Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century

Hypertension and Atrial Fibrillation: A Frontier Review From the AF-SCREEN International Collaboration

Hypertension is the leading modifiable risk factor for atrial fibrillation (AF) and is estimated to be present in >70% of AF patients. This Frontiers Review was prepared by 29 expert members of the AF-SCREEN International Collaboration to summarize existing evidence and knowledge gaps on links between hypertension, AF, and their cardiovascular sequelae; simultaneous screening for hypertension and AF; and the prevention of AF through antihypertensive therapy. Hypertension and AF are inextricably connected. Both are easily diagnosed, often silent, and frequently treated inadequately. Together, they additively increase the risk of ischemic stroke, heart failure, and many types of dementia, resulting in greater all-cause mortality, considerable disease burden, and increased health care expenditures. Automated upper arm cuff blood pressure devices with implemented technology can be used to simultaneously detect both hypertension and AF. However, positive screening for AF with an oscillometric blood pressure monitor still requires ECG confirmation. The current evidence suggests that high-risk individuals aged ≥65 years or with treatment-resistant hypertension could benefit from AF screening. Since antihypertensive therapy effectively lowers AF risk, particularly in individuals with left ventricular dysfunction, hypertension should be the key target for AF prediction and prevention rather than merely a comorbidity of AF. Nevertheless, several important gaps in knowledge need to be filled over the next years, including the ideal method and selection of patients for simultaneous screening of hypertension and AF and the optimal antihypertensive drug class and blood pressure targets for AF prevention.

5-Year Results From the AMPLATZER Amulet Left Atrial Appendage Occluder Randomized Controlled Trial

BACKGROUND

The Amulet IDE trial (AMPLATZER Amulet Left Atrial Appendage Occluder [LAAO] Investigational Device Exemption [IDE] Trial) evaluated the safety and effectiveness of the Amulet occluder (Abbott) in patients with nonvalvular atrial fibrillation. The Amulet IDE trial is the largest randomized LAAO trial, comparing the Amulet occluder with the Watchman 2.5 device (Boston Scientific).

OBJECTIVES

This analysis presents the 5-year results from the trial comparing the 2 devices head to head.

METHODS

Patients enrolled in the Amulet IDE trial were at a high risk of stroke or systemic embolism defined as a CHADS2 score ≥2 or CHA2DS2-VASc score ≥3. Oral anticoagulation (OAC) use and key clinical outcomes are presented through 5 years.

RESULTS

A total of 1,878 patients were randomized, with 1,833 undergoing a device implantation attempt (n = 917, Amulet occluder; and n = 916, Watchman device). A significantly higher percentage of patients were free of OAC in the Amulet occluder group at each follow-up visit, with 94.0% and 90.9% free of OAC at the last 5-year follow-up visit in the Amulet and Watchman device groups, respectively (P = 0.009). The 5-year clinical outcomes were similar between the Amulet and Watchman devices, including the composite of ischemic stroke or systemic embolism (7.4% vs 7.1%; P = 0.851), the composite of stroke, systemic embolism, or cardiovascular death (20.3% vs 20.7%; P = 0.666), major bleeding (20.1% vs 20.0%; P = 0.882), cardiovascular (CV) death (14.3% vs 15.4%; P = 0.429), and all-cause death (28.7% vs 31.1%; P = 0.217). Annualized ischemic stroke rates at 5 years were low and the same for Amulet (1.6%/y) and Watchman (1.6%/y) devices. Strokes in patients with the Amulet occluder were less severe (n = 38, nondisabling; n = 11, disabling; n = 11, fatal; n = 12, unknown) than strokes in patients with the Watchman device (n = 19, nondisabling; n = 22, disabling; n = 17, fatal; n = 10, unknown). Moreover, device factors (device-related thrombus or peridevice leak ≥3 mm) preceded stroke events and CV deaths more frequently in patients with the Watchman device (n = 63) compared with patients with the Amulet occluder (n = 31).

CONCLUSIONS

The 5-year outcomes from the largest randomized LAAO clinical trial demonstrated the long-term safety and effectiveness of the Amulet occluder and Watchman 2.5 devices. The dual-seal Amulet occluder reduces atrial fibrillation-related thromboembolic events while eliminating the need for long-term OAC. (AMPLATZER Amulet Left Atrial Appendage Occluder [LAAO] Investigational Device Exemption [IDE] Trial [Amulet IDE trial]; NCT02879448).

Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation: A Retrospective Observational Cohort Study

OBJECTIVE

To summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF).

DESIGN

Retrospective observational study.

SETTING

A single quaternary teaching hospital.

PARTICIPANTS

Adult patients with AF undergoing the convergent procedure before January 2024.

INTERVENTIONS

Retrospective chart review.

MEASUREMENTS/MAIN RESULTS

The study cohort comprised 40 patients, including 35 patients with persistent longstanding AF. The mean age was 64 (SD, 6) years, and 33 patients (83%) were male. Common comorbidities included obesity (n = 27; 68%), obstructive sleep apnea (n = 29; 73%), history of tachycardia-mediated cardiomyopathy (n = 10; 25%), and significant alcohol use (n = 10; 25%). Sixteen of the 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) had required a cardioversion in the past. In all, 39 patients (98%) were receiving anticoagulation, and 38 (95%) were on at least 1 antiarrhythmic medication prior to the procedure. All patients received general anesthesia, inhalational in 39 patients (98%) and total intravenous in 1 patient (3%), with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of the 40 patients (93%) were extubated in the operating room, and 11 patients (28%) required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 day and 4 days, respectively.

CONCLUSIONS

This retrospective analysis of medical records showed that many patients with recurrent AF presenting for convergent procedure carry a burden of multiple comorbidities (eg, obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy and potentially complicated and requires meticulous preparation (eg, endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and the possibility of CPB.

Global Research Progress on Radiofrequency Ablation in Cardiology

Radiofrequency ablation (RFA) has become a cornerstone in treating cardiac arrhythmias, offering a minimally invasive approach to managing conditions such as atrial fibrillation, ventricular tachycardia, and other rhythm disorders. The historical evolution of RFA, from its early inception to its current state, underscores the technological advancements that have significantly enhanced its efficacy and safety. Global trends indicate a steady increase in the adoption of RFA, with notable research contributions from North America, Europe, and Asia. Comparative studies reveal outcome variability driven by differences in patient populations, procedural techniques, and healthcare infrastructures. Despite its success, RFA faces challenges, including complications related to the procedure, patient selection, and long-term efficacy. Emerging technologies, such as integrating artificial intelligence and enhanced imaging modalities, hold promise for overcoming these barriers and further refining the procedure. Gaps in current research are identified, particularly in understanding the long-term outcomes of RFA and its application in complex arrhythmias. The critical role of RFA in modern cardiology is emphasized, along with the potential for future innovations that could expand its therapeutic utility. This synthesis of the latest evidence provides valuable insights for optimizing the use of RFA in managing cardiac arrhythmias.

Secondary Prevention of Stroke in Patients with Non-Valvular Atrial Fibrillation and Advanced Chronic Kidney Disease

AIMS

Evidence supporting the prescription of anticoagulant therapy for patients with atrial fibrillation (AF) with advanced chronic kidney disease (CKD) has been limited, and its clinical application in this context remains controversial.

METHODS

We identified AF patients with advanced CKD (G4-G5) and a history of stroke who were admitted to the First Affiliated Hospital of Dalian Medical University between January 1, 2011, and June 30, 2023. Patients were classified into warfarin, non-vitamin K antagonist oral anticoagulant (NOAC), antiplatelet therapy, and control (no antithrombotic therapy) groups. We evaluated the benefits and safety of different antithrombotic therapies by comparing the long-term clinical outcome measures, including the incidence of subsequent ischemic stroke events, bleeding, and all-cause death.

RESULTS

In total, 570 patients were included. In this cohort, 87 (15.3%) patients had no antithrombotic treatment, 252 (44.2%) received antiplatelet therapy, 105 (18.4%) received warfarin, and 126 (22.1%) received NOAC therapy. Compared with patients without treatment, we found that treatment with anticoagulant therapy significantly decreased the risk of ischemic stroke, but antiplatelet therapy did not. Treatment with anticoagulant therapy was associated with significantly lower mortality than no antithrombotic therapy or antiplatelet therapy , at least within the study period. Furthermore, compared with warfarin treatment, patients treated with NOAC therapy showed a significant decrease in the incidence of bleeding risks.

CONCLUSION

Among AF patients with advanced CKD and prior stroke, receiving anticoagulants resulted in a reduced risk of recurrent ischemic stroke events than no antithrombotic treatment, and lower mortality than no antithrombotic treatment or antiplatelet therapy.

Long-term pulse pressure trajectories and risk of incident atrial fibrillation: the Tromsø Study

BACKGROUND AND AIMS

Sex-based differences in the association of long-term trends in pulse pressure with future risk of atrial fibrillation (AF) have been explored using data from the population-based Tromsø Study 1986-2016.

METHODS

Women (n = 8331) and men (n = 7638) aged ≥20 years who attended at least two of the three Tromsø Study surveys conducted between 1986 and 2001 (the exposure period) were followed up for incident AF throughout 2016 (the follow-up period). Pulse pressure ≥60 mmHg was considered elevated. Group-based trajectory modelling and Cox regression were used for statistical analyses.

RESULTS

Three long-term trajectory groups for pulse pressure were identified: Group 1 had normal pulse pressure throughout the exposure period, Group 2 had normal pulse pressure at the beginning and elevated pulse pressure at the end of the exposure period, and Group 3 had elevated pulse pressure throughout. Over the follow-up period, 568 (6.8%) women and 798 (10.5%) men developed AF. After adjustment for potential confounders at baseline, the long-term trajectory groups for elevated pulse pressure were associated with increased risk of AF in women, but not in men. In women, the adjusted hazard ratios of AF were 1.60 (95% confidence interval: 1.23, 2.09) for trajectory Group 2 and 2.78 (1.93, 4.02) for trajectory Group 3, compared with Group 1.

CONCLUSIONS

Long-term elevated pulse pressure trajectories were independently associated with increased risk of AF in women, but not in men. Our findings call for further investigations to understand the mechanisms behind these sex-based differences.

Development and validation of an interpretable machine learning model for predicting left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients

PURPOSE

Left atrial thrombus or spontaneous echo contrast (LAT/SEC) are widely recognized as significant contributors to cardiogenic embolism in non-valvular atrial fibrillation (NVAF). This study aimed to construct and validate an interpretable predictive model of LAT/SEC risk in NVAF patients using machine learning (ML) methods.

METHODS

Electronic medical records (EMR) data of consecutive NVAF patients scheduled for catheter ablation at the First Hospital of Jilin University from October 1, 2022, to February 1, 2024, were analyzed. A retrospective study of 1,222 NVAF patients was conducted. Nine ML algorithms combined with demographic, clinical, and laboratory data were applied to develop prediction models for LAT/SEC in NVAF patients. Feature selection was performed using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression. Multiple ML classification models were integrated to identify the optimal model, and Shapley Additive exPlanations (SHAP) interpretation was utilized for personalized risk assessment. Diagnostic performances of the optimal model and the CHA2DS2-VASc scoring system for predicting LAT/SEC risk in NVAF were compared.

RESULTS

Among 1,078 patients included, the incidence of LAT/SEC was 10.02%. Six independent predictors, including age, non-paroxysmal AF, diabetes, ischemic stroke or thromboembolism (IS/TE), hyperuricemia, and left atrial diameter (LAD), were identified as the most valuable features. The logistic classification model exhibited the best performance with an area under the receiver operating characteristic curve (AUC) of 0.850, accuracy of 0.812, sensitivity of 0.818, and specificity of 0.780 in the test set. SHAP analysis revealed the contribution of explanatory variables to the model and their relationship with LAT/SEC occurrence. The logistic regression model significantly outperformed the CHA2DS2-VASc scoring system, with AUCs of 0.831 and 0.650, respectively (Z = 7.175, P < 0.001).

CONCLUSIONS

ML proves to be a reliable tool for predicting LAT/SEC risk in NVAF patients. The constructed logistic regression model, along with SHAP interpretation, may serve as a clinically useful tool for identifying high-risk NVAF patients. This enables targeted diagnostic evaluations and the development of personalized treatment strategies based on the findings.

Long-term outcomes of catheter ablation compared with medical therapy in atrial fibrillation

BACKGROUND

The long-term effects of catheter ablation (CA) compared with medical therapy on cardiovascular outcomes for atrial fibrillation (AF) remain undetermined.

OBJECTIVE

Using a population-based cohort, we sought to determine what the association between CA and medical therapy was on these outcomes.

METHODS

By use of Alberta administrative data, patients with AF as the primary diagnosis during hospitalization, emergency department visit, or physician visit were included between October 1, 2008, and March 31, 2018. Based on therapy received, patients were assigned to categories of CA, rate control, or rhythm control with medication. The association of treatment with the primary composite outcome of all-cause death, hospitalization for heart failure, or stroke was examined after adjustment for age, sex, comorbidities, and baseline medications.

RESULTS

Of 39,966 treated AF patients, 2077 (5.2%), 29,467 (73.7%), and 8422 (21.1%) were treated with CA, rate control, and rhythm control with medication, respectively. Patients in the CA group had a lower incidence of the primary outcome (4.0/100 person-years) compared with the rate control group (8.7/100 person-years) or the rhythm control with medication group (6.8/100 person-years) during a median follow-up of 6.3 years. In multivariable analysis, compared with CA, both rate control (hazard ratio, 1.28; 95% confidence interval, 1.09-1.50) and rhythm control with medication (hazard ratio, 1.21; 95% confidence interval, 1.03-1.43) were associated with a higher risk of the primary outcome.

CONCLUSION

In this cohort study, patients who received CA demonstrated a reduction in the risk of long-term adverse cardiovascular outcomes compared with medical therapy in patients with AF, providing some data to indicate the effects of CA in the long-term.

Trends over time in oral anticoagulation and stroke rates in atrial fibrillation: A community-based study

OBJECTIVES

Over the last decade, direct oral anticoagulants (DOAC) have become preferred over warfarin for stroke prevention in atrial fibrillation (AF). The objectives of this study were to quantify the shift over time from warfarin to DOACs and parallel changes in ischemic and hemorrhagic stroke rates in AF.

MATERIALS AND METHODS

This community-based retrospective study was undertaken within a single integrated health care network from 2011 to 2021. Changes over time in warfarin and DOAC use were quantified by year, both overall and stratified by CHA2DS2-VASc score. Ischemic and hemorrhagic stroke rate changes over time were evaluated by Poisson regression. Stroke rates were evaluated in different time eras: 2011-2015 and 2016-2021.

RESULTS

Among 31,978 AF patients followed an average of 5.5 years, any OAC use increased from 50.2 % (2011) to 59.4 % (2020) (p < 0.001). Warfarin use decreased from 49.3 % to 30.8 %, while DOAC use increased from 2.0 % to 30.8 % (both p < 0.001). In 2020, patients with CHA2DS2-VASc 0-1 and 2-5 were more likely to use DOACs than warfarin (18.6 % vs. 6.7 %; 33.0 % vs. 28.2 %), whereas in CHA2DS2-VASc 6-9 DOACs were used less frequently (30.0 % vs. 40.8 %). Ischemic stroke rates significantly increased by 19 % (95 % CI: 7 %, 32 %) from 2011 to 2015, but significantly decreased by 18 % (10 %, 26 %) from 2016 to 2021. Hemorrhagic stroke rates stabilized in 2016-2021 (+3 %; -18 %, 30 %) after increasing in 2011-2015 (+36 %; 4 %, 78 %).

CONCLUSION

Improvements in ischemic and hemorrhagic stroke rates coincided temporally with increased uptake of OACs and a shift toward increased uptake of DOACs relative to warfarin.

Quality of care among patients diagnosed with atrial fibrillation in Greenland

This cross-sectional study sought to assess the prevalence of atrial fibrillation (AF) diagnosis in Greenland among various age groups and examine the corresponding quality of care. We collected data from Greenland's electronic medical records and evaluated the quality of care using six internationally recommended indicators, which are: percentage of AF patients with an assessment of smoking status within the previous year, an assessment of body mass index within the previous year, assessment of blood pressure within the previous year, measurement of thyroid stimulating hormone (TSH), treatment with an anticoagulant and percentage of patients with a measurement of serum-creatinine. We found the prevalence of AF among patients aged 20 years or older in Greenland to be 1.75% (95% CI 1.62-1.88). We found an increasing prevalence of AF with age and a greater proportion of men than women until the age of 74 years. Our study suggests that the associated quality of care could be higher as the requirement of only one of the six quality indicators was met. A lack of registration may partly explain this, and initiatives to improve the quality of care are recommended.

Atrial arrhythmia in adults with sickle cell anemia: a missing link toward understanding and preventing strokes

ABSTRACT

Although patients with homozygous sickle cell anemia (SCA) carry both significant left atrial (LA) remodeling and an increased risk of stroke, the prevalence of atrial arrhythmia (AA) has never been prospectively evaluated. The aim of this study was to identify the prevalence and predictors of atrial arrhythmia in SCA. From 2018 to 2022, consecutive adult patients with SCA were included in the DREPACOEUR prospective registry and referred to the physiology department for cardiac evaluation, including a 24-hour electrocardiogram monitoring (ECG-Holter). The primary endpoint was the occurrence of AA, defined by the presence of excessive supraventricular ectopic activity (ESVEA) on ECG-Holter (ie >720 premature atrial contractions [PACs] or any run ≥ 20 PACs) or any recent history of atrial fibrillation. Overall, 130 patients with SCA (mean age: 45±12 years, 48% of male) were included. AA was found in 34 (26%) patients. Age (52±9 vs. 42±12 years, P=0,002), LA dilation (LAVi, 71±24 vs. 52±14 mL/m², P<0.001) and history of stroke without underlying cerebral vasculopathy (26% vs. 5%, P=0.009, OR=6.6 (95%CI 1.4-30.3]) were independently associated with AA. Age and LAVi correlated with PAC load per 24 hours on ECG-Holter. An age over 47 years or a LAVi >55mL/m² could predict AA with a PPV of 33% and a NPV of 92%. AAs are frequent in middle-aged patients with SCA and increase with age and LA remodeling, leading to a major additional risk factor for ischemic stroke. This study provides arguments and means to early screen for AA and potentially prevent cerebral complications.

The burden of atrial fibrillation on emergency medical services: A population-based cohort study

BACKGROUND

Atrial fibrillation (AF) is a growing burden on healthcare resources, despite improvements in prevention and management. AF is a common cause of hospitalisation, and Emergency Medical Services (EMS) use. However, there is a paucity of data describing the burden of AF on EMS. We aimed to determine the prevalence, characteristics, and outcomes of patients presenting with AF to EMS using a large population-based sample.

METHODS

Consecutive attendances for AF in Victoria, Australia (January 2015-June 2019) were included if patients had a diagnosis of "AF" or "arrhythmia" with AF on electrocardiogram. Data were individually linked to emergency, hospital, and mortality records.

RESULTS

Of 2,613,056 EMS attendances, 16,525 were a first attendance for AF and linked to hospital records. Median (IQR) age was 76 (67,84) years (43% female). Seventy-eight percent had high thromboembolic risk (CHA2DS2-VASc score ≥ 2), and 72% had a heart rate ≥ 100 bpm. Forty-two percent of patients received no treatment by paramedics and 99.4% were transported to hospital. Fifty-three percent were discharged from ED. Median length of hospital stay was 2 days. Of 2542 cases reattended for AF, 19% occurred within 30 days, with increased odds for females and those of low socioeconomic status. Overall, 24% died during the study period, 12% within 30 days. Increasing age, heart failure, stroke, COPD, and low socioeconomic status increased the odds of 30-day mortality.

CONCLUSIONS

EMS utilisation for AF is common and associated with frequent reattendance. Further studies are required to investigate novel pathways of care to reduce AF burden on healthcare systems.

Association between venous thromboembolism and atrial fibrillation: a Mendelian randomization study

BACKGROUND

Although previous observational studies have shown an association between venous thromboembolism (VTE) and atrial fibrillation (AF), the underlying causal relationship between them remains uncertain.

METHODS AND RESULTS

This two-sample bidirectional Mendelian randomization (MR) analysis was performed to investigate the causal relationship between VTE and AF. The VTE dataset were obtained from FinnGen, including 9,176 cases and 209,616 controls. Meanwhile a genome-wide association study (GWAS) of 60,620 individuals with AF and 970,216 control subjects identified genetic variations associated with AF. The principal MR analytic approach used in this study is the inverse-variance weighting (IVW) method. Furthermore, we performed complementary MR analyses, including the MR-Egger, Weighted median (WM), and Weighted Mode. MR pleiotropy residual sum was applied to identify pleiotropy. The MR analysis showed suggestive causal associations between VTE and the risk of AF (p = 0.0245, OR [95%CI]: 1.027 [1.003, 1.051]). The reverse MR analysis found that genetic susceptibility to AF was not significantly associated with VTE, as determined by the IVW method (p = 0.7773). The robustness of these findings was corroborated through MR sensitivity analyses.

CONCLUSIONS

There is a unidirectional causal relationship between VTE and AF, meaning that VTE is a causal risk factor for AF, whereas no effect of AF on VTE was identified.

Hypertension and atrial fibrillation: the clinical impact of hypertension on perioperative outcomes of atrial fibrillation ablation and its optimal control for the prevention of recurrence

Hypertension (HTN) is one of the major risk factors for developing atrial fibrillation (AF), and it has been estimated that approximately 70% of hypertensive patients are at risk of developing AF. On the other hand, 60-80% of AF patients have HTN. These two diseases share many risk factors such as diabetes mellitus, obesity, alcohol consumption, and sleep apnea syndrome during their onset and disease progression. The mutual presence of these diseases has the potential to create a negative spiral, exacerbating each other's impact and ultimately leading to cardiovascular events such as heart failure and cerebrovascular disorders, thereby increasing mortality rates. With regard to the treatment of HTN, the variety of antihypertensive drugs and treatment options have significantly increased. Alongside the widespread adoption of antihypertensive therapy, a certain level of efficacy has been recognized in suppressing the incidence of new-onset AF. Catheter ablation is an established and effective treatment for AF. However, a notable recurrence rate persists. In recent years, management of these multiple risk factors has been recognized to be essential for suppressing AF recurrence, and recent guidelines for AF underscore the significance of proactively managing these risks before treatment. Notably, effective HTN management assumes paramount importance given its impact on the morbidity of AF patients. This review summarizes the correlation between HTN control before and after ablation and the risk of AF recurrence. The focus is on elucidating the pathophysiological background and its impact on clinical outcomes.

Regional Disparities in Atrial Fibrillation Management: An IMPACT-AF Substudy

Background

In rural regions, atrial fibrillation (AF) management is performed predominately by local primary care professionals (PCPs). Prior work has suggested that a disparity in outcomes in AF occurs for those patients living in a rural, vs urban, location.

Methods

This post hoc analysis of the cluster randomized trial Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF) compared a clinical decision support system to standard of care. Patients were classified as living in a rural (population < 10,000) or urban location. The outcomes were as follows: AF-related emergency department (ED) visits, unplanned cardiovascular (CV) hospitalizations, AF-related referrals and guideline adherence for AF treatment.

Results

A total of 1133 patients were enrolled from 2016 to 2018; 54.1% (n = 613) were classified as living in a rural location. No differences were present in age (mean, 72 ± 9.63 vs 72.5 ± 10.42 years) or Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score (mean, 2.1 ± 1.36 vs 2.16 ± 1.34). Referral rates to general internists were higher in the rural population (13.4% vs 3.9%, P < 0.001), whereas the rate of cardiology referrals was higher in the urban population (10% vs 15%, P = 0.0098). At 12 months, no difference in the composite outcome of AF-related ED visits and CV hospitalizations was seen. Fewer recurrent AF-related ED visits and CV hospitalizations occurred in the urban group (incidence rate ratio [IRR], 0.65 [95% confidence interval (0.44, 0.95), P = 0.0262). The incidence of guideline adherence was similar between the rural (IRR, 3.7 ± 1.2) and urban (IRR, 3.6 ± 1.2; P = 0.11) groups.

Conclusions

AF patients living in rural locations had higher rates of recurrent AF-related ED visits and unplanned CV hospitalizations. Further research to optimize AF-related outcomes is needed to ensure equitable delivery of care to all Canadians, irrespective of geography.

Clinical Trial Registration

NCT01927367.

Automated interpretations of single-lead electrocardiograms predict incident atrial fibrillation: The VITAL-AF trial

BACKGROUND

Single-lead electrocardiograms (1L ECGs) are increasingly used for atrial fibrillation (AF) detection. Automated 1L ECG interpretation may have prognostic value for future AF in cases in which screening does not result in a short-term AF diagnosis.

OBJECTIVE

We sought to investigate the association between automated 1L ECG interpretation and incident AF.

METHODS

VITAL-AF was a randomized controlled trial investigating the effectiveness of screening for AF by 1L ECGs. For this study, participants were divided into 4 groups based on automated classification of 1L ECGs. Patients with prevalent AF were excluded. Associations between groups and incident AF were assessed by Cox proportional hazards models adjusted for risk factors. The start of follow-up was defined as 60 days after the latest 1L ECG (as some individuals had numerous screening 1L ECGs).

RESULTS

The study sample included never screened (n = 16,306), normal (n = 10,914), other (n = 2675), and possible AF (n = 561). Possible AF had the highest AF incidence (5.91 per 100 person-years; 95% confidence interval [CI], 4.24-8.23). Possible AF was associated with greater hazard of incident AF compared with normal (adjusted hazard ratio, 2.48; 95% CI, 1.66-3.71). Other was associated with greater hazard of incident AF compared with normal (1.41; 95% CI, 1.04-1.90).

CONCLUSION

In patients undergoing AF screening with 1L ECGs without prevalent AF or AF within 60 days of screening, presumptive positive and indeterminate 1L ECG interpretations were associated with future AF. Abnormal 1L ECG recordings may identify individuals at higher risk for future AF.

Dietary interventions in the management of atrial fibrillation

Atrial fibrillation (AF) represents the most common cardiac arrhythmia with significant morbidity and mortality implications. It is a common cause of hospital admissions, significantly impacts quality of life, increases morbidity and decreases life expectancy. Despite advancements in treatment options, prevalence of AF remains exceptionally high. AF is a challenging disease to manage, not just clinically but also financially. Evidence suggests lifestyle modification, including dietary changes, plays a significant role in the treatment of AF. This review aims to analyze the existing literature on the effects of dietary modifications on the incidence, progression, and outcomes of atrial fibrillation. It examines various dietary components, including alcohol, caffeine, omega-3 polyunsaturated fatty acids and minerals, and their impact on AF incidence, progression, and outcomes. The evidence surrounding the effects of dietary patterns, such as the Mediterranean and low carbohydrate diets, on AF is also evaluated. Overall, this review underscores the importance of dietary interventions as part of a comprehensive approach to AF management and highlights the need for further research in this emerging field.

Clinical service organisation for adults with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is an increasingly prevalent heart rhythm condition in adults. It is considered a common cardiovascular condition with complex clinical management. The increasing prevalence and complexity in management underpin the need to adapt and innovate in the delivery of care for people living with AF. There is a need to systematically examine the optimal way in which clinical services are organised to deliver evidence-based care for people with AF. Recommended approaches include collaborative, organised multidisciplinary, and virtual (or eHealth/mHealth) models of care.

OBJECTIVES

To assess the effects of clinical service organisation for AF versus usual care for people with all types of AF.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and CINAHL to October 2022. We also searched ClinicalTrials.gov and the WHO ICTRP to April 2023. We applied no restrictions on date, publication status, or language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), published as full texts and as abstract only, involving adults (≥ 18 years) with a diagnosis of any type of AF. We included RCTs comparing organised clinical service, disease-specific management interventions (including e-health models of care) for people with AF that were multicomponent and multidisciplinary in nature to usual care.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected studies, assessed risk of bias, and extracted data from the included studies. We calculated risk ratio (RR) for dichotomous data and mean difference (MD) or standardised mean difference (SMD) for continuous data with 95% confidence intervals (CIs) using random-effects analyses. We then calculated the number needed to treat for an additional beneficial outcome (NNTB) using the RR. We performed sensitivity analyses by only including studies with a low risk of selection and attrition bias. We assessed heterogeneity using the I² statistic and the certainty of the evidence according to GRADE. The primary outcomes were all-cause mortality and all-cause hospitalisation. The secondary outcomes were cardiovascular mortality, cardiovascular hospitalisation, AF-related emergency department visits, thromboembolic complications, minor cerebrovascular bleeding events, major cerebrovascular bleeding events, all bleeding events, AF-related quality of life, AF symptom burden, cost of intervention, and length of hospital stay.

MAIN RESULTS

We included 8 studies (8205 participants) of collaborative, multidisciplinary care, or virtual care for people with AF. The average age of participants ranged from 60 to 73 years. The studies were conducted in China, the Netherlands, and Australia. The included studies involved either a nurse-led multidisciplinary approach (n = 4) or management using mHealth (n = 2) compared to usual care. Only six out of the eight included studies could be included in the meta-analysis (for all-cause mortality and all-cause hospitalisation, cardiovascular mortality, cardiovascular hospitalisation, thromboembolic complications, and major bleeding), as quality of life was not assessed using a validated outcome measure specific for AF. We assessed the overall risk of bias as high, as all studies had at least one domain at unclear or high risk of bias rating for performance bias (blinding) in particular. Organised AF clinical services probably result in a large reduction in all-cause mortality (RR 0.64, 95% CI 0.46 to 0.89; 5 studies, 4664 participants; moderate certainty evidence; 6-year NNTB 37) compared to usual care. However, organised AF clinical services probably make little to no difference to all-cause hospitalisation (RR 0.94, 95% CI 0.88 to 1.02; 2 studies, 1340 participants; moderate certainty evidence; 2-year NNTB 101) and may not reduce cardiovascular mortality (RR 0.64, 95% CI 0.35 to 1.19; 5 studies, 4564 participants; low certainty evidence; 6-year NNTB 86) compared to usual care. Organised AF clinical services reduce cardiovascular hospitalisation (RR 0.83, 95% CI 0.71 to 0.96; 3 studies, 3641 participants; high certainty evidence; 6-year NNTB 28) compared to usual care. Organised AF clinical services may have little to no effect on thromboembolic complications such as stroke (RR 1.14, 95% CI 0.74 to 1.77; 5 studies, 4653 participants; low certainty evidence; 6-year NNTB 588) and major cerebrovascular bleeding events (RR 1.25, 95% CI 0.79 to 1.97; 3 studies, 2964 participants; low certainty evidence; 6-year NNTB 556). None of the studies reported minor cerebrovascular events.

AUTHORS' CONCLUSIONS

Moderate certainty evidence shows that organisation of clinical services for AF likely results in a large reduction in all-cause mortality, but probably makes little to no difference to all-cause hospitalisation compared to usual care. Organised AF clinical services may not reduce cardiovascular mortality, but do reduce cardiovascular hospitalisation compared to usual care. However, organised AF clinical services may make little to no difference to thromboembolic complications and major cerebrovascular events. None of the studies reported minor cerebrovascular events. Due to the limited number of studies, more research is required to compare different models of care organisation, including utilisation of mHealth. Appropriately powered trials are needed to confirm these findings and robustly examine the effect on inconclusive outcomes. The findings of this review underscore the importance of the co-ordination of care underpinned by collaborative multidisciplinary approaches and augmented by virtual care.

Detection of atrial fibrillation using a nonlinear Lorenz Scattergram and deep learning in primary care

BACKGROUND

Atrial fibrillation (AF) is highly correlated with heart failure, stroke and death. Screening increases AF detection and facilitates the early adoption of comprehensive intervention. Long-term wearable devices have become increasingly popular for AF screening in primary care. However, interpreting data obtained by long-term wearable ECG devices is a problem in primary care. To diagnose the disease quickly and accurately, we aimed to build AF episode detection model based on a nonlinear Lorenz scattergram (LS) and deep learning.

METHODS

The MIT-BIH Normal Sinus Rhythm Database, MIT-BIH Arrhythmia Database and the Long-Term AF Database were extracted to construct the MIT-BIH Ambulatory Electrocardiograph (MIT-BIH AE) dataset. We converted the long-term ECG into a two-dimensional LSs. The LSs from MIT-BIH AE dataset was randomly divided into training and internal validation sets in a 9:1 ratio, which was used to develop and internally validated model. We built a MOBILE-SCREEN-AF (MS-AF) dataset from a single-lead wearable ECG device in primary care for external validation. Performance was quantified using a confusion matrix and standard classification metrics.

RESULTS

During the evaluation of model performance based on the LS, the sensitivity, specificity and accuracy of the model in diagnosing AF were 0.992, 0.973, and 0.983 in the internal validation set respectively. In the external validation set, these metrics were 0.989, 0.956, and 0.967, respectively. Furthermore, when evaluating the model's performance based on ECG records in the MS-AF dataset, the sensitivity, specificity and accuracy of model diagnosis paroxysmal AF were 1.000, 0.870 and 0.876 respectively, and 0.927, 1.000 and 0.973 for the persistent AF.

CONCLUSIONS

The model based on the nonlinear LS and deep learning has high accuracy, making it promising for AF screening in primary care. It has potential for generalization and practical application.

Assessing adherence to treatment guidelines and complications among atrial fibrillation patients in the United Arab Emirates

Background

Atrial fibrillation (AF), a potential trigger for stroke development, is considered a modifiable condition that can halt complications, decrease mortality, and prevent morbidity. The CHA₂DS₂-VASc and HAS-BLED scores are categorized as risk assessment tools used to estimate the risk of thrombosis development and assess major bleeding among atrial fibrillation patients.

Objectives

Our study aims to assess the adherence to post-discharge treatment recommendations according to CHA₂DS₂-VASc score risk group and evaluate the impact of CHA₂DS₂-VASc score and HAS-BLED score risk categories on death, length of hospital stay, complications, and hospital readmission among United Arab Emirates (UAE) patients.

Methods

This was a multicenter retrospective study conducted from November 2022 to April 2023 in the United Arab Emirates. Medical charts for AF patients were assessed for possible enrolment in the study.

Results

A total number of 400 patients were included with a mean age of 55 (±14.5) years. The majority were females (67.8%), and most had high CHA₂DS₂-VASc and HAS-BLED scores (60% and 57.3%, respectively). Our study showed that adherence to treatment recommendations upon discharge was 71.8%. The bivariate analysis showed that patients with a high CHA₂DS₂-VASc score had a significantly higher risk of death (p-value of 0.001), hospital readmission (p-value of 0.007), and complications (p-value of 0.044) vs. the low and moderate risk group with a p-value of <0.05. Furthermore, our findings showed that the risk of death (0.001), complications (0.057), and mean hospital stay (0.003) were significantly higher in the high HAS-BLED risk score compared to both the low- and moderate-risk categories. Hospital stay was significantly higher in CHA₂DS₂-VASc and HAS-BLED high-risk score categories compared to the low-risk score category with a p-value of <0.001.

Conclusion

Our study concluded that the adherence to treatment guidelines in atrial fibrillation patients was high and showed that patients received the most effective and patient-centered treatment. In addition, our study concluded that the risk of complications and mortality was higher in high-risk category patients.

Assessing the impact of atrial fibrillation self-care interventions: A systematic review

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population.

Association between types of antihypertensive medication and the risk of atrial fibrillation: a nationwide population study

Background

Patients with hypertension are at a high risk of atrial fibrillation (AF). Recent research has indicated the varying effects of antihypertensive medications on developing AF.

Objectives

We investigated the relationship between different types of antihypertensive medications and the risk of AF occurrence.

Methods

We analyzed data from 113,582 subjects with national health screening examinations between 2009 and 2014. The study population was categorized according to antihypertensive medication type. The primary outcome was the incidence of AF.

Results

Among 113,582 subjects (mean age 59.4 ± 12.0 years, 46.7% men), 93,557 received monotherapy [angiotensin receptor blockers (ARB), angiotensin-converting enzyme inhibitors (ACEi), beta-blockers, calcium channel blockers (CCB), or diuretics], while 34,590 received combination therapy (ARB/beta-blockers, ARB/CCB, ARB/diuretics, or ARB/CCB/diuretics). During a mean follow-up duration of 7.6 ± 2.1 years, 3.9% of patients were newly diagnosed with AF. In monotherapy, ACEi and CCB had similar AF risks as ARB, while beta-blockers and diuretics showed higher AF risks than ARB. In combination therapy, ARBs/CCBs and ARBs/diuretics had the lowest AF risk, whereas ARBs/beta-blockers had the highest compared to ARB/CCB. Among the specific ARBs, the AF risk varied insignificantly, except for telmisartan and candesartan.

Conclusions

In hypertensive patients receiving monotherapy, ACEi and CCB showed a similar AF risk as ARBs, while beta-blockers and diuretics were associated with a higher risk. Among those receiving combination therapy, ARBs/CCBs and ARBs/diuretics had the lowest AF risk, whereas ARBs/beta-blockers showed the highest risk. Various types of ARBs have different associations with AF risk.

Identification of Plasmatic MicroRNA-206 as New Predictor of Early Recurrence of Atrial Fibrillation After Catheter Ablation Using Next-generation Sequencing

BACKGROUND

Catheter ablation (CA) of atrial fibrillation (AF) is indicated in patients with recurrent and symptomatic AF episodes. Despite the strict inclusion/exclusion criteria, AF recurrence after CA remains high. Identification of a novel biomarker that would predict AF recurrence would help to stratify the patients. The aim of the study was to seek novel biomarkers among the plasmatic microRNAs (miRNAs, miRs).

METHODS

A prospective monocentric study was conducted. A total of 49 consecutive AF patients indicated for CA were included. Blood sampling was performed prior to CA. RNA was isolated from plasma using commercial kits. In the exploration phase, small RNA sequencing was performed in ten AF patients (five with and five without AF recurrence) using Illumina instrument. In the validation phase, levels of selected miRNAs were determined using quantitative reverse transcription polymerase chain reaction (qRT-PCR) in all participants.

RESULTS

Altogether, 22 miRNAs were identified as altered between the groups by next-generation sequencing (using the DESeq2 algorithm). Using qRT-PCR, levels of the five most altered miRNAs (miR-190b/206/326/505-5p/1296-5p) were verified in the whole cohort. Plasma levels of hsa-miR-206 were significantly higher in patients with early (within 6 months) AF recurrence and showed an increase of risk recurrence,2.65 times by every increase in its level by 1 unit in the binary logistic regression.

CONCLUSION

We have identified a set of 22 plasmatic miRNAs that differ between the patients with and without AF recurrence after CA and confirmed hsa-miR-206 as a novel miRNA associated with early AF recurrence. Results shall be verified in a larger independent cohort.

Atypical Antiadrenergic Effect of Refralon as a Mechanism of High Antiarrhythmic Effectiveness

We studied the effect of Refralon on the electrophysiological properties of the supraventricular myocardium against the background of adrenergic (epinephrine) influence in the zone of the pulmonary veins, the area where 50-90% of atrial arrhythmias is triggered. The experiments were carried out on isolated tissue preparations of Wistar rats. The multichannel microelectrode array technique was used to record action potentials simultaneously in the atrium and in the ostium and distal parts of the pulmonary veins. Epinephrine application (12-50 nM) led to depolarization of the resting potential and the conduction block in the distal part of the pulmonary veins. Refralon (30 μg/kg) restored the resting potential in the distal part of the pulmonary veins. Against the background of epinephrine, Refralon did not significantly change the duration of the action potential at 90% repolarization in comparison with control. At the same time, the comparison drug E-4031 against the background of epinephrine significantly increased the duration of action potential in the atrium and in the ostium of the pulmonary veins, and sotalol increased it only in the ostium. Neither E-4031, nor sotalol restored conduction in their distal part. Refralon has a biphasic effect under conditions of adrenergic stimulation: the fast component is responsible for stabilizing the resting potential in the pulmonary vein and reduces the dispersion of action potential duration in the atrium and pulmonary vein and is also quickly washed away, and the slow component is responsible for the increase of the action potential duration and is slowly washed away.

Digital recruitment and compliance to treatment recommendations in the Norwegian Atrial Fibrillation self-screening pilot study

Aims

Atrial fibrillation (AF) is prevalent, undiagnosed in approximately one-third of cases, and is associated with severe complications. Guidelines recommend screening individuals at increased risk of stroke. This report evaluated the digital recruitment procedure and compliance with the follow-up recommendations in participants with screen-detected AF in the Norwegian Atrial Fibrillation self-screening pilot study.

Methods and results

Norwegians ≥65 years were invited through Facebooks posts, web pages, and newspapers to participate in the study. Targeted Facebook posts promoted over 11 days reached 84 208 users and 10 582 visitors to the study homepage. This accounted for 51% of the total homepage visitors (n = 20 704). A total of 2118 (10%) of the homepage visitors provided digital consent to participate after they met the inclusion criteria. The mean (standard deviation) age of the participants was 70 (4) years, and the majority [n = 1569 (74%)] were women. A total of 1849 (87%) participants completed the electrocardiogram self-screening test, identifying AF in 41 (2.2%) individuals. Of these, 39 (95%) participants consulted a general practitioner, and 34 (83%) participants initiated anticoagulation therapy.

Conclusion

Digital recruitment and inclusion in digital AF screening with a high rate of initiation of anticoagulation therapy in AF positive screening cases are feasible. However, digital recruitment and inclusion may introduce selection bias with regard to age and gender. Larger studies are needed to determine the efficacy and cost-effectiveness of a fully digital AF screening.

Trial registration

Clinical trials: NCT04700865.

Pulmonary Vein Isolation With or Without Left Atrial Appendage Ligation in Atrial Fibrillation: The aMAZE Randomized Clinical Trial

Importance

Left atrial appendage elimination may improve catheter ablation outcomes for atrial fibrillation.

Objective

To assess the safety and effectiveness of percutaneous left atrial appendage ligation adjunctive to catheter pulmonary vein isolation for nonparoxysmal atrial fibrillation.

Design, Setting, and Participants

This multicenter, prospective, open-label, randomized clinical trial evaluated the safety and effectiveness of percutaneous left atrial appendage ligation adjunctive to planned pulmonary vein isolation for nonparoxysmal atrial fibrillation present for less than 3 years. Eligible patients were randomized in a 2:1 ratio to undergo left atrial appendage ligation and pulmonary vein isolation or pulmonary vein isolation alone. Use of a 2:1 randomization ratio was intended to provide more device experience and safety data. Patients were enrolled from October 2015 to December 2019 at 53 US sites, with the final follow-up visit on April 21, 2021.

Interventions

Left atrial appendage ligation plus pulmonary vein isolation compared with pulmonary vein isolation alone.

Main Outcomes and Measures

A bayesian adaptive analysis was used for primary end points. Primary effectiveness was freedom from documented atrial arrythmias of greater than 30 seconds duration 12 months after undergoing pulmonary vein isolation. Rhythm was assessed by Holter monitoring at 6 and 12 months after pulmonary vein isolation, symptomatic event monitoring, or any electrocardiographic tracing obtained through 12 months after pulmonary vein isolation. Primary safety was a composite of predefined serious adverse events compared with a prespecified 10% performance goal 30 days after the procedure. Left atrial appendage closure was evaluated through 12 months after pulmonary vein isolation.

Results

Overall, 404 patients were randomized to undergo left atrial appendage ligation plus pulmonary vein isolation and 206 were randomized to undergo pulmonary vein isolation alone. Primary effectiveness was 64.3% with left atrial appendage ligation and pulmonary vein isolation and 59.9% with pulmonary vein isolation only (difference, 4.3% [bayesian 95% credible interval, -4.2% to 13.2%]; posterior superiority probability, 0.835), which did not meet the statistical criterion to establish superiority (0.977). Primary safety was met, with a 30-day serious adverse event rate of 3.4% (bayesian 95% credible interval, 2.0% to 5.0%; posterior probability, 1.0) which was less than the prespecified threshold of 10%. At 12 months after pulmonary vein isolation, complete left atrial appendage closure (0 mm residual communication) was observed in 84% of patients and less than or equal to 5 mm residual communication was observed in 99% of patients.

Conclusions and Relevance

Percutaneous left atrial appendage ligation adjunctive to pulmonary vein isolation did not meet prespecified efficacy criteria for freedom from atrial arrhythmias at 12 months compared with pulmonary vein isolation alone for patients with nonparoxysmal atrial fibrillation, but met prespecified safety criteria and demonstrated high rates of closure at 12 months.

Trial Registration

ClinicalTrials.gov Identifier: NCT02513797.

Predicting Adverse Outcomes Following Catheter Ablation Treatment for Atrial Flutter/Fibrillation

BACKGROUND & AIM

To develop prognostic survival models for predicting adverse outcomes after catheter ablation treatment for non-valvular atrial fibrillation (AF) and/or atrial flutter (AFL).

METHODS

We used a linked dataset including hospital administrative data, prescription medicine claims, emergency department presentations, and death registrations of patients in New South Wales, Australia. The cohort included patients who received catheter ablation for AF and/or AFL. Traditional and deep survival models were trained to predict major bleeding events and a composite of heart failure, stroke, cardiac arrest, and death.

RESULTS

Out of a total of 3,285 patients in the cohort, 177 (5.3%) experienced the composite outcome-heart failure, stroke, cardiac arrest, death-and 167 (5.1%) experienced major bleeding events after catheter ablation treatment. Models predicting the composite outcome had high-risk discrimination accuracy, with the best model having a concordance index >0.79 at the evaluated time horizons. Models for predicting major bleeding events had poor risk discrimination performance, with all models having a concordance index <0.66. The most impactful features for the models predicting higher risk were comorbidities indicative of poor health, older age, and therapies commonly used in sicker patients to treat heart failure and AF and AFL.

DISCUSSION

Diagnosis and medication history did not contain sufficient information for precise risk prediction of experiencing major bleeding events. Predicting the composite outcome yielded promising results, but future research is needed to validate the usefulness of these models in clinical practice.

CONCLUSIONS

Machine learning models for predicting the composite outcome have the potential to enable clinicians to identify and manage high-risk patients following catheter ablation for AF and AFL proactively.

Circulating adipose tissue proteins involved in atrial fibrillation: An explorative scoping review

Obesity increases the risk of atrial fibrillation (AF), potentially through proteins secreted by adipose tissue (AT) that affect atrial electrical and structural remodeling. We aim to give a comprehensive overview of circulating AT proteins involved in inflammation and fibrosis, that are associated with prevalent AF (paroxysmal or persistent) and the risk on developing new-onset AF. These include adipokines, defined as proteins enriched in AT as adiponectin, but also proteins less specific to AT. We systematically performed an explorative search for studies reporting associations between proteins secreted from cells residing in the AT and AF, and additionally assessed the effect of obesity on these proteins by a secondary search. The AT proteins involved in inflammation were mostly increased in patients with prevalent and new-onset AF, and with obesity, while the AT enriched adipokines were mostly not associated with AF. This review provides insight into circulating adipose tissue proteins involved in AF substrate formation.

Suprastin (Chloropyramine) Causes Proarrhythmic Deterioration of Excitation Conduction, Depolarization and Potentiates Adrenergic Automaticity in the Pulmonary Veins Myocardium

A number of pharmacological drugs have side effects that contribute to the occurrence of atrial fibrillation, the most common type of cardiac rhythm disorders. The clinical use of antihistamines is widespread; however, information regarding their anti- and/or proarrhythmic effects is contradictory. In this work, we studied the effects and mechanisms of the potential proarrhythmic action of the first-generation antihistamine chloropyramine (Suprastin) in the atrial myocardium and pulmonary vein (PV) myocardial tissue. In PV, chloropyramine caused depolarization of the resting potential and led to reduction of excitation wave conduction. These effects are likely due to suppression of the inward rectifier potassium current (IK1). In presence of epinephrine, chloropyramine induced spontaneous automaticity in the PV and could not be suppressed by atrial pacing. Chloropyramine change functional characteristics of PV and contribute to occurrence of atrial fibrillation. It should be noted that chloropyramine does not provoke atrial tachyarrhythmias, but create conditions for their occurrence during physical exercise and sympathetic stimulation.

Screening for Atrial Fibrillation by Digital Health Technology in Older People in Homecare Settings: A Feasibility Trial

Aims

Users of homecare services are often excluded from clinical trials due to advanced age, multimorbidity, and frailty. Atrial fibrillation (AF) is a common and frequently undiagnosed arrhythmia in the elderly and is associated with severe mortality, morbidity, and healthcare costs. Timely identification prevents associated complications through evidence-based treatment. This study is aimed at assessing the feasibility of AF screening using new digital health technology in older people in a homecare setting.

Methods

Users of homecare services ≥ 65 years old with at least one additional risk factor for stroke in two Norwegian municipalities were assessed for study participation by nurses. Participants performed a continuous prolonged ECG recording using a patch ECG device (ECG247 Smart Heart Sensor).

Results

A total of 144 individuals were assessed for study participation, but only 18 (13%) were included. The main reasons for noninclusion were known AF and/or anticoagulation therapy (25%), severe cognitive impairment (26%), and lack of willingness to participate (36%). The mean age of participants performing the ECG test was 81 (SD ± 7) years, and 9 (50%) were women. All ECG tests were interpretable; the mean ECG monitoring time was 104 hours (IQR 34-338 hours). AF was detected in one individual (6%).

Conclusion

This feasibility study highlights the challenges of enrolling older people receiving homecare services in clinical trials. However, all included participants performed an interpretable and prolonged continuous ECG recording with a digital ECG patch device. This trial is registered with NCT04700865.

High Diagnostic Accuracy of Long-Term Electrocardiogram Interpretation by General Practitioners

Aims

Traditional long-term ECG monitoring systems have primarily been used by cardiologist. New remote and wearable easy-to-use devices have led to increased use of ECG recordings also outside cardiology clinics. The aims of this study were to assess the feasibility and diagnostic accuracy of interpretation of the one-lead ECG recordings from a patch ECG device (ECG247 Smart Heart Sensor system) by general practitioners (GP).

Methods

Norwegian GPs were invited to digitally assess 10 long-term ECG recordings with different arrhythmias performed by the ECG247 Smart Heart Sensor system. For all ECG examinations, the presence/absence of different arrhythmias was registered.

Results

A total of 40 GPs accepted the invitation and assessed all the 10 long-term ECG recordings. All the tests were assessed as interpretable by all the GPs. Arrhythmias (atrial fibrillation/flutter, supraventricular tachycardia, and ventricular tachycardia) were correctly identified in most cases, with sensitivity of 98% (95% CI 95-99%), specificity of 75% (95% CI 68-82%), and diagnostic accuracy of 89% (85-92%). Incorrect automatic system algorithm interpretations were rarely corrected by the GPs.

Conclusion

GPs interpreted one-lead recordings by the ECG247 Smart Heart Sensor system with high diagnostic accuracy for common arrhythmias. However, in cases with rare arrhythmias, we recommend consulting a cardiologist to confirm the diagnosis before treatment is initiated. This trial is registered with NCT04700865.

Mediterranean diet and epicardial adipose tissue in patients with atrial fibrillation treated with ablation: a substudy of the 'PREDIMAR' trial

AIMS

To analyse the relationship between Mediterranean diet (MedDiet) adherence and epicardial adipose tissue (EAT) in patients with atrial fibrillation (AF) and the association between EAT or MedDiet adherence at baseline with AF recurrence after ablation.

METHODS AND RESULTS

We included 199 patients from the PREDIMAR trial (PREvención con DIeta Mediterránea de Arritmias Recurrentes), in a single centre in this substudy. All of them had a computed tomography with EAT measurement. Lifestyle and clinical characteristics were obtained at baseline. The traditional MedDiet pattern was defined according to the MedDiet Adherence Screener (MEDAS). Any documented AF > 30 s after ablation was considered a recurrence. Multivariable-adjusted linear and logistic regression models were run to assess the cross-sectional association of MedDiet with EAT, and of EAT with the AF type at baseline. Also, Cox regression models were used to prospectively assess the associations of MedDiet adherence and EAT with AF recurrences after ablation. Median EAT was 135 g (interquartile range: 112-177), and the mean MedDiet score was 7.75 ± 2 points. A higher MEDAS ≥ 7 that was associated with lower odds of an EAT ≥ 135 g [multivariable odds ratio (mOR) = 0.45; 95% CI = 0.22-0.91; P = 0.025] was significantly associated with persistent AF after adjusting for traditional risk factors (mOR: 2.22; 95% CI: 1.03-4.79; P = 0.042). No significant associations were observed between EAT ≥ 135 g and the risk of atrial tachyarrhythmia recurrences after ablation [multivariable-adjusted hazard ratio (mHR) = 1.18; 95% CI: 0.72-1.94; P = 0.512], or between MEDAS ≥ 7 and AF recurrence (mHR = 0.78; 95% CI: 0.47-1.31; P = 0.344).

CONCLUSION

In patients with AF, higher adherence to MedDiet is associated with a significantly lower amount of EAT. Epicardial adipose tissue ≥ 135 g was significantly associated with persistent AF.

Safety and efficacy of percutaneous Watchman 2.5 device versus Amplatzer Amulet for left atrial appendage closure in patients with non-valvular atrial fibrillation: A systematic review and study-level meta-analysis

INTRODUCTION

In patients with non-valvular atrial fibrillation (NVAF), mechanical occlusion of the left atrial appendage (LAA) using a permanently implanted device may be an effective alternative to oral anti-coagulants (OAC). To facilitate left atrial appendage closure (LAAC), multiple percutaneous devices have been proposed. Watchman Generation 2.5 and Amplatzer Amulet are the two most popular used devices for preventing stroke in patients with NVAF. We sought to compare safety and efficacy outcomes between Watchman 2.5 and Amplatzer Amulet in patients undergoing LAAC procedure.

METHODS

We carried out a comprehensive and systematic search of the databases PubMed and Scopus, for all studies that compared the safety and efficacy of Watchman 2.5 and Amplatzer Amulet devices, from inception, till June 2023. We performed the statistical analysis using Review Manager (V.5.4.1 Cochrane Collaboration, London, United Kingdom). The safety outcomes of interest included device success, device-related thrombus, device embolization perioperatively and at follow-up, perioperative pericardial perfusion events, and perioperative cardiac tamponade events. Efficacy outcomes were all-cause mortality perioperatively and at follow-up, cardiovascular (CV) mortality at follow-up, stroke, major and minor bleeding events at follow-up, transient ischemic attack (TIA) in follow-up period, thromboembolic events in follow-up period, and peri-device leakage in perioperative period. All data was analysed using a random-effects model, and presented as risk ratios (RRs) with 95% confidence intervals (95%CIs).

RESULTS

Regarding safety outcomes, device success was non-significantly reduced in Watchman group when compared with Amulet (RR 0.99, p = 0.57; I2 = 34%). In contrast, device-related thrombus was non-significantly increased in Watchman 2.5 group in comparison to Amulet (RR 1.44, p = 0.11; I2 = 0%). There was no significant difference between the devices in terms of device embolization in the perioperative (RR 0.36, p = 0.38; I2 = 22%) and follow-up (RR 2.24, p = 0.13; I2 = 0%) periods. Likewise, there was no significant difference in the risks of pericardial effusion (RR 0.98, p = 0.98; I2 = 0%), and cardiac tamponade (RR 0.65, p = 0.76; I2 = 62%) perioperatively. Regarding efficacy outcomes, no significant difference was observed in all-cause mortality between devices perioperatively (RR 0.51, p = 0.32; I2 = 0%) and at follow-up (RR 1.08, p = 0.56; I2 = 0%). CV-mortality was non-significantly reduced in Watchman group when compared with Amulet (RR 0.57, p = 0.20; I2 = 0%). The Amulet device was not superior to the Watchman device in terms of stroke at follow-up (RR 1.13, p = 0.63; I2 = 0%). Sub-group analysis showed comparable ischaemic and haemorrhagic stroke events between two devices. Furthermore, at follow-up, there was no significant difference in major (RR 1.06, p = 0.63; I2 = 0%) and minor bleeding events (RR 1.81, p = 0.17; I2 = 0%) between the two devices. No difference was observed for trans-ischemic attack (RR 1.89, p = 0.24; I2 = 0%) and thromboembolic events (RR 0.96, p = 0.96; I2 = 0%) at follow-up. No significant difference was observed between devices for peri-device leakage in perioperative period (RR 2.16, p = 0.05; I2 = 0%).

CONCLUSION

The data suggested that LAAC is safe and efficacious procedure irrespective of device used, with generally low complication rates. Watchman generation 2.5 remains non-superior to Amplatzer Amulet in terms of safety and efficacy outcomes.

The Association between Diagnosis-to-Ablation Time and the Recurrence of Atrial Fibrillation: A Retrospective Cohort Study

BACKGROUND

Catheter ablation (CA) for atrial fibrillation (AF) is superior to antiarrhythmic drugs in maintaining sinus rhythm. Novel evidence suggests that increasing the time between the first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), is a predictor for AF recurrence post-ablation.

PURPOSE

Our primary objective was to investigate the relationship between DAT and AF recurrence after a first ablation.

METHODS

Patients with AF who underwent CA in our center were enrolled consecutively, and a retrospective analysis was performed. DAT was treated as a continuous variable and reported as a median for the group with recurrence and the group without recurrence. DAT was also considered as a categorical variable and patients were stratified into three categories: DAT < 1 year, DAT < 2 years, and DAT < 4 years.

RESULTS

The cohort included 107 patients, with a mean age of 54.3 ± 11.7 years. Mean DAT was significantly longer in those with AF recurrence: 4.9(3.06) years versus 3.99(3.5) (p = 0.04). The Kaplan-Meier curve revealed a higher likelihood of AF-free status over time for patients with DAT < 2 years compared to those with DAT > 2 years (p = 0.04). Cox multivariate analysis indicated that left atrial volume index (LAVI), obstructive sleep apnoea (OSA), and DAT > 2 years were independently associated with AF recurrence after a single AF ablation procedure (p = 0.007, p = 0.02, and p = 0.03, respectively).

CONCLUSION

A shorter duration between the first AF diagnosis and AF ablation is associated with an increased likelihood of procedural success after a single AF ablation procedure.

Paroxysmal atrial fibrillation and hemochromatosis: a narrative review

Paroxysmal atrial fibrillation (PAF) and hemochromatosis have a complex relationship. This review explores its mechanisms, prevalence, correlations, and clinical manifestations. Hereditary hemochromatosis (HH) involves iron overload due to HFE protein mutations, while atrial fibrillation (AF) is characterized by irregular heart rhythms. Iron overload in hemochromatosis can promote cardiac arrhythmias. AF is prevalent in developed countries and may be linked to cryptogenic strokes. Genetic variations and demographic factors influence the occurrence of both conditions. HH affects multiple organ systems, including the heart, while AF causes palpitations and reduced exercise tolerance. Diagnosis involves iron markers, genotypic testing, and electrocardiogram (ECG) findings. Treatment strategies focus on reducing iron levels in hemochromatosis and managing AF through antithrombotic therapy and rhythm control. Untreated hemochromatosis carries a higher risk of complications, and PAF is associated with increased cardiovascular-related mortality. For better understanding of the mechanisms and to improve management, additional studies are required. Tailored approaches and combined treatments may enhance patient outcomes.

Characteristics and Outcomes of Atrial Fibrillation in Chronic Heart Failure Patients: A Comprehensive Analysis of the Colombian Heart Failure Registry

Background

Heart failure (HF) and atrial fibrillation (AF) represent conditions that commonly coexist. The impact of AF in HF has yet to be well studied in Latin America. This study aimed to characterize the sociodemographic and clinical features, along with patients' outcomes with AF and HF from the Colombian Heart Failure Registry (RECOLFACA).

Methods

Patients with ambulatory HF and AF were included in RECOLFACA, mainly with persistent or permanent AF. A 6-month follow-up was performed. Primary outcome was all-cause mortality. To assess the impact of AF on mortality, we used a logistic regression model. A P value of < 0.05 was considered significant. All statistical tests were two-tailed.

Results

Of 2,528 patients with HF in the registry, 2,514 records included information regarding AF diagnosis. Five hundred sixty (22.3%) were in AF (mean age 73 ± 11, 56% men), while 1,954 had no AF (mean age 66 ± 14 years, 58% men). Patients with AF were significantly older and had a different profile of comorbidities and implanted devices compared to non-AF patients. Moreover, AF diagnosis was associated with lower quality of life score (EuroQol-5D), mainly in mobility, personal care, and daily activity. AF was prevalent in patients with preserved ejection fraction (EF), while no significant differences in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were observed. Although higher mortality was observed in the AF group compared to individuals without AF (8.9% vs. 6.1%, respectively; P = 0.016), this association lost statistical significance after adjusting by age in a multivariate regression model (odds ratio (OR): 1.35; 95% confidence interval (CI): 0.95 - 1.92).

Conclusions

AF is more prevalent in HF patients with higher EF, lower quality of life and different clinical profiles. Similar HF severity and non-independent association with mortality were observed in our cohort. These results emphasize the need for an improved understanding of the AF and HF coexistence phenomenon.

Sex Differences in High-Cost Users of Healthcare for Atrial Fibrillation

Background

Healthcare resource use for atrial fibrillation (AF) is high, but it may not be equivalent across all patients. We examined whether sex differences exist for AF high-cost users (HCUs), who account for the top 10% of total acute care costs.

Methods

All patients aged ≥ 20 years who presented to the emergency department (ED) or were hospitalized with AF were identified in Alberta, Canada, between 2011 and 2015. The cohort was categorized by sex into HCUs and non-HCUs. Healthcare utilization was defined as ED, hospital, and physician visits, and costs included those for hospitalization, ambulatory care, physician billing, and drugs. All costs were inflated to 2022 Canadian dollars (CAD$).

Results

Among 48,030 AF patients, 45.1% were female. Of these, 31.8% were HCUs, and the proportions of female and male patients were equal (31.9% vs 31.7%). Female HCUs were older, more likely to have hypertension and heart failure, and had a higher stroke risk than male HCUs. Mean healthcare utilization did not differ among HCUs by sex, except for number of ED visits, which was higher in male patients (12.7% vs 9.2%, P < 0.0001). Overall, HCUs accounted for 65.8% of the total costs (CAD$3.4 billion). Almost half of total HCU costs were attributable to female HCUs (CAD$966.1 million). Significant differences were present in the distributions of HCU-related costs (male patients: 74.6% hospitalization, 9.5% ambulatory care, 12.4% physician billing, 3.5% drugs; female patients: 77.7% hospitalization, 7.4% ambulatory care, 11.5% physician billing, 3.5% drugs, P < 0.0001).

Conclusions

Despite having a lower AF prevalence, female patients represent an equal proportion of HCUs, and account for almost half the total HCU costs. Interventions targeted at reducing the number of AF HCU are needed, particularly for female patients.

The association between asthma and atrial fibrillation: systematic review and meta-analysis

Respiratory disease and atrial fibrillation (AF) frequent coexist, but the risk of AF among asthma patients is less characterized. Growing evidence suggest that AF shares with asthma a systemic inflammation background and asthma treatments, such as beta agonists, have been associated with increased risk of cardiac arrhythmias. The aim of this systematic review was to assess the risk of AF in patients with asthma in observational studies. We search for longitudinal studies reporting AF outcome in asthma and control patients through MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE. Pooled estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were derived by random effects meta-analysis. Heterogeneity was assessed using the I2 test. The risk of bias of individual studies was evaluated using the ROBINS-E tool. The study protocol was registered at PROSPERO: CRD42020215707. Seven cohort/nested case-control studies with 1 405 508 individuals were included. The mean follow-up time was 9 years, ranging from 1 to 15 years. Asthma was associated with a higher risk of AF (OR 1.15. 95% CI 1.01-1.29). High heterogeneity (I2 = 81%) and overall "serious" risk of bias, lead to a very low confidence in in this result. Asthma was associated with an increased risk of AF. However, the high risk of bias and high heterogeneity reduces the robustness of these results, calling for further high-quality data.

Comparing the Efficacy of Targeted and Blast Portal Messaging in Message Opening Rate and Anticoagulation Initiation in Patients With Atrial Fibrillation in the Preventing Preventable Strokes Study II: Prospective Cohort Study

BACKGROUND

The gap in anticoagulation use among patients with atrial fibrillation (AF) is a major public health threat. Inadequate patient education contributes to this gap. Patient portal-based messaging linked to educational materials may help bridge this gap, but the most effective messaging approach is unknown.

OBJECTIVE

This study aims to compare the responsiveness of patients with AF to an AF or anticoagulation educational message between 2 portal messaging approaches: sending messages targeted at patients with upcoming outpatient appointments 1 week before their scheduled appointment (targeted) versus sending messages to all eligible patients in 1 blast, regardless of appointment scheduling status (blast), at 2 different health systems: the University of Massachusetts Chan Medical School (UMass) and the University of Florida College of Medicine-Jacksonville (UFL).

METHODS

Using the 2 approaches, we sent patient portal messages to patients with AF and grouped patients by high-risk patients on anticoagulation (group 1), high-risk patients off anticoagulation (group 2), and low-risk patients who may become eligible for anticoagulation in the future (group 3). Risk was classified based on the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age between 65 and 74 years, and sex category (CHA2DS2-VASc) score. The messages contained a link to the Upbeat website of the Heart Rhythm Society, which displays print and video materials about AF and anticoagulation. We then tracked message opening, review of the website, anticoagulation use, and administered patient surveys across messaging approaches and sites using Epic Systems (Epic Systems Corporation) electronic health record data and Google website traffic analytics. We then conducted chi-square tests to compare potential differences in the proportion of patients opening messages and other evaluation metrics, adjusting for potential confounders. All statistical analyses were performed in SAS (version 9.4; SAS Institute).

RESULTS

We sent 1686 targeted messages and 1450 blast messages. Message opening was significantly higher with the targeted approach for patients on anticoagulation (723/1156, 62.5% vs 382/668, 57.2%; P=.005) and trended the same in patients off anticoagulation; subsequent website reviews did not differ by messaging approach. More patients off anticoagulation at baseline started anticoagulation with the targeted approach than the blast approach (adjusted percentage 9.3% vs 2.1%; P<.001).

CONCLUSIONS

Patients were more responsive in terms of message opening and subsequent anticoagulation initiation with the targeted approach.

First Experience With Amulet in the United States: Early Insights From EMERGE LAA Postapproval Study

BACKGROUND

The Food and Drug Administration approved the Amulet occluder (Abbott) after demonstrating safety and effectiveness in the Amulet IDE (AMPLATZER Amulet LAA Occluder) trial.

OBJECTIVES

The aim of the EMERGE Left Atrial Appendage study is to evaluate early postapproval outcomes of the Amulet occluder in the United States using data from the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry.

METHODS

Patients with a commercial Amulet occluder implant attempt between Food and Drug Administration approval (August 14, 2021) and December 31, 2022, were included. The safety composite endpoint included all-cause death, ischemic stroke, systemic embolism, or device/procedure-related events requiring open cardiac surgery or endovascular intervention between device implantation and 7 days or hospital discharge (whichever is later). Major adverse events through 45 days were also reported and stratified by operator experience (early [<10 cases], moderate [10-29 cases], and high [30+ cases]).

RESULTS

A total of 5,499 patients underwent attempted Amulet occluder implantation. Implant success was 95.8%, and complete closure was 97.2% post-left atrial appendage occlusion and 87.1% at 45 days. A safety composite endpoint event occurred in 0.76% patients. Any major adverse event occurred in 2.9% and 5.7% of patients in-hospital and through 45 days, respectively, driven by major bleeding and pericardial effusion (PE) requiring intervention. PE requiring surgery or percutaneous intervention decreased significantly with increasing experience both in-hospital (early vs high operator experience 1.8% vs 1.1%; P = 0.006) and at 45 days (2.3% vs 1.5%; P = 0.012).

CONCLUSIONS

The EMERGE Left Atrial Appendage study demonstrates favorable safety and effectiveness of the Amulet occluder in the real-world setting. More experienced operators had improved implant success and fewer PEs, suggesting a learning curve effect implanting this dual occlusive mechanism device.

Genetically predicted waist circumference and risk of atrial fibrillation

INTRODUCTION

Observational studies have revealed an association between waist circumference (WC) and atrial fibrillation (AF). However, it is difficult to infer a causal relationship from observational studies because the observed associations could be confounded by unknown risk factors. Therefore, the causal role of WC in AF is unclear. This study was designed to investigate the causal association between WC and AF using a two-sample Mendelian randomization (MR) analysis.

METHODS

In our two-sample MR analysis, the genetic variation used as an instrumental variable for MR was acquired from a genome-wide association study (GWAS) of WC (42 single nucleotide polymorphisms with a genetic significance of P <5 × 10 -8 ). The data of WC (from the Genetic Investigation of ANthropometric Traits consortium, containing 232,101 participants) and the data of AF (from the European Bioinformatics Institute database, containing 55,114 AF cases and 482,295 controls) were used to assess the causal role of WC on AF. Three different approaches (inverse variance weighted [IVW], MR-Egger, and weighted median regression) were used to ensure that our results more reliable.

RESULTS

All three MR analyses provided evidence of a positive causal association between high WC and AF. High WC was suggested to increase the risk of AF based on the IVW method (odds ratio [OR] = 1.43, 95% confidence interval [CI], 1.30-1.58, P = 2.51 × 10 -13 ). The results of MR-Egger and weighted median regression exhibited similar trends (MR-Egger OR = 1.40 [95% CI, 1.08-1.81], P = 1.61 × 10 -2 ; weighted median OR = 1.39 [95% CI, 1.21-1.61], P = 1.62 × 10 -6 ). MR-Egger intercepts and funnel plots showed no directional pleiotropic effects between high WC and AF.

CONCLUSIONS

Our findings suggest that greater WC is associated with an increased risk of AF. Taking measures to reduce WC may help prevent the occurrence of AF.

Exercise and Atrial Fibrillation: The Dose Makes the Poison? A Narrative Review

"All things are poison, and nothing is without poison; the dosage alone makes it so a thing is not a poison" (Paracelsus, ~ 1538 AD). This well-known quote seems to aptly summarize the current understanding of the interaction between exercise and atrial fibrillation (AF). A host of data strongly suggests that regular exercise has a protective effect against developing AF. A small but well-conducted group of trials also demonstrates beneficial effects of exercise in the treatment of AF. Recently, however, potentially detrimental effects of large volumes of high-intensity exercise on the probability of developing AF have moved into the sports-cardiological focus. This effect is well documented for elite athletes; data regarding the general population is less clear. This review presents the current data regarding the protective, therapeutic and potentially risk-enhancing effects of exercise regarding AF. The authors demonstrate that the benefits are clear and strongly outweigh the potential disadvantages.

Emergency medicine updates: Atrial fibrillation with rapid ventricular response

INTRODUCTION

Atrial fibrillation (AF) may lead to stroke, heart failure, and death. When AF occurs in the context of a rapid ventricular rate/response (RVR), this can lead to complications, including hypoperfusion and cardiac ischemia. Emergency physicians play a key role in the diagnosis and management of this dysrhythmia.

OBJECTIVE

This paper evaluates key evidence-based updates concerning AF with RVR for the emergency clinician.

DISCUSSION

Differentiating primary and secondary AF with RVR and evaluating hemodynamic stability are vital components of ED assessment and management. Troponin can assist in determining the risk of adverse outcomes, but universal troponin testing is not required in patients at low risk of acute coronary syndrome or coronary artery disease - especially patients with recurrent episodes of paroxysmal AF that are similar to their prior events. Emergent cardioversion is indicated in hemodynamically unstable patients. Rate or rhythm control should be pursued in hemodynamically stable patients. Elective cardioversion is a safe option for select patients and may reduce AF symptoms and risk of AF recurrence. Rate control using beta blockers or calcium channel blockers should be pursued in those with AF with RVR who do not undergo cardioversion. Anticoagulation is an important component of management, and several tools (e.g., CHA2DS2-VASc) are available to assist with this decision. Direct oral anticoagulants are the first-line medication class for anticoagulation. Disposition can be challenging, and several risk assessment tools (e.g., RED-AF, AFFORD, and the AFTER (complex, modified, and pragmatic) scores) are available to assist with disposition decisions.

CONCLUSION

An understanding of the recent updates in the literature concerning AF with RVR can assist emergency clinicians in the care of these patients.

Relationship of health-related social needs and hospital readmissions in patients following a hospitalization for atrial fibrillation

Atrial fibrillation (AF) has a high economic burden on the healthcare system with rehospitalizations as the most significant contributing factor necessitating an understanding of aspects related to hospitalizations to minimize economic costs and improve patient outcomes. Our study aims to assess whether all-cause 30-day hospital readmission following AF-specific hospitalization is associated with health-related social needs (HRSN) using the Nationwide Readmissions Database (NRD). All hospitalization data were abstracted from the 2015-2019 NRD, including hospitalizations for patients at least 18 years of age with a primary discharge diagnosis of AF. For each hospitalization, we identified secondary diagnoses for five HRSN domains including employment, family, housing, psychosocial, and socioeconomic status. Primary outcomes included all-cause 30-day readmission rates. Secondary outcomes included all-cause 90-day readmissions and diagnosis on readmissions. An estimated 1,807,460 index hospitalizations in the United States included a primary discharge diagnosis of AF. Of these, 97.3 % included a diagnosis in only one HRSN domain with the most frequently diagnosed HRSN domain being housing (54.5 %) followed by socioeconomic (29.4 %), family (10.0 %), employment (6.1 %), and psychosocial (2.8 %). Index hospitalizations that included any HRSN diagnosis had 2.2-times greater unadjusted odds of all-cause 30-day readmission (95 % CI: 2.1 to 2.3-times greater, p < .001). Index hospitalizations that included an HRSN diagnosis were associated with higher rates of 90-day readmission due to conduction disorder and COPD. In conclusion, there is a significant association between HRSN and hospital readmissions in patients with AF. Further research is required to explain the true nature of this relationship with a specific emphasis on housing insecurity.

DAPT Is Comparable to OAC Following LAAC With WATCHMAN FLX: A National Registry Analysis

BACKGROUND

Left atrial appendage occlusion (LAAO) is an approved alternative for stroke prevention in atrial fibrillation for patients with an "appropriate rationale" to avoid long-term oral anticoagulation (OAC). Many patients undergoing LAAO are at high risk of bleeding.

OBJECTIVES

This study sought to investigate whether dual antiplatelet therapy (DAPT) is a safe alternative to OAC (direct oral anticoagulation [DOAC] or warfarin) with aspirin after LAAO.

METHODS

Using National Cardiovascular Data Registry LAAO registry data, patients undergoing Watchman FLX (Boston Scientific) implantation (August 5, 2020-September 30, 2021) were included in 1:1 propensity-matched analyses comparing discharge medication regimens (DAPT, DOAC/aspirin, or warfarin/aspirin). A composite endpoint (death, stroke, major bleeding, and systemic embolism), its components, and device-related thrombus between discharge and 45 days were evaluated.

RESULTS

In 49,968 patients implanted with the Watchman FLX during the study period, the mean age was 77 years, and 40% were women. Postimplant DOAC/aspirin was prescribed in 24,497 patients, warfarin/aspirin in 3,913, and DAPT in 4,155. DAPT patients had more comorbid conditions than patients receiving OAC/aspirin. After propensity score matching, the 45-day composite endpoint rates were similar among the groups (DAPT = 3.44% vs DOAC/aspirin: 4.06%; P = 0.13 and DAPT = 3.23% vs warfarin/aspirin: 3.08%; P = 0.75). Death, stroke, and device-related thrombus were also similar; major bleeding was slightly increased in DOAC/aspirin patients (DAPT = 2.48% vs DOAC/aspirin = 3.25%; P = 0.04 and DAPT = 2.25% vs warfarin/aspirin = 2.22%; P = 0.93).

CONCLUSIONS

In a large registry, DAPT had a similar safety profile compared with current Food and Drug Administration-approved postimplant drug regimens of OAC with aspirin following LAAO with the Watchman FLX. Shared decision making for nonpharmacologic stroke prevention should include a discussion of postprocedure medical therapy options.

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

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

Phenotyping of atrial fibrillation with cluster analysis and external validation

OBJECTIVES

Atrial fibrillation (AF) is a heterogeneous condition. We performed a cluster analysis in a cohort of patients with AF and assessed the prognostic implication of the identified cluster phenotypes.

METHODS

We used two multicentre, prospective, observational registries of AF: the SAKURA AF registry (Real World Survey of Atrial Fibrillation Patients Treated with Warfarin and Non-vitamin K Antagonist Oral Anticoagulants) (n=3055, derivation cohort) and the RAFFINE registry (Registry of Japanese Patients with Atrial Fibrillation Focused on anticoagulant therapy in New Era) (n=3852, validation cohort). Cluster analysis was performed by the K-prototype method with 14 clinical variables. The endpoints were all-cause mortality and composite cardiovascular events.

RESULTS

The analysis subclassified derivation cohort patients into five clusters. Cluster 1 (n=414, 13.6%) was characterised by younger men with a low prevalence of comorbidities; cluster 2 (n=1003, 32.8%) by a high prevalence of hypertension; cluster 3 (n=517, 16.9%) by older patients without hypertension; cluster 4 (n=652, 21.3%) by the oldest patients, who were mainly female and with a high prevalence of heart failure history; and cluster 5 (n=469, 15.3%) by older patients with high prevalence of diabetes and ischaemic heart disease. During follow-up, the risk of all-cause mortality and composite cardiovascular events increased across clusters (log-rank p<0.001, p<0.001). Similar results were found in the external validation cohort.

CONCLUSIONS

Machine learning-based cluster analysis identified five different phenotypes of AF with unique clinical characteristics and different clinical outcomes. The use of these phenotypes may help identify high-risk patients with AF.

Development and Validation of a Predictive Model Based on LASSO Regression: Predicting the Risk of Early Recurrence of Atrial Fibrillation after Radiofrequency Catheter Ablation

BACKGROUND

Although recurrence rates after radiofrequency catheter ablation (RFCA) in patients with atrial fibrillation (AF) remain high, there are a limited number of novel, high-quality mathematical predictive models that can be used to assess early recurrence after RFCA in patients with AF.

PURPOSE

To identify the preoperative serum biomarkers and clinical characteristics associated with post-RFCA early recurrence of AF and develop a novel risk model based on least absolute shrinkage and selection operator (LASSO) regression to select important variables for predicting the risk of early recurrence of AF after RFCA.

METHODS

This study collected a dataset of 136 atrial fibrillation patients who underwent RFCA for the first time at Peking University Shenzhen Hospital from May 2016 to July 2022. The dataset included clinical characteristics, laboratory results, medication treatments, and other relevant parameters. LASSO regression was performed on 100 cycles of data. Variables present in at least one of the 100 cycles were selected to determine factors associated with the early recurrence of AF. Then, multivariable logistic regression analysis was applied to build a prediction model introducing the predictors selected from the LASSO regression analysis. A nomogram model for early post-RFCA recurrence in AF patients was developed based on visual analysis of the selected variables. Internal validation was conducted using the bootstrap method with 100 resamples. The model's discriminatory ability was determined by calculating the area under the curve (AUC), and calibration analysis and decision curve analysis (DCA) were performed on the model.

RESULTS

In a 3-month follow-up of AF patients (n = 136) who underwent RFCA, there were 47 recurrences of and 89 non-recurrences of AF after RFCA. P, PLR, RDW, LDL, and CRI-II were associated with early recurrence of AF after RFCA in patients with AF (p < 0.05). We developed a predictive model using LASSO regression, incorporating four robust factors (PLR, RDW, LDL, CRI-II). The AUC of this prediction model was 0.7248 (95% CI 0.6342-0.8155), and the AUC of the internal validation using the bootstrap method was 0.8403 (95% CI 0.7684-0.9122). The model demonstrated a strong predictive capability, along with favorable calibration and clinical applicability. The Hosmer-Lemeshow test indicated that there was good consistency between the predicted and observed values. Additionally, DCA highlighted the model's advantages in terms of its clinical application.

CONCLUSIONS

We have developed and validated a risk prediction model for the early recurrence of AF after RFCA, demonstrating strong clinical applicability and diagnostic performance. This model plays a crucial role in guiding physicians in preoperative assessment and clinical decision-making. This novel approach also provides physicians with personalized management recommendations.

Trends in treatment and outcomes of atrial fibrillation during 2007-17 in Finland

AIMS

Guidelines on the management of atrial fibrillation (AF) have evolved significantly during the past two decades, but the concurrent developments in real-life management and prognosis of AF are unknown. We assessed trends in the treatment and outcomes of patients with incident AF between 2007 and 2017.

METHODS AND RESULTS

The registry-based nationwide FinACAF (Finnish AntiCoagulation in Atrial Fibrillation) cohort covers all patients with AF in Finland from all levels of care. We determined the proportion of patients who were treated with oral anticoagulants (OACs) or rhythm control therapies, experienced an ischaemic stroke or bleeding event requiring hospitalization, or died within 1-year follow-up after AF diagnosis. We identified 206 909 patients (mean age 72.6 years) with incident AF. During the study period, use of OACs increased from 43.6 to 76.3%, and the increase was most evident in patients with at least moderate stroke risk. One-year mortality decreased from 13.3 to 10.6%, and the ischaemic stroke rate from 5.3 to 2.2%. The prognosis especially improved in patients over 75 years of age. Concurrently, a small increase in major bleeding events was observed. Use of catheter ablation increased continuously over the study period, but use of other rhythm-control therapies decreased after 2013.

CONCLUSION

Stroke prevention with OACs in patients with incident AF improved considerably from 2007 to 2017 in Finland. This development was accompanied by decreasing 1-year mortality and the reduction of the ischaemic stroke rate by more than half, particularly among elderly patients, whereas there was only slight increase in severe bleeding events.