Performance of the CHA2DS2-VASc score in predicting new onset atrial fibrillation during hospitalization for community-acquired pneumonia

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

Acute Coronary Syndrome, Stroke, and Mortality after Community-Acquired Pneumonia: Systematic Review and Meta-Analysis

One-third of adult inpatients with community-acquired pneumonia (CAP) develop acute coronary syndrome (ACS), stroke, heart failure (HF), arrhythmias, or die. The evidence linking CAP to cardiovascular disease (CVD) events is contradictory. We aimed to systematically review the role of CAP as a CVD risk factor. We registered the protocol (CRD42022352910) and searched for six databases from inception to 31 December 2022. We included 13 observational studies, 276,109 participants, 18,298 first ACS events, 12,421 first stroke events, 119 arrhythmic events, 75 episodes of new onset or worsening HF, 3379 deaths, and 218 incident CVD events. CAP increased the odds of ACS (OR 3.02; 95% CI 1.88–4.86), stroke (OR 2.88; 95% CI 2.09–3.96), mortality (OR 3.22; 95% CI 2.42–4.27), and all CVD events (OR 3.37; 95% CI 2.51–4.53). Heterogeneity was significant (I2 = 97%, p < 0.001). Subgroup analysis found differences according to the continent of origin of the study, the follow-up length, and the sample size (I2 > 40.0%, p < 0.10). CAP is a significant risk factor for all major CVD events including ACS, stroke, and mortality. However, these findings should be taken with caution due to the substantial heterogeneity and the possible publication bias.

Prevalence of new-onset atrial fibrillation in hospitalized patients with community-acquired pneumonia: a systematic review and meta-analysis

Community-acquired pneumonia (CAP) is a common lower respiratory tract infection, often complicated by cardiovascular events, including cardiac arrhythmias. New-onset atrial fibrillation (newAF) has been associated with increased mortality in CAP patients, especially in those critically ill; however, limited data on the prevalence of newAF in patients with CAP are available. We aim to estimate the pooled prevalence of newAF and its impact on adverse outcomes in patients with CAP, through a systematic review and meta-analysis. MEDLINE and EMBASE were systematically searched from inception to 27 January 2022. All studies reporting the prevalence of newAF in CAP patients were included and all-cause mortality was extracted when available. The pooled prevalence of newAF, 95% Confidence Intervals (CI), and 95% Prediction Intervals (PI) were computed. The inconsistency index (I2) was calculated to measure heterogeneity. Subgroup analyses were also performed. A protocol for this study was registered on PROSPERO (CRD42022307422). Among 7,655 records retrieved, 10 studies were included, with a total of 280,589 CAP patients. Pooled prevalence of newAF in CAP patients was 7.6% (95% CI 6.4-9.0%, 95% PI 4.3-13.1%, I2 = 95%). Subgroup analyses showed no significant differences according to geographical location or study design. Patients with newAF had a higher risk of mortality among the studies included in the systematic review. NewAF is a common complication, occurring in 7.6% of CAP patients, with prediction intervals suggesting an even higher burden. CAP patients who develop newAF during hospitalization may be at higher risk of mortality in both short- and long-term follow-up.

Risk of cardiovascular events leading to hospitalisation after Streptococcus pneumoniae infection: a retrospective cohort LIFE Study

OBJECTIVES

To elucidate the risk of cardiovascular event occurrence following Streptococcus pneumoniae infection.

DESIGN

Retrospective cohort study using a LIFE Study database.

SETTING

Three municipalities in Japan.

PARTICIPANTS

Municipality residents who were enrolled in either National Health Insurance or the Latter-Stage Elderly Healthcare System from April 2014 to March 2020.

EXPOSURE

Occurrence of S. pneumoniae infection.

PRIMARY OUTCOME MEASURES

Occurrence of one of the following cardiovascular events that led to hospitalisation after S. pneumoniae infection: (1) coronary heart disease (CHD), (2) heart failure (HF), (3) stroke or (4) atrial fibrillation (AF).

RESULTS

S. pneumoniae-infected patients were matched with non-infected patients for each cardiovascular event. We matched 209 infected patients and 43 499 non-infected patients for CHD, 179 infected patients and 44 148 non-infected patients for HF, 221 infected patients and 44 768 non-infected patients for stroke, and 241 infected patients and 39 568 non-infected patients for AF. During follow-up, the incidence rates for the matched infected and non-infected patients were, respectively, 38.6 (95% CI 19.9 to 67.3) and 30.4 (29.1 to 31.8) per 1000 person-years for CHD; 69.6 (41.9 to 108.8) and 50.5 (48.9 to 52.2) per 1000 person-years for HF; 75.4 (48.3 to 112.2) and 35.5 (34.1 to 36.9) per 1000 person-years for stroke; and 34.7 (17.9 to 60.6) and 11.2 (10.4 to 12.0) per 1000 person-years for AF. Infected patients were significantly more likely to develop stroke (adjusted HR: 2.05, 95% CI 1.22 to 3.47; adjusted subdistribution HR: 1.94, 95% CI 1.15 to 3.26) and AF (3.29, 1.49 to 7.26; 2.74, 1.24 to 6.05) than their non-infected counterparts.

CONCLUSIONS

S. pneumoniae infections elevate the risk of subsequent stroke and AF occurrence. These findings indicate that pneumococcal infections have short-term effects on patients' health and increase their midterm to long-term susceptibility to serious cardiovascular events.

Atrial electromechanical delay is impaired in patients with COVID-19

Background: COVID-19 infection has the potential to affect the cardiovascular system. Intra/ interatrial electromechanical delay (EMD) demonstrated by P wave dispersion (PD) and tissue doppler echocardiography (TDE) is related to the development of atrial fibrillation. This study aimed to investigate atrial conduction time by PD and TDE in patients with COVID-19. Material and Method: A total of 143 participants were selected in the current study. The COVID-19 group included 90 subjects and the control group included 53 individuals. Two groups were compared with each other, in terms of electrocardiographic P wave measurements, and atrial electromechanical coupling (AEC) parameters by TDE. Results: Maximum P-wave duration (Pmax) and PD were significantly higher in COVID-19 patients compared to the control group (p

Risk of atrial fibrillation in patients with pneumonia

BACKGROUND

Cardiac arrhythmias have a strong association with pneumonia due to the cardiovascular response to infection. Electrocardiographic (ECG) changes in patients with pneumonia are associated with greater disease severity. Atrial fibrillation (AF) is the most common type of cardiac arrhythmia.

OBJECTIVE

This population-based cohort study investigated the incidence of AF among Taiwanese adults with pneumonia using data from the National Health Insurance Research Database in Taiwan.

METHODS

A total of 34,883 patients with pneumonia and an equal number of individuals without pneumonia were eligible after excluding those with a previous diagnosis of AF and matching 1:1 by age, sex, and comorbidities. The Cox proportional hazards model was used to estimate hazard ratios for AF in both groups.

RESULTS

Patients were more likely to develop AF throughout the 1-year follow-up period after the diagnosis of pneumonia. The incidence of AF was 1.2 (414/334,746) per 1000 person-months. Patients with pneumonia had a 4.08-fold (95% confidence interval 3.37-4.95) increased risk for AF compared to patients without pneumonia.

CONCLUSION

Patients with pneumonia exhibited an increased risk for AF, especially in the early period after diagnosis of pneumonia.

Usefulness of C-reactive protein/albumin ratio as a predictor of new-onset atrial fibrillation in SARS-COV-2

Aim: To investigate whether C-reactive protein/albumin ratio (CAR) has an association with new onset atrial fibrillation (NOAF) in SARS-CoV-2. Materials & methods: This study included 782 patients with SARS-CoV-2 infection, who were hospitalized in Turkey. The end point of the study was an occurrence of NOAF. Results: NOAF was identified in 41 patients (5.2%). Subjects who developed NOAF had a higher CAR compared with those who did not develop NOAF (p < 0.001). In the multivariate logistic regression analysis the CAR (odds ratio = 2.879; 95% CI: 1.063–7.793; p = 0.037) was an independent predictor of NOAF. Conclusion: A high level of CAR in blood samples is associated with an increased risk of developing NOAF in SARS-CoV-2.

Prevalence and predictors of subclinical atrial fibrillation in hospitalized older adults

Subclinical atrial fibrillation (SCAF) is associated with an increased risk of clinical AF, major cardiovascular events and death. Short-term evidence on SCAF in older populations is scarce, especially in the hospital setting. We performed a cross-sectional study on 60 multimorbid older consecutive patients (aged 80+) admitted to an Internal Medicine and Geriatrics Unit for acute medical diseases with no history of AF, in order to investigate prevalence and predictors of SCAF. Portable ECG monitoring was placed on admission and ECG recording lasted for 5 days. Mean age: 85.7±4.9 years. Female prevalence: 58.3%. High burden of comorbidities: 87.9%. All enrolled patients had CHA₂DS₂-VASc score ≥3. SCAF was detected in 16 patients (26.7%) and 11 patients (18.4%) had at least a SCAF episode lasting 6 minutes or longer. No clinical, laboratory and echocardiographic parameters predicted SCAF. Patients with ≥2004 supraventricular ectopic beats/24h (SVEBs/24h) had a 6-fold higher prevalence of SCAF than patients with <411 SVEBs/24h (p=0.038). Time to first SCAF episode was within 3 days of ECG recording in all enrolled patients. SCAF is highly prevalent in older adults hospitalized for acute diseases. This finding may affect clinical management and prognosis. Our study could foster larger multicenter studies in similar settings.

Long-term outcomes of postoperative atrial fibrillation following non cardiac surgery: A systematic review and metanalysis

BACKGROUND

New-onset atrial fibrillation (AF) in non-cardiac postoperative setting is common and is associated with a high risk of in-hospital mortality and morbidity. The long-term risks of stroke, mortality and AF recurrence rate in patients with postoperative AF (POAF) are unclear.

METHODS

We performed a systematic literature review in electronic databases from inception to March 5th, 2020 of studies reporting the incidence of stroke, mortality and AF recurrence in patients with POAF. We confined our analysis to studies with a cohort of at least 150 patients with POAF and with a median follow-up of 12 months as a minimum. Odds Ratios (OR) were pooled using a random-effects model.

RESULTS

Qualitative analysis included 8 studies (7 observational cohort studies and 1 randomized controlled trial) enrolling 3,718,587 patients. Six studies underwent metanalysis comprising 17,684 postoperative patients with POAF and 2,169,248 postoperative patients without POAF. The development of POAF conferred a four-fold increased risk of stroke in the long-term [OR 4.05; 95% confidence interval (CI) 2.91-5.62]. Mortality in the two studies reporting long-term data was higher in patients with POAF compared to those without POAF (OR 3.59; CI 95% 2.84-4.53). Data about recurrence were too heterogeneous to undergo metanalysis.

CONCLUSIONS

POAF is associated with a greater risk of stroke and mortality over the long-term period. Studies focusing on AF recurrence are needed to address the perception of POAF as a benign transient entity. The increased mortality risk following POAF should encourage systematic detection and prevention of this arrhythmia.

New onset atrial fibrilation and risk faktors in COVID-19

BACKGROUND

There is limited data concerning the prevalence of arrhythmias, particularly atrial fibrillation (AF), which may develop as a consequence of direct myocardial injury and the inflammatory state existing in COVID-19.

METHODS

This single-center study included data concerning 658 COVID-19 patients, who were hospitalized in our institute, between April 20th, 2020 and July 30th, 2020. Demographic data, findings of the imaging studies, and laboratory test results were retrieved from the institutional digital database.

RESULTS

New onset AF (NOAF) was identified in 33 patients (5%). Patients who developed AF were older (72.42 ± 6.10 vs 53.78 ± 13.80, p < 0.001) and had higher frequencies of hypertension and heart failure compared to patients without NOAF (p < 0.001, for both). The CHA2DS2-VASc score was higher in patients, who developed NOAF, compared to those who did not during hospitalization for COVID-19 (p < 0.001). Subjects, who developed NOAF during hospitalization, had a higher leukocyte count, neutrophil / lymphocyte ratio (NLR), C-reactive protein, erythrocyte sedimentation rate, and procalcitonin levels compared to those without NOAF (p < 0.001 for all comparisons). Diffuse lung infiltration was also more frequent in COVID-19 patients, who developed NOAF, during hospitalization (p = 0.015). Multivariate logistic regression analysis demonstrated that age, CHA2DS2-VASc score, CRP, erythrocyte sedimentation rate, and presence of diffuse lung infiltration on thorax CT were predictive for NOAF.

CONCLUSION

The prevalence of NOAF in hospitalized COVID-19 patients is higher than the general population. Age, CHA2DS2-VASc score, C-reactive protein, erythrocyte sedimentation rate, and presence of diffuse lung infiltration on thorax CT may be used to identify patients at high risk for development of NOAF. Especially among these parameters, the presence of diffuse lung infiltration on thorax CT it was the most powerful independent predictor of NOAF development.

Platelets and Their Role in the Pathogenesis of Cardiovascular Events in Patients With Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) remains an important cause of morbidity and mortality throughout the world with much recent and ongoing research focused on the occurrence of cardiovascular events (CVEs) during the infection, which are associated with adverse short-term and long-term survival. Much of the research directed at unraveling the pathogenesis of these events has been undertaken in the settings of experimental and clinical CAP caused by the dangerous, bacterial respiratory pathogen, Streptococcus pneumoniae (pneumococcus), which remains the most common bacterial cause of CAP. Studies of this type have revealed that although platelets play an important role in host defense against infection, there is also increasing recognition that hyperactivation of these cells contributes to a pro-inflammatory, prothrombotic systemic milieu that contributes to the etiology of CVEs. In the case of the pneumococcus, platelet-driven myocardial damage and dysfunction is exacerbated by the direct cardiotoxic actions of pneumolysin, a major pore-forming toxin of this pathogen, which also acts as potent activator of platelets. This review is focused on the role of platelets in host defense against infection, including pneumococcal infection in particular, and reviews the current literature describing the potential mechanisms by which platelet activation contributes to cardiovascular complications in CAP. This is preceded by an evaluation of the burden of pneumococcal infection in CAP, the clinical features and putative pathogenic mechanisms of the CVE, and concludes with an evaluation of the potential utility of the anti-platelet activity of macrolides and various adjunctive therapies.

Cardiovascular Events After Community-Acquired Pneumonia: A Global Perspective with Systematic Review and Meta-Analysis of Observational Studies

Acute cardiovascular disease after community-acquired pneumonia is a well-accepted complication for which definitive treatment strategies are lacking. These complications share some common features but have distinct diagnostic and treatment approaches. We therefore undertook an updated systematic review and meta-analysis of observational studies reporting the incidence of overall complications, acute coronary syndromes, new or worsening heart failure, new or worsening arrhythmias and acute stroke, as well as short-term mortality outcomes. To set a framework for future research, we further included a holistic review of the interplay between the two conditions. From 1984 to 2019, thirty-nine studies were accrued, involving 92,188 patients, divided by setting (inpatients versus outpatients) and clinical severity (low risk versus high risk). Overall cardiac complications occurred in 13.9% (95% confidence interval (CI) 9.6-18.9), acute coronary syndromes in 4.5% (95% CI 2.9-6.5), heart failure in 9.2% (95% CI 6.7-12.2), arrhythmias in 7.2% (95% CI 5.6-9.0) and stroke in 0.71% (95% CI 0.1-3.9) of pooled inpatients. During this period, meta-regression analysis suggests that the incidence of overall and individual cardiac complications is decreasing. After adjusting for confounders, cardiovascular events taking place after community-acquired pneumonia independently increase the risk for short-term mortality (range of odds-ratio: 1.39-5.49). These findings highlight the need for effective, large trial based, preventive and therapeutic interventions in this important patient population.

Left Atrium Dilatation and Left Ventricular Hypertrophy Predispose to Atrial Fibrillation in Patients With Community-Acquired Pneumonia

Atrial fibrillation (AF) is one of the most common cardiovascular complications in patients hospitalized with community-acquired pneumonia (CAP). However, predisposing clinical factors associated with AF in CAP patients have not been fully elucidated. We enrolled 545 patients consecutively hospitalized for CAP. Data on demographic characteristics and co-morbidities were collected and all patients underwent ECG, echocardiography, and laboratory measurements. During the in-hospital stay, 9.5% of patients experienced a new episode of AF within 24 to 72 hours from admission. CAP patients who experienced AF had a higher indexed left atrial area (LAAi) and a higher proportion of concentric left ventricular hypertrophy than those not presenting AF. Univariate logistic regression analysis showed that hypertension, history of coronary heart disease, high Pneumonia Severity Index classes, history of paroxysmal AF, systolic heart failure, concentric left ventricular hypertrophy, and an enlarged LAAi were associated with a new episode of AF. A multivariable logistic analysis showed that history of paroxysmal AF (odds ratio [OR] 11.7; 95% confidence interval [CI] 5.8 to 23.7; p <0.001), enlarged LAAi (OR 5.4; 95% CI 2.5 to 11.9; p <0.001), and concentric left ventricular hypertrophy (OR 2.2; 95 CI 1.1 to 4.6; p = 0.034) remained independently associated with AF occurrence. In conclusion, in this large cohort of CAP patients, history of paroxysmal AF, enlarged LAAi, and concentric left ventricular hypertrophy are independent predictors of AF occurrence during the early stages of pneumonia.

[Atrial fibrillation in patients with sepsis and non-cardiac infections]

Atrial fibrillation (AF) is by far the most frequent cardiac arrhythmia associated with sepsis and infections. Newly occurring AF due to infections is associated with a deterioration of the prognosis for acute events and also for the long-term prognosis of patients. The risk of developing AF during an infection depends on general (e.g. age, structural heart disease) as well as infection-specific risk factors (e.g. sepsis severity, vasopressor treatment). Current guidelines do not make specific recommendations on the treatment of infection-associated AF and very few prospective data are available. The use of beta blockers appears to be safe for both prevention and frequency control of AF even in patients requiring catecholamines. For specific antiarrhythmic treatment, the use of class I antiarrhythmic agents is conceivable as an alternative to the predominantly used amiodarone. Newly occurring AF within infections has long been considered a specific entity with a low risk of recurrence, so that only a small proportion of patients received long-term effective anticoagulation; however, data from large retrospective studies suggest significantly higher recurrence rates. Therefore, the question of whether this group of patients benefits from long-term effective anticoagulation and extended monitoring of arrhythmia should be the subject of future research.