 661 participants (mean age, 56 years; 46% men) free of AF at baseline and with complete information about risk factors were included from the UK Biobank cohort. The hazard ratios and population-attributable risk (PAR) percentages of incident AF associated with 23 risk factors were examined, including 3 social factors, 7 health behaviours, 6 cardiometabolic factors, 6 clinical comorbidities, and the genetic risk score (GRS), across 3 age groups (40-49, 50-59, and 60-69 years) and 3 genetic risk groups (low, moderate, and high GRS).

RESULTS

After a follow-up of 5 027 587 person-years, 23 847 participants developed AF. Most cardiometabolic factors and clinical comorbidities showed a significant interaction with age, whereby the associations were generally strengthened in younger groups (Pinteraction < .002). However, only low LDL cholesterol, renal dysfunction, and cardiovascular disease showed a significant interaction with genetic risk, and the associations with these factors were stronger in lower genetic risk groups (Pinteraction < .002). Cardiometabolic factors consistently accounted for the largest number of incident AF cases across all age groups (PAR: 36.2%-38.9%) and genetic risk groups (34.0%-41.9%), with hypertension and overweight/obesity being the two leading modifiable factors. Health behaviours (PAR: 11.5% vs. 8.7%) and genetic risk factors (19.1% vs. 14.3%) contributed to more AF cases in the 40-49 years group than in the 60-69 years group, while the contribution of clinical comorbidities remained relatively stable across different age groups. The AF risk attributable to overall cardiometabolic factors (PAR: 41.9% in the low genetic risk group and 34.0% in the high genetic risk group) and clinical comorbidities (24.7% and 15.9%) decreased with increasing genetic risk. The impact of social factors on AF was relatively low across the groups by age and genetic risk.

CONCLUSIONS

This study provided comprehensive information about age- and genetic predisposition-related risk factor profiles for AF in a cohort of UK adults. Prioritizing risk factors according to age and genetic risk stratifications may help to achieve precise and efficient prevention of AF.

Ten-year trends in incidence and prevalence of atrial fibrillation and flutter in Denmark according to demographics, ethnicity, educational level, and area of residence (2009-2018)

BACKGROUND

Atrial fibrillation is the most common cardiac arrhythmia and a major global health burden. Updated trends in the epidemiology of atrial fibrillation or flutter (AF) are needed.

METHODS

Using the Danish Heart Statistics, we investigated nationwide trends 2009-2018 in incidence rate and prevalence of AF according to age as well as age-standardized incidence rate (ASIR) and prevalence (ASP) of AF according to sex, ethnicity, educational level, and area of residence. Comparing year 2018 to 2009, we calculated stratum-specific ASIR ratios (ASIRR) and changes in ASP.

RESULTS

During 2009-2015 the ASIR for AF increased for both men and women, followed by a decline from 2015-2018. Overall, this resulted in a 9% increase among men (ASIRR: 1.09, 95% CI: 1.06-1.12), but no change among women (ASIRR: 1.00, 95% CI: 0.97-1.04). The ASP increased by 29% among men and 26% among women. An increase in ASIR was observed in all ethnic groups except men of Far Eastern ethnicity. Lower educational level was associated with greater increases in both ASIR and ASP. ASIR and ASP differed slightly between the Danish regions but increased in all of them.

CONCLUSIONS

During 2009-2018 the incidence and prevalence of AF in Denmark increased although the increase in incidence was transient among women. Factors associated with higher incidence were male sex, higher age, Danish and Western ethnicity as well as Middle Eastern/North African ethnicity among women, and lower educational level. Within Denmark, we observed only minor regional differences in AF incidence and prevalence.

n-6 fatty acid biomarkers and incident atrial fibrillation: an individual participant-level pooled analysis of 11 international prospective studies

BACKGROUND

The presence of atrial fibrillation (AF) is associated with an over 2-fold increased risk of stroke, heart failure, and cardiovascular mortality. Long chain n-6 PUFAs have been suggested to have a variety of beneficial biologic effects that may reduce AF development; however, prior studies evaluating this relationship are limited.

OBJECTIVES

We prospectively evaluated the association between circulating levels of linoleic acid (LA) and arachidonic acid (AA) with incident AF.

METHODS

We used participant-level data from a global consortium of 11 prospective cohort studies with measurements of LA and AA in adults (aged ≥18 y). Participating studies conducted de novo analyses using a prespecified analytical plan with harmonized definitions for exposures, outcomes, covariates, and subgroups. Associations were pooled using inverse-variance weighted meta-analysis.

RESULTS

Among 41,335 participants, 6173 incident cases of AF were ascertained, with median follow-up time of 14 y. In multivariable analysis, per interquintile range (difference between the 10th and 90th percentiles for each fatty acid), circulating n-6 levels were not associated with incident AF. For LA, the hazard ratio per interquintile range was 0.96 (95% confidence interval [CI]: 0.89, 1.04), and for AA, 1.02 (95% CI: 0.94, 1.10), with little evidence of heterogeneity between cohorts. Associations were similarly nonsignificant across subgroups of age, race, and biomarker fraction.

CONCLUSIONS

Biomarkers of n-6 fatty acids including LA and AA are not associated with incident AF. These findings suggest that overall effects of n-6 PUFAs on influencing AF development are neutral.

Association of hypertension severity and control with risk of incident atrial fibrillation: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study

BACKGROUND

The association of hypertension (HTN) severity and control with the risk of incident atrial fibrillation (AF) is unclear.

HYPOTHESIS

Increased HTN severity and poorer blood pressure control would be associated with an increased risk of incident AF.

METHODS

This analysis included 9485 participants (mean age 63 ± 8 years; 56% women; 35% Black). Participants were stratified into six mutually exclusive groups at baseline-normotension (n = 1629), prehypertension (n = 704), controlled HTN (n = 2224), uncontrolled HTN (n = 4123), controlled apparent treatment-resistant hypertension (aTRH) (n = 88), and uncontrolled aTRH (n = 717). Incident AF was ascertained at the follow-up visit, defined by either electrocardiogram or self-reported medical history of a physician diagnosis. Multivariable logistic regression analyses adjusted for demographic and clinical variables.

RESULTS

Over an average of 9.3 years later, 868 incident AF cases were detected. Compared to those with normotension, incident AF risk was highest for those with aTRH (controlled aTRH: odds ratio (OR) 2.95; 95% confidence interval (CI) 1.60, 5.43, & uncontrolled aTRH: OR 2.47; 95% CI 1.76, 3.48). The increase in AF risk was smaller for those on no more than three antihypertensive agents regardless of their blood pressure control (controlled OR 1.72; 95% CI 1.30, 2.29 and uncontrolled OR 1.56; 95% CI 1.14, 2.13).

CONCLUSIONS

The risk of developing AF is increased in all individuals with HTN. Risk is highest in those aTRH regardless of blood pressure control. A more aggressive approach that focuses on lifestyle and pharmacologic measures to either prevent HTN or better control HTN during earlier stages may be particularly beneficial in reducing related AF risk.

Associations of dietary patterns with risk of incident atrial fibrillation in the REasons for Geographic And Racial Differences in Stroke (REGARDS)

BACKGROUND

We examined whether the risk of incident atrial fibrillation (AF) in a large, biracial, prospective cohort is lower in participants who adhere to heart-healthy dietary patterns and higher in participants who adhere to less heart-healthy diets.

METHODS

Between 2003 and 2007, the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study enrolled 30,239 Black and White Americans aged 45 years or older. Dietary patterns (convenience, plant-based, sweets, Southern, and alcohol and salads) and the Mediterranean diet score (MDS) were derived based on food frequency questionnaire data. The primary outcome was incident AF at the follow-up visit 2013-2016, defined by either electrocardiogram or self-reported medical history of a physician diagnosis.

RESULTS

This study included 8977 participants (mean age 63 ± 8.3 years; 56% women; 30% Black) free of AF at baseline who completed the follow-up exam an average of 9.4 years later. A total of 782 incident AF cases were detected. In multivariable logistic regression analyses, neither the MDS score (odds ratio (OR) per SD increment = 1.03; 95% confidence interval (CI) 0.95-1.11) or the plant-based dietary pattern (OR per SD increment = 1.03; 95% CI 0.94-1.12) were associated with AF risk. Additionally, an increased AF risk was not associated with any of the less-healthy dietary patterns.

CONCLUSIONS

While specific dietary patterns have been associated with AF risk factors, our findings fail to show an association between diet patterns and AF development.

Incidence and Prevalence of Atrial Fibrillation in Latinos: What's New Since the Study in Latinos (SOL)?

PURPOSE OF REVIEW

To assess contemporary epidemiological trends in AF incidence and prevalence in the LatinX population after the Hispanic Community Health Study/Study of Latinos.

RECENT FINDINGS

Atrial fibrillation (AF) remains the most abnormal heart rhythm condition globally and disproportionately impacts morbidity and mortality of communities that have been historically disadvantaged. The incidence and prevalence of AF is lower in the LatinX population compared to White individuals despite a higher burden of classic risk factors associated with AF. Since the Hispanic Community Health Study/Study of Latinos study on AF, recent data continues to demonstrate a similar lower burden of AF in the LatinX population compared to White individuals. However, the rates of incident AF may be accelerating faster in the LatinX population compared to their White counterparts. Furthermore, studies have found environmental and genetic risk factors that are associated with the development of AF within LatinX individuals, which may help explain the rising development of AF among the LatinX community. Recent research continues to show that LatinX populations are less likely to be treated with stroke reduction and rhythm control strategies and have a disproportionately higher burden of poor outcomes associated with AF compared to White patients. Our review illuminates that further inclusion of LatinX individuals in AF randomized control trials and observational studies is imperative to understand the incidence and prevalence of AF in the LatinX community and improve overall morbidity and mortality.

Impact of Atrial Fibrillation on Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI): The K-TAVI Registry

PURPOSE

The incidence and prognostic implications of atrial fibrillation (AF) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are controversial, especially for Korean patients. Furthermore, the pattern of antithrombotic therapy for these patients is unknown. The present study sought to identify the impact of AF on Korean patients undergoing TAVI and demonstrate the status of antithrombotic therapy for these patients.

MATERIALS AND METHODS

A total of 660 patients who underwent TAVI for severe AS were recruited from the nationwide K-TAVI registry in Korea. The enrolled patients were stratified into sinus rhythm (SR) and AF groups. The primary endpoint was all-cause death at 1-year.

RESULTS

AF was recorded in 135 patients [pre-existing AF 108 (16.4%) and new-onset AF 27 (4.1%)]. The rate of all-cause death at 1 year was significantly higher in patients with AF than in those with SR [16.2% vs. 6.4%, adjusted hazard ratio (HR): 2.207, 95% confidence interval (CI): 1.182-4.120, p=0.013], regardless of the onset timing of AF. The rate of new pacemaker insertion at 1 year was also significantly higher in patients with AF than in those with SR (14.0% vs. 5.5%, adjusted HR: 3.137, 95%CI: 1.621-6.071, p=0.001). Among AF patients, substantial number of patients received the combination of multiple antithrombotic agents (77.8%), and the most common combination was that of aspirin and clopidogrel (38.1%).

CONCLUSION

AF was an independent predictor of 1-year mortality and new pacemaker insertion in Korean patients undergoing TAVI.

Clinical and Genetic Atrial Fibrillation Risk and Discrimination of Cardioembolic From Noncardioembolic Stroke

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Atrial fibrillation (AF) is a common cause of stroke but may not be detectable at the time of stroke. We hypothesized that an AF polygenic risk score (PRS) can discriminate between cardioembolic stroke and noncardioembolic strokes.

METHODS

We evaluated AF and stroke risk in 26 145 individuals of European descent from the Stroke Genetics Network case-control study. AF genetic risk was estimated using 3 recently developed PRS methods (LDpred-funct-inf, sBayesR, and PRS-CS) and 2 previously validated PRSs. We performed logistic regression of each AF PRS on AF status and separately cardioembolic stroke, adjusting for clinical risk score (CRS), imputation group, and principal components. We calculated model discrimination of AF and cardioembolic stroke using the concordance statistic (c-statistic) and compared c-statistics using 2000-iteration bootstrapping. We also assessed reclassification of cardioembolic stroke with the addition of PRS to either CRS or a modified CHA2DS2-VASc score alone.

RESULTS

Each AF PRS was significantly associated with AF and with cardioembolic stroke after adjustment for CRS. Addition of each AF PRS significantly improved discrimination as compared with CRS alone (P<0.01). When combined with the CRS, both PRS-CS and LDpred scores discriminated both AF and cardioembolic stroke (c-statistic 0.84 for AF; 0.74 for cardioembolic stroke) better than 3 other PRS scores (P<0.01). Using PRS-CS PRS and CRS in combination resulted in more appropriate reclassification of stroke events as compared with CRS alone (event reclassification [net reclassification indices]+=14% [95% CI, 10%-18%]; nonevent reclassification [net reclassification indices]-=17% [95% CI, 15%-0.19%]) or the modified CHA2DS2-VASc score (net reclassification indices+=11% [95% CI, 7%-15%]; net reclassification indices-=14% [95% CI, 12%-16%]) alone.

CONCLUSIONS

Addition of polygenic risk of AF to clinical risk factors modestly improves the discrimination of cardioembolic from noncardioembolic strokes, as well as reclassification of stroke subtype. Polygenic risk of AF may be a useful biomarker for identifying strokes caused by AF.

Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1

Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia. It was once thought to be benign as long as the ventricular rate was controlled, however, AF is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a MEDLINE search to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched via the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare noninvasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.

Association of obesity with incident atrial fibrillation in Korea and the United Kingdom

Obesity has been linked to atrial fibrillation (AF) burden and severity, and epidemiological studies suggest that AF is more prevalent in whites than Asian. We aimed to investigate whether obesity mediates associations with AF in Europe and Asia using patient-level data comparisons of two cohort studies. Using Korean National Health Insurance Service's Health Screening (NHIS-HealS) and U.K. Biobank data, we included 401,206 Korean and 477,926 British aged 40-70 years without previous AF who received check-ups. The incidence and risk of AF were evaluated regarding different body mass index (BMI) values. The obese proportion (BMI ≥ 30.0 kg/m², 2.8% vs. 24.3%, P < 0.001) was higher in the U.K. than the Korean. In the Korean and U.K. cohort, the age- and sex-adjusted incidence rates of AF were 4.97 and 6.54 per 1000 person-years among obese individuals. Compared to Koreans, the risk of AF was higher in the British population, with adjusted hazard ratios of 1.41 (Korea, 95% CI 1.26-1.58) and 1.68 (UK, 95% CI 1.54-1.82) in obese participants (P for interaction < 0.05). Obesity was associated with AF in both populations. British subjects had a greater incidence of AF related to the high proportion of obese individuals, especially participants in the obesity category, the risk of AF also increased.

Variations in documentation of atrial fibrillation predicted by population and service level characteristics in primary health care in England

BACKGROUND

Identifying features associated with atrial fibrillation (AF) documentation could inform screening. This study used published data to describe differences in documented and estimated AF prevalence in general practices, and explored predictors of variations in AF prevalence.

METHODS

Cross-sectional study of 7318 general practices in England. Descriptive and inferential statistics were undertaken. Multiple linear regression was used to model the difference between estimated AF and documented AF, adjusted for population, practice and practice performance variables.

RESULTS

Documented AF prevalence was lower than estimated (- 0.55% 95% confidence intervals, -1.89, 2.99). The proportion of variability accounted for in the final regression model was 0.25. Factors positively associated with AF documentation (increase in difference between estimated and documented), were patients 65-74 years, 75 years +, Black or South Asian ethnicity, diabetes mellitus and practices in East and Midlands of England. Eight variables (female patients, deprivation score, heart failure and peripheral artery disease, total patients per practice, full-time GPs and nurses; and location in South of England) were negatively associated with AF documentation (reduction in difference).

CONCLUSION

Variations in AF documentation were predicted by several practice and population characteristics. Screening could target these sources of variation to decrease variation and improve AF documentation.

Association between cardiac conditions with venous leg ulcers in patients with chronic venous insufficiency

INTRODUCTION

Venous leg ulcers (VLUs) are the final stage of chronic venous insufficiency. This study aims to characterize the association between cardiovascular diseases and VLU.

METHODS

A multicentric case-control study analyzed 17,788 patients between 2015 and 2020. Cases were matched (1:2) by age and sex, and odds ratios (OR) were analyzed with conditional logistic regressions adjusted by risk factors.

RESULTS

The prevalence of VLU was 15.2%. 2390 cases were analyzed. Diseases found to be associated with VLU were atrial fibrillation (OR, 1.21; 95% CI: 1.03-1.42), pulmonary hypertension (OR, 1.45; 95% CI: 1.06-2.00), right heart failure (OR, 1.27; 95% CI: 1.13-1.43), peripheral artery disease (OR, 2.21; 95% CI: 1.90-2.56), and history of pulmonary embolism (OR, 1.45; 95% CI: 1.06-2.00).

CONCLUSIONS

Certain cardiovascular conditions showed an association with VLU. Further studies are warranted to evaluate the effect that treating concomitant cardiovascular diseases might exert on the natural history of venous leg ulcers.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

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

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

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

CONCLUSIONS

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

Obesity among Asian American people in the United States: A review

Standard measures of obesity, i.e., body weight and BMI, suggest that Asian American people have a lower obesity prevalence than other racial groups in the United States. However, Asian American people face a unique challenge in their pattern of adiposity with central obesity, which raises the risk for multiple comorbidities, such as type 2 diabetes, metabolic syndrome, and cardiovascular disease, at a lower BMI compared with other populations. Several organizations recommend lower BMI cutoffs for obesity in Asian people (BMI ≥25.0 or ≥27.5 kg/m² ) instead of the standard ≥30.0 kg/m² threshold. The risks of obesity and related comorbidities in this population are further influenced by diet, physical activity, perceptions of health, and access to information and therapies. Asian-specific parameters for assessing obesity should become a standard part of clinical practice. Asian American people should equally be offered subgroup-specific tailored interventions owing to heterogeneity of this population. Access to medications and surgery should be improved, in part by updating US indications for therapies to reflect race-specific obesity thresholds and through inclusion of Asian American people of all subtypes with lower BMI values in clinical trials.

Transforming Atrial Fibrillation Research to Integrate Social Determinants of Health: A National Heart, Lung, and Blood Institute Workshop Report

Importance

Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia's often paroxysmal nature and individuals' disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF.

Observations

The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF.

Conclusions and Relevance

Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.

A prospective study on the association between atrial fibrillation and blood pressure in an elderly Chinese population

BACKGROUND

Intensive blood pressure (BP) lowering in patients with hypertension has been associated with a lowered risk of atrial fibrillation (AF). It is still uncertain what is the optimal BP levels to prevent AF in the general elderly population. In the present prospective study, we investigated the association between incident AF and BP in an elderly Chinese population.

METHODS AND FINDINGS

Elderly (≥65 years) residents were recruited from 6 communities in Shanghai. 9019 participants who did not have AF at baseline and had at least one ECG recording during follow-up were included in the present analysis. During a median of 3.5 years follow-up, the overall incidence rate of AF was 5.6 per 1000 person-years (n = 178). Systolic BP was associated with increased AF risk (age- and sex-adjusted hazard ratio [HR] per 20-mmHg increase for systolic BP 1.21, 95% CI 1.04-1.39, P = 0.01), but risk estimate was attenuated after adjustment for common AF risk factors. In categorical analyses, statistical significance was achieved for HR relative to optimal BP only in stage 2 or 3 systolic and diastolic hypertension (multivariate-adjusted HR 1.76, 95% CI 1.00-3.08, P = 0.05). The association between AF incidence and BP status tended to be stronger in the absence than presence of a history of cardiovascular disease at baseline (P for interaction = 0.06).

CONCLUSION

In this Chinese population of 65 years and older, linear increases in systolic and diastolic BP were not independently associated with increased risk of AF, and only exposure to stage 2 or 3 hypertension carries a higher risk of AF.

Epidemiology and modifiable risk factors for atrial fibrillation

The global prevalence of atrial fibrillation (AF) has increased substantially over the past three decades and is currently approximately 60 million cases. Incident AF and its clinical consequences are largely the result of risk factors that can be modified by lifestyle changes. In this Review, we provide evidence that the lifetime risk of AF is modified not only by sex and race but also through the clinical risk factor and comorbidity burden of individual patients. We begin by summarizing the epidemiology of AF, focusing on non-modifiable and modifiable risk factors, as well as targets and strategies for the primary prevention of AF. Furthermore, we evaluate the role of modifiable risk factors in the secondary prevention of AF as well as the potential effects of risk factor interventions on the frequency and severity of subsequent AF episodes. We end the Review by proposing strategies that require evaluation as well as global policy changes that are needed for the prevention of incident AF and the management of recurrent episodes in patients already affected by AF.

Is there any difference in the therapeutic effects of Levosimendan on advanced HFrEF patients with sinus rhythm or atrial fibrillation?

Patients with advanced heart failure have a high incidence of atrial fibrillation (AF) and develop into heart failure with reduced ejection fraction (HFrEF), and require higher doses of inotropes. However, it is uncertain about the differences in the effects of levosimendan in HFrEF patients with sinus rhythm or AF. A total of 63 advanced HFrEF subjects (ejection fraction < 40%) were divided into sinus rhythm (SR, n = 34) and atrial fibrillation (AF, n = 29) cohorts. All patients received six cycles of intermittent repeated levosimendan infusion. After 3 months of treatment, B-type natriuretic peptide (BNP), estimated glomerular filtration rate, resting heart rate (rHR), creatinine, left ventricle ejection fraction (LVEF), left ventricular end diastolic diameter and blood pressure body weight, NYHA classification were measured. After completing the course of treatment, LVEF, BNP, and rHR were significantly decreased (p < 0.0.5), and no significant differences between the two groups were observed (p > 0.05). The NYHA classification improved in the SR group but not in the AF group. There was no significant difference between patients with different rHRs (≤70 bpm vs. >70 bpm) in the SR group (p > 0.05) or in the AF group (rHR ≤ 90 bpm vs. rHR >90 bpm) (p > 0.05). This study showed no difference in the therapeutic effect of intermittent repeated levosimendan infusion on advanced HFrEF with different heart rhythms (SR or AF); Advanced HFrEF patients receive levosimendan treatment without taking the inference of heart rhythm.

Atrial fibrillation: Epidemiology, pathophysiology, and clinical complications (literature review)

The last three decades have been characterized by an exponential increase in knowledge and advances in the clinical management of atrial fibrillation. The purpose of the study is to provide an overview of the pathogenesis of nonvalvular atrial fibrillation and a comprehensive investigation of the epidemiological data associated with various risk factors for atrial fibrillation. The leading research methods are analysis and synthesis, comparison, observation, induction and deduction, and grouping method. Research has shown that old age, male gender, and European descent are important risk factors for developing atrial fibrillation. Other modifiable risk factors include a sedentary lifestyle, smoking, obesity, diabetes mellitus, obstructive sleep apnea, and high blood pressure predisposing to atrial fibrillation, and each has been shown to induce structural and electrical atrial remodeling. Both heart failure and myocardial infarction increase the risk of developing atrial fibrillation and vice versa creating feedback that increases mortality. The review is a comprehensive study of the epidemiological data linking nonmodifiable and modifiable risk factors for atrial fibrillation, and the pathophysiological data supporting the relationship between each risk factor and the occurrence of atrial fibrillation. This may be necessary for the practice of the treatment of the cardiac system.

American Indians and atrial fibrillation

The American Indian population is known to experience high rates of cardiovascular disease and have a heightened vulnerability to severe outcomes driven by an overall poor health status and lower access to quality health care. Our group has previously published an analysis demonstrating that American Indians have the highest risk of atrial fibrillation (AF), as well as of AF-related stroke, when compared with other races and ethnicities. Despite this, AF in this population has not been extensively studied and additional publications are scarce. Our review article provides an up-to-date summary of the relevant literature addressing the relationship between race, ethnicity, and AF by focusing on American Indians.

Atrial fibrillation prevalence and management patterns in a Middle Eastern community in the United States: A retrospective study

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia in the United States, and its prevalence is expected to increase along with associated morbidity and economic burden. Prior research has demonstrated differing prevalence patterns of AF between racial and ethnic groups, with lower rates identified in Black patients. However, to date there have been no studies on AF prevalence in people of Middle Eastern descent within the United States. This retrospective cross-sectional study aimed to characterize prevalence patterns of AF in Middle Eastern patients in Southeast Michigan relative to White and Black patients. The final cohort included 919,454 patients with a median (IQR) age of 53 (33) years (515,902 [56 %] female). The overall prevalence of AF was approximately 5 %. We observed a lower prevalence of AF in Middle Eastern (2.8 %) and Black patients (3.4 %) than in White patients (6.5 %). Middle Eastern patients with AF were younger with a lower prevalence of cardiovascular risk factors than White patients. Multivariable analysis showed that Middle Eastern (OR 0.75; 95 % CI 0.71-0.80; P < 0.001) and Black racial identity (OR 0.48; 95 % CI 9.47-0.49; P < 0.001) were associated with a lower odds of AF, even after adjustment for traditional risk factors.

U-Shaped Association Between Blood Pressure and Mortality Risk in ICU Patients With Atrial Fibrillation: The MIMIC-III Database

Background

Existing evidence on the association between blood pressure (BP) and mortality risk in intensive care unit (ICU) patients with atrial fibrillation (AF) is scarce.

Aim

This study aimed to assess the associations between blood pressure (BP) and risks of in-hospital and all-cause mortality in ICU patients with AF.

Methods

A total of 2,345 records of patients with AF whose BP was monitored after admission to the ICU were obtained from the MIMIC-III database. Incidences were calculated for endpoints (hospital mortality, 7-day mortality, 30-day mortality, and 1-year mortality). We performed smooth curve and logistic regression analyses to evaluate the association between BP and the risk of each endpoint.

Results

Smooth curve regression showed that systolic blood pressure (SBP), mean arterial pressure (MBP), and diastolic blood pressure (DBP) followed U-shaped curves with respect to endpoints (hospital mortality, 7-day mortality, 30-day mortality, and 1-year mortality). The incidence of these endpoints was lowest at 110/70/55 mm Hg. There was an increased risk of 1-year mortality observed with BP > 110/70/55 mm Hg (SBP, odds ratio [OR] = 1.008, 95% CI 1.001–1.015, p = 0.0022; MBP, OR = 1.010, 95% CI 1.005–1.016, p < 0.001) after adjusting for age, sex, and medical history. In contrast, an inverse association between BP and the risk of 1-year mortality was observed with BP ≤ 110/70/55 mm Hg (SBP, OR = 0.981, 95% CI 0.974–0.988, p < 0.001; MBP OR = 0.959, 95% CI 0.939–0.979, p < 0.001; and DBP, OR = 0.970, 95% CI 0.957–0.983, p < 0.001).

Conclusions

We observed a U-shaped association between BP and in-hospital/all-cause mortality in ICU patients with AF. However, the underlying causes need to be investigated.

Thirty-Year Trends in the Incidence of Atrial Fibrillation: The ARIC Study

Background Long-term data to study recent trends in the incidence of atrial fibrillation (AF), overall and among sex and race groups, are scarce. We evaluated the 30-year trends in the incidence of AF in the ARIC (Atherosclerosis Risk in Communities) study cohort and explored race and sex differences in these trends. Methods and Results We included 15 343 men and women aged 45 to 64 years in 1987 to 1989 without AF from 4 US communities in the ARIC cohort. Incident AF was identified based on study ECGs, hospital discharge codes, and death certificates through 2017. We calculated age and period-specific incidence rates (IRs) of AF. We used Poisson regression to calculate IR ratios of AF over time adjusting for age, sex, and race. A total of 3241 AF cases were identified during a mean (SD) follow-up of 22 years (8.4 years) (599 in Black participants, 2642 in White participants, 1582 in women, and 1659 in men). Overall, the IR of AF in the ARIC cohort was 9.6 per 1000 person-years (6.9 in Black participants, 10.5 in White participants, 8.1 in women, and 11.6 in men). Age-specific IR by time period did not show significant changes over time. In a model adjusted for sex, race, and age group, the rate of AF did not change significantly from 1987 to 1991 compared with 2012 to 2017 (IR ratio, 1.10 [95% CI, 0.88-1.36] comparing 2012-2017 with 1987-1991). Similarly, no evidence of changes over time in AF rates were identified in men and women or White and Black participants separately. Conclusions Even though IRs of AF increase as age increases, our analysis provided evidence suggesting that the overall IRs of AF have not changed over time in a multicenter cohort of Black and White individuals in the United States from 1987 to 2017.

Relationship between social support and incident hypertension in the Jackson Heart Study: a cohort study

OBJECTIVES

Social support may be an important mitigating factor against adverse cardiovascular outcomes by facilitating health-promoting behaviours or by buffering against the negative effects of stress. This study examined the association of social support with incident hypertension.

DESIGN

Prospective cohort study.

SETTING

We evaluated the association of social support with incident hypertension among participants in the Jackson Heart Study, a community-based cohort of African Americans.

PARTICIPANTS

This study included African American adults, who were free of hypertension at baseline (2000-2004). Functional social support, structural social support and satisfaction with social support were assessed at baseline among 1516, 1240 and 1503 participants, respectively.

OUTCOME MEASURES

Incident hypertension was assessed at follow-up examinations in 2005-2008 and 2009-2013. Incident hypertension was defined by the first visit with systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg or self-reported antihypertensive medication use. Multivariable Poisson regression was used to estimate the association of baseline social support with incident hypertension, adjusting for relevant confounders.

RESULTS

At baseline, the mean age of participants was 50 years and 64% were men. During a median follow-up time of 6.9 years, 54% of participants developed hypertension. A high level of functional social support was associated with lower risk of incident hypertension (incident rate ratio 0.64, (95% CI 0.41 to 0.97)), compared with a low level of functional social support. Level of structural social support and satisfaction with social support were not associated with hypertension risk.

CONCLUSIONS

These results suggest that greater functional support may be associated with a lower risk of incident hypertension.

Association between lung function and the risk of atrial fibrillation in a nationwide population cohort study

We investigated the association between lung function and atrial fibrillation (AF) in 21,349 adults without AF aged ≥ 40 years who underwent spirometry. The study participants were enrolled from the Korean National Health and Nutritional Examination Survey between 2008 and 2016. The primary outcome was new-onset non-valvular AF identified from the National Health Insurance Service database. During the median follow-up of 6.5 years, 2.15% of participants developed new-onset AF. The incidence rate of AF per 1000 person-years was inversely related to the forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), and FEV₁/FVC quartile. After adjustment for multiple variables, the AF risk in the lowest FEV₁ quartile was 1.64-fold higher than that in the highest quartile (hazard ratio (HR) 1.64 (95% confidence interval (CI) 1.26–2.12) for lowest FEV₁ quartile). The lowest quartile of FVC had 1.56-fold higher AF risk than the highest quartile (HR 1.56 (95% CI 1.18–2.08) for lowest FVC quartile). Although the lowest FEV₁/FVC quartile was associated with an increased risk of AF in the unadjusted model, this increased risk was not statistically significant in the multivariable analysis. Compared to those with normal lung function, participants with restrictive or obstructive lung function had 1.49 and 1.42-fold higher AF risks, respectively. In this large nationwide cohort study, both obstructive and restrictive patterns of reduced lung function were significantly associated with increased AF risk.

Cardiovascular Event Reporting in Modern Cancer Radiation Therapy Trials

Purpose

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in cancer survivors, particularly after chest radiation therapy (RT). However, the extent to which CVD events are consistently reported in contemporary prospective trials is unknown.

Methods and Materials

From 10 high-impact RT, oncology, and medicine journals, we identified all latter phase trials from 2000 to 2019 enrolling patients with breast, lung, lymphoma, mesothelioma, or esophageal cancer wherein chest-RT was delivered. The primary outcome was the report of major adverse cardiac events (MACEs), defined as incident myocardial infarction, heart failure, coronary revascularization, arrhythmia, stroke, or CVD death across treatment arms. The secondary outcome was the report of any CVD event. Multivariable regression was used to identify factors associated with CVD reporting. Pooled annualized incidence rates of MACEs across RT trials were compared with contemporary population rates using relative risks (RRs).

Results

The 108 trials that met criteria enrolled 59,070 patients (mean age, 58.0 ± 10.2 years; 46.0% female), with 273,587 person-years of available follow-up. During a median follow-up of 48 months, 468 MACEs were reported (including 96 heart failures, 75 acute coronary syndrome, 1 revascularization, 94 arrhythmias, 28 strokes, and 20 CVD deaths; 307 occurred in the intervention arms vs 144 in the control arms; RR, 1.96; P < .001). Altogether, 50.0% of trials did not report MACEs, and 37.0% did not report any CVD. The overall weighted-trial incidence was 376 events per 100,000 person-years compared with 1408 events per 100,000 person-years in similar nontrial patients (RR, 0.27; P < .001). There were no RT factors associated with CVD reporting.

Conclusion

In contemporary chest RT–based clinical trials, reported CVD rates were lower than expected population rates.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

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

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

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

CONCLUSIONS

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

Pharmacological Management of Atrial Fibrillation: A Century of Expert Opinions in Cecil Textbook of Medicine

BACKGROUND

Advances in drug therapy for atrial fibrillation (AF) have had a significant impact on the quality of life of a substantial majority of affected persons, which has contributed to a remarkable decrease in the frequency and severity of thromboembolic complications, hospitalizations, and mortality.

STUDY QUESTION

What are the milestones of the changes in the expert approach to the pharmacological management of AF in the past century?

STUDY DESIGN

To determine the changes in the experts' approach to the management of AF, as presented in a widely used textbook in the United States.

DATA SOURCES

The chapters presenting the management of AF in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020.

RESULTS

AF was consistently described in Cecil Textbook of Medicine as the most common sustained arrhythmia in adults. The authors emphasized its thromboembolic complications and potential for hemodynamic deterioration. Rate control with digitalis and rhythm control with quinidine were the standard in 1927. The pharmacological advances have focused on atrioventricular nodal blocking for rate control, conversion to and maintenance of sinus rhythm, and preventive anticoagulation. The first new class of drugs for rate control was beta-adrenergic receptor blockers, starting with propranolol which was introduced in 1979, followed by the calcium channel blocker verapamil in 1988. Rhythm control with amiodarone, a potassium channel blocker, has been recommended since 2004, and the sodium channel blockers propafenone and flecainide became part of standard therapy in 2008. Anticoagulation with warfarin was recommended starting in 2000, followed by the introduction of direct thrombin inhibitor in 2012 and factor Xa inhibitors in 2016.

CONCLUSIONS

The pharmacological management of AF was unchanged for more than 50 years (1927-1979), a period during which the devastating effects of thromboembolic complications were not addressed. The major therapeutic advance is represented by preventive anticoagulation with the newer, safer, and more user-friendly direct thrombin and factor Xa inhibitors.

Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk

Implantable loop recorder (ILR) is recommended to detect subclinical atrial fibrillation (AF) after cryptogenic stroke; however, the clinical outcomes of this practice is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate 12-month AF detection, change in oral anticoagulation (OAC), and recurrent stroke in ILR versus usual care after ischemic stroke. We searched Medline, Embase, Web of Science, Cochrane Library for randomized controlled trials comparing ILR with usual care after any ischemic stroke. Primary outcomes were cumulative AF detection and recurrent stroke (ischemic or hemorrhagic) or transient ischemic attack over 12 months. Secondary outcome was OAC initiation. Meta-analysis was performed with Mantel-Haenszel pooled odds ratios (ORs) and random effects models. Of 200 identified articles, 3 trials were included (1,233 participants). Cryptogenic stroke and underlying AF included cryptogenic stroke only, stroke of known cause and underlying-AF included small or large vessel stroke only, and post embolic rhythm detection with implantable vs external monitoring included all ischemic strokes. The 12-month AF detection was 13% in the ILR group and 2.4% in controls. ILR was more likely to detect AF compared with usual care (OR 5.8, 95% confidence interval 3.2 to 10.2). Stroke or transient ischemic attack occurred in 7% with ILR and 9% with usual care (OR 0.8, 95% confidence interval 0.5 to 1.2). In patients with detected AF, 97% and 100% were started on OAC in cryptogenic stroke and underlying AF and post embolic rhythm detection with implantable vs external monitoring, respectively, compared with 68% in stroke of known cause and underlying-AF. In conclusion, ILR was superior to usual care in AF detection, but the relative low incidence of AF and the nondifferential risk of stroke between the ILR and usual care arms may suggest that most patients do not benefit from ILR implantation. Further studies are warranted to understand if patient selection can be improved to increase the diagnostic yield of ILR.