The imminent epidemic of atrial fibrillation and its concomitant diseases - Myocardial infarction and heart failure - A cause for concern

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation incorporate the most recent evidence for surgical ablation and left atrial appendage occlusion in different clinical scenarios. Substantial new evidence regarding the risks and benefits of surgical left atrial appendage occlusion and the long-term benefits of surgical ablation has been produced in the last 5 years. Compared with the 2017 clinical practice guideline, the current update has an emphasis on surgical ablation in first-time, nonemergent cardiac surgery and its long-term benefits, an extension of the recommendation to perform surgical ablation in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery, and a new class I recommendation for left atrial appendage occlusion in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery. Further guidance is provided for patients with structural heart disease and atrial fibrillation being considered for transcatheter valve repair or replacement, as well as patients in need of isolated left atrial appendage management who are not candidates for surgical ablation. The importance of a multidisciplinary team assessment, treatment planning, and long-term follow-up are reiterated in this clinical practice guideline with a class I recommendation, along with the other recommendations from the 2017 guidelines that remained unchanged in their class of recommendation and level of evidence.

The Intersection of Atrial Fibrillation and Coronary Artery Disease in Middle Eastern Patients. Analysis from the Jordan Atrial Fibrillation Study

Background

There is a scarcity of clinical studies which evaluate the association of atrial fibrillation (AF) and coronary artery disease (CAD) in the Middle East. The aim of this study was to evaluate the impact of CAD on baseline clinical profiles and one-year outcomes in a Middle Eastern cohort with AF.

Methods

Consecutive AF patients evaluated in 29 hospitals and cardiology clinics were enrolled in the Jordan AF Study (May 2019-December 2020). Clinical and echocardiographic features, use of medications and one-year outcomes in patients with AF/CAD were compared to AF/no CAD patients.

Results

Of 2020 AF patients enrolled, 216 (10.7%) had CAD. Patients with AF/CAD were more likely to be men and had significantly higher prevalence of hypertension, diabetes, dyslipidemia, heart failure and chronic kidney disease compared to the AF/no CAD patients. They also had lower mean left ventricular ejection fraction and larger left atrial size. Mean CHA2DS2 VASc and HAS-BLED scores were higher in AF/CAD patients than those with AF/no CAD (4.3 ± 1.7 vs. 3.6 ± 1.8, p < 0.0001) and (2.0 ± 1.1 vs. 1.6 ± 1.1, p < 0.0001), respectively. Oral anticoagulant agents were used in similar rates in the two groups (83.8% vs. 82.9%, p = 0.81), but more patients with AF/CAD were prescribed additional antiplatelet agents compared to patients with AF/no CAD (73.7% vs. 41.5%, p < 0.0001). At one year, AF/CAD patients, compared to AF/no CAD patients had significantly higher hospitalization rate (39.4% vs. 29.2%, p = 0.003), more acute coronary syndrome and coronary revascularization (6.9% vs. 2.4%, p = 0.004), and higher all-cause mortality (18.5% vs. 10.9%, p = 0.002).

Conclusions

In this cohort of Middle Eastern patients with AF, one in 10 patients had CAD. The coexistence of AF and CAD was associated with a worse baseline clinical profile and one-year outcomes. Clinical study registration: the study is registered on clinicaltrials.gov (unique identifier number NCT03917992).

Diagnostic yield of a proactive strategy for early detection of cardiovascular disease versus usual care in adults with type 2 diabetes or chronic obstructive pulmonary disease in primary care in the Netherlands (RED-CVD): a multicentre, pragmatic, cluster-randomised, controlled trial

BACKGROUND

Progressive cardiovascular diseases (eg, heart failure, atrial fibrillation, and coronary artery disease) are often diagnosed late in high-risk individuals with common comorbidities that might mimic or mask symptoms, such as chronic obstructive pulmonary disease (COPD) and type 2 diabetes. We aimed to assess whether a proactive diagnostic strategy consisting of a symptom and risk factor questionnaire and low-cost and accessible tests could increase diagnosis of progressive cardiovascular diseases in patients with COPD or type 2 diabetes in primary care.

METHODS

In this multicentre, pragmatic, cluster-randomised, controlled trial (RED-CVD), 25 primary care practices in the Netherlands were randomly assigned to usual care or a proactive diagnostic strategy conducted during routine consultations and consisting of a validated symptom questionnaire, followed by physical examination, N-terminal-pro-B-type natriuretic peptide measurement, and electrocardiography. We included adults (≥18 years) with type 2 diabetes, COPD, or both, who participated in a disease management programme. Patients with an established triple diagnosis of heart failure, atrial fibrillation, and coronary artery disease were excluded. In the case of abnormal findings, further work-up or treatment was done at the discretion of the general practitioner. The primary endpoint was the number of newly diagnosed cases of heart failure, atrial fibrillation, and coronary artery disease, adjudicated by an expert clinical outcome committee using international guidelines, at 1-year follow-up, in the intention-to-treat population.

FINDINGS

Between Jan 31, 2019, and Oct 7, 2021, we randomly assigned 25 primary care centres: 11 to usual care and 14 to the intervention. We included patients between June 21, 2019, and Jan 31, 2022. Following exclusion of ineligible patients and those who did not give informed consent, 1216 participants were included: 624 (51%) in the intervention group and 592 (49%) in the usual care group. The mean age of participants was 68·4 years (SD 9·4), 482 (40%) participants were female, and 734 (60%) were male. During 1 year of follow-up, 50 (8%) of 624 participants in the intervention group and 18 (3%) of 592 in the control group were newly diagnosed with heart failure, atrial fibrillation, or coronary artery disease (adjusted odds ratio 2·97 [95% CI 1·66-5·33]). This trial is registered with the Netherlands Trial Registry, NTR7360, and was completed on Jan 31, 2023.

INTERPRETATION

An easy-to-use, proactive, diagnostic strategy more than doubled the number of new diagnoses of heart failure, atrial fibrillation, and coronary artery disease in patients with type 2 diabetes or COPD in primary care compared with usual care. Although the effect on patient outcomes remains to be studied, our diagnostic strategy might contribute to improved early detection and timely initiation of treatment in individuals with cardiovascular disease.

FUNDING

Dutch Heart Foundation.

Unraveling the Signaling Dynamics of Small Extracellular Vesicles in Cardiac Diseases

Effective intercellular communication is essential for cellular and tissue balance maintenance and response to challenges. Cellular communication methods involve direct cell contact or the release of biological molecules to cover short and long distances. However, a recent discovery in this communication network is the involvement of extracellular vesicles that host biological contents such as proteins, nucleic acids, and lipids, influencing neighboring cells. These extracellular vesicles are found in body fluids; thus, they are considered as potential disease biomarkers. Cardiovascular diseases are significant contributors to global morbidity and mortality, encompassing conditions such as ischemic heart disease, cardiomyopathies, electrical heart diseases, and heart failure. Recent studies reveal the release of extracellular vesicles by cardiovascular cells, influencing normal cardiac function and structure. However, under pathological conditions, extracellular vesicles composition changes, contributing to the development of cardiovascular diseases. Investigating the loading of molecular cargo in these extracellular vesicles is essential for understanding their role in disease development. This review consolidates the latest insights into the role of extracellular vesicles in diagnosis and prognosis of cardiovascular diseases, exploring the potential applications of extracellular vesicles in personalized therapies, shedding light on the evolving landscape of cardiovascular medicine.

Temporal Relation Between Myocardial Infarction and New-Onset Atrial Fibrillation: Results from a Nationwide Registry Study

Myocardial infarction (MI) and atrial fibrillation (AF) are commonly seen in the same patient. In this study, we evaluated the temporal relations and prognosis of MI and AF. This is a substudy of the nationwide registry-based Finnish Anticoagulation in Atrial Fibrillation (FinACAF) study, comprising all Finnish patients with new-onset AF from 2010 to 2017. Patients with MI and AF were divided into groups depending on the temporal relation between the disease onsets: (1) MI before AF (MIAF), and (4) no MI. The 1-year mortality in the groups were studied with the Cox proportional hazards model. Of the 153,207 patients with new-onset AF (mean age 72.7 years, 50.0% women), 16,265 (10.6%) were diagnosed with MI. Altogether, 8,889 (54.7%) of the patients with MI were in the MIAF group. Of all MIs, 42.2% were diagnosed within 1 year from new-onset AF. The MI>AF group had the worst survival, with an adjusted hazard ratio for death of 3.08 (confidence interval [CI] 2.89 to 3.27) compared with patients without MI. For the MI Collapse

Key Words

• atrial fibrillation
• mortality
• myocardial infarction
• real life
• register study
• survival

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MESH Headings

• Humans
• Female
• Aged
• Male
• Atrial Fibrillation/complications
• Atrial Fibrillation/epidemiology
• Atrial Fibrillation/diagnosis
• Risk Factors
• Retrospective Studies
• Myocardial Infarction/complications
• Registries

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Affiliation(s)

Elin Karlsson Faculty of Medicine, University of Helsinki, Helsinki, Finland.
Tuomas Kiviniemi Turku University Hospital, University of Turku, Turku, Finland
Olli Halminen Aalto University, Espoo, Finland
Ossi Lehtonen Aalto University, Espoo, Finland
Konsta Teppo Turku University Hospital, University of Turku, Turku, Finland
Jari Haukka Faculty of Medicine, University of Helsinki, Helsinki, Finland
Pirjo Mustonen Turku University Hospital, University of Turku, Turku, Finland
Jukka Putaala Faculty of Medicine, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Helsinki, Finland
Miika Linna Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
Juha Hartikainen Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
K E Juhani Airaksinen Turku University Hospital, University of Turku, Turku, Finland
Mika Lehto Faculty of Medicine, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Helsinki, Finland; Jorvi Hospital, Department of Internal Medicine, HUS Helsinki University Hospital, Espoo, Finland

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Heart failure in older patients with atrial fibrillation: incidence and risk factors

INTRODUCTION AND OBJECTIVES

Atrial fibrillation (AF) is linked to heart failure (HF). However, little has been published on the factors that may precipitate the onset of HF in AF patients. We aimed to determine the incidence, predictors, and prognosis of incident HF in older patients with AF with no prior history of HF.

METHODS

Patients with AF older than 80 years and without prior HF were identified between 2014 and 2018.

RESULTS

A total of 5794 patients (mean age, 85.2±3.8 years; 63.2% women) were followed up for 3.7 years. Incident HF, predominantly with preserved left ventricular ejection fraction, developed in 33.3% (incidence rate, 11.5-100 people-year). Multivariate analysis identified 11 clinical risk factors for incident HF, irrespective of HF subtype: significant valvular heart disease (HR, 1.99; 95%CI, 1.73-2.28), reduced baseline left ventricular ejection fraction (HR, 1.92; 95%CI, 1.68-2.19), chronic pulmonary obstructive disease (HR, 1.59; 95%CI, 1.40-1.82), enlarged left atrium (HR 1.47, 95%CI 1.33-1.62), renal dysfunction (HR 1.36, 95%CI 1.24-1.49), malnutrition (HR, 1.33; 95%CI, 1.21-1.46), anemia (HR, 1.30; 95%CI, 1.17-1.44), permanent AF (HR, 1.15; 95%CI, 1.03-1.28), diabetes mellitus (HR, 1.13; 95%CI, 1.01-1.27), age per year (HR, 1.04; 95%CI, 1.02-1.05), and high body mass index for each kg/m2 (HR, 1.03; 95%CI, 1.02-1.04). The presence of incident HF nearly doubled the mortality risk (HR, 1.67; 95%CI, 1.53-1.81).

CONCLUSIONS

The presence of HF in this cohort was relatively frequent and nearly doubled the mortality risk. Eleven risk factors for HF were identified, expanding the scope for primary prevention among elderly patients with AF.

Prevalence of Postoperative Atrial Fibrillation and Impact to Nursing Practice—A Cross Sectional Study

Background: Atrial fibrillation is the most common clinically significant cardiac arrhythmia, and it might lead to heart failure, which prolongs the duration of hospitalization and consequently increases the cost of treatment. Thus, diagnosing and treating atrial fibrillation should be the first line of defense against further complications. This study aimed to determine the incidence rate of postoperative atrial fibrillation and correlation with cardiac surgery on heart valves. A specific aim was to determine the relationship between the prevalence of atrial fibrillation and socio-demographic features. Methods: The study has a prospective cross-sectional design. The questionnaire was anonymous, requesting socio-demographic information as inclusion criteria, and the data were analyzed using descriptive statistics methods. Results: The sample was 201 patients. χ2 test and t-test were performed where we found that the frequency of atrial fibrillation was higher in the groups that have had valve surgery compared to other cardiac surgeries (χ2 = 7.695, ss = 2, p = 0.021). Atrial fibrillation increased with the age of the patients, but the prevalence of atrial fibrillation was not correlated with body weight. Conclusion: The results of this this study show that atrial fibrillation was higher in the participants who had valve surgery compared to other cardiac surgeries. There was also an increase in atrial fibrillation in the older participants. The results of this study can help to improve nursing practice and the quality of care for cardiac surgery patients with regard to daily activities, or planning nursing care due to the patient’s condition.

Healthcare Resource Utilization in Patients with Newly Diagnosed Atrial Fibrillation: A Global Analysis from the GARFIELD-AF Registry

The management of atrial fibrillation (AF), the most common sustained arrhythmia, impacts healthcare resource utilization (HCRU). This study aims to estimate global resource use in AF patients, using the GARFIELD-AF registry. A prospective cohort study was conducted to characterize HCRU in AF patients enrolled in sequential cohorts from 2012 to 2016 in 35 countries. Components of HCRU studied were hospital admissions, outpatient care visits, and diagnostic and interventional procedures occurring during follow-up. AF-related HCRU was reported as the percentage of patients demonstrating at least one event and was quantified as rate-per-patient-per-year (PPPY) over time. A total of 49,574 patients was analyzed, having an overall median follow-up of 719 days. Almost all patients (99.5%) had at least one outpatient care visit, while hospital admissions were the second most frequent medical contact, with similar proportions in North America (37.5%) and Europe (37.2%), and slightly higher in the other GARFIELD-AF countries (42.0%; namely Australia, Egypt, and South Africa). Asia and Latin America showed lower percentages of hospitalizations, outpatient care visits, and diagnostic and interventional procedures. Analyses of GARFIELD-AF highlighted the vast AF-related HCRU, underlying significant geographical differences in the type, quantity, and frequency of AF-related HCRU. These differences were likely attributable to health service availability and differing models of care.

Interaction of Cardiovascular Nonmodifiable Risk Factors, Comorbidities and Comedications With Ischemia/Reperfusion Injury and Cardioprotection by Pharmacological Treatments and Ischemic Conditioning

Preconditioning, postconditioning, and remote conditioning of the myocardium enhance the ability of the heart to withstand a prolonged ischemia/reperfusion insult and the potential to provide novel therapeutic paradigms for cardioprotection. While many signaling pathways leading to endogenous cardioprotection have been elucidated in experimental studies over the past 30 years, no cardioprotective drug is on the market yet for that indication. One likely major reason for this failure to translate cardioprotection into patient benefit is the lack of rigorous and systematic preclinical evaluation of promising cardioprotective therapies prior to their clinical evaluation, since ischemic heart disease in humans is a complex disorder caused by or associated with cardiovascular risk factors and comorbidities. These risk factors and comorbidities induce fundamental alterations in cellular signaling cascades that affect the development of ischemia/reperfusion injury and responses to cardioprotective interventions. Moreover, some of the medications used to treat these comorbidities may impact on cardioprotection by again modifying cellular signaling pathways. The aim of this article is to review the recent evidence that cardiovascular risk factors as well as comorbidities and their medications may modify the response to cardioprotective interventions. We emphasize the critical need for taking into account the presence of cardiovascular risk factors as well as comorbidities and their concomitant medications when designing preclinical studies for the identification and validation of cardioprotective drug targets and clinical studies. This will hopefully maximize the success rate of developing rational approaches to effective cardioprotective therapies for the majority of patients with multiple comorbidities. SIGNIFICANCE STATEMENT: Ischemic heart disease is a major cause of mortality; however, there are still no cardioprotective drugs on the market. Most studies on cardioprotection have been undertaken in animal models of ischemia/reperfusion in the absence of comorbidities; however, ischemic heart disease develops with other systemic disorders (e.g., hypertension, hyperlipidemia, diabetes, atherosclerosis). Here we focus on the preclinical and clinical evidence showing how these comorbidities and their routine medications affect ischemia/reperfusion injury and interfere with cardioprotective strategies.

Trajectories and determinants of left ventricular ejection fraction after the first myocardial infarction in the current era of primary coronary interventions

BACKGROUND

Left ventricular ejection fraction (EF) is an independent predictor of adverse outcomes after myocardial infarction (MI). However, current data on trajectories and determinants of EF are scarce. The present study aimed to describe the epidemiology of EF after MI.

METHODS

Data from a single-center prospectively-designed registry of consecutive patients hospitalized at a large tertiary cardiology center were utilized.

RESULTS

Out of 1,593 patients in the registry, 1,065 were hospitalized for MI type I (65.4% STEMI) and had no previous history of heart failure or MI. At discharge, EF < 40% was present in 238 (22.3%), EF 40-50% in 326 (30.6%) and EF > 50% in 501 (47.0%). Patients with EF < 40% were often those who suffered subacute and anterior STEMI, had higher heart rate at admission and higher maximal troponin level, and had more often HF signs requiring intravenous diuretics. Among subjects with EF < 40%, the follow-up EF was available in 166 (80% of eligible). Systolic function recovered to EF > 50% in 39 (23.1%), slightly improved to EF 40-50% in 44 (26.0%) and remained below 40% in 86 (50.9%). Systolic function improvement to EF > 40% was predicted by lower severity of coronary atherosclerosis, lower leukocyte count, and the absence of atrial fibrillation.

CONCLUSIONS

Despite recent improvements in in-hospital MI care, one in five patients has systolic dysfunction at hospital discharge. Out of these, EF improves in 51%, and full recovery is observed in 23%. The severity of coronary atherosclerosis, inflammatory response to MI, and atrial fibrillation may affect EF recovery.

Oral anticoagulant therapy for patients with new-onset atrial fibrillation following acute myocardial infarction: A narrative review

Background

To evaluate the advantages and disadvantages of anticoagulant therapy and provide a piece of information on anti-thrombotic treatment strategies for patients with new-onset atrial fibrillation (NOAF) and acute myocardial infarction (AMI).

Methods

Literature from PubMed and Google scholar were screened until August 2022. Studies assessing oral anticoagulant (OAC) treatments for NOAF in patients with AMI were evaluated for inclusion.

Results

Three retrospective cohort studies were included. In the study performed by Madsen et al., patients with previously diagnosed AMI with or without NOAF were followed up for 5.8 years. About 38% of NOAF patients with anticoagulant therapies, which could reduce long-term mortality [adjusted hazard ratio (HR): 0.69; 95% confidence interval (CI): 0.47–1.00]. Hofer et al. performed a single-center cohort study containing 1,372 patients with AMI with an 8.6-year follow-up period. Dual anti-thrombotic therapy (DAT) did not show the effect on the survival in NOAF (adjusted HR: 0.97; 95% CI: 0.65–1.57), while triple antithrombotic therapy (TAT) could reduce long-term cardiovascular mortality (adjusted HR: 0.86; 95% CI: 0.45–0.92). Petersen et al. also did a cohort study with 1-year follow-up duration. It showed that anticoagulant therapies demonstrated positive results (HR: 0.78; 95% CI: 0.41–1.47).

Conclusion

Recent studies have shown that anticoagulant therapy in AMI-NOAF patients can obviously reduce the mortality of AMI-NOAF patients, especially OAC therapy. Further clinical trials could confirm these findings.

Shift work is associated with 10-year incidence of atrial fibrillation in younger but not older individuals from the general population: results from the Tromsø Study

OBJECTIVES

Shift work is associated with myocardial infarction and stroke. We studied if shift work is also associated with incident atrial fibrillation (AF) and if this association differs, depending on sex and age.

METHODS

We studied 22 339 participants (age 37.0±9.8 years, 49% women) with paid work from the third (1986-1987), fourth (1994-1995), fifth (2001) and sixth (2007-2008) surveys of the population-based Tromsø Study, Norway. Participants were followed up for ECG-confirmed AF through 2016. Shift work was assessed by questionnaire at each survey. We used unadjusted and multivariable-adjusted Cox regression models to study the association of shift work with 10-year incident AF and incident AF during extensive follow-up up to 31 years. Interactions with sex and age were tested in the multivariable model.

RESULTS

Shift work was reported by 21% of participants at the first attended survey. There was an interaction between shift work and age for 10-year incident AF (p=0.069). When adjusted for AF risk factors, shift work was significantly associated with 10-year incident AF in participants <40 years (HR 2.90, 95% CI 1.12 to 7.49) but not≥40 years of age (HR 0.90, 95% CI 0.53 to 1.51). Shift work was not associated with incident AF during extensive follow-up (HR 1.03, 95% CI 0.89 to 1.20). There was no interaction between shift work and sex.

CONCLUSIONS

Shift work was associated with 10-year incident AF in individuals <40 years but not ≥40 years of age. Shift work was not associated with incident AF during extensive follow-up up to 31 years, and there were no sex differences.

Application of Machine Learning Methods for Epilepsy Risk Ranking in Patients with Hematopoietic Malignancies Using

Machine learning methods to predict the risk of epilepsy, including vascular epilepsy, in oncohematological patients are currently considered promising. These methods are used in research to predict pharmacoresistant epilepsy and surgical treatment outcomes in order to determine the epileptogenic zone and functional neural systems in patients with epilepsy, as well as to develop new approaches to classification and perform other tasks. This paper presents the results of applying machine learning to analyzing data and developing diagnostic models of epilepsy in oncohematological and cardiovascular patients. This study contributes to solving the problem of often unjustified diagnosis of primary epilepsy in patients with oncohematological or cardiovascular pathology, prescribing antiseizure drugs to patients with single seizure syndromes without finding a disease associated with these cases. We analyzed the hospital database of the V.A. Almazov Scientific Research Center of the Ministry of Health of Russia. The study included 66,723 treatment episodes of patients with vascular diseases (I10–I15, I61–I69, I20–I25) and 16,383 episodes with malignant neoplasms of lymphoid, hematopoietic, and related tissues (C81–C96 according to ICD-10) for the period from 2010 to 2020. Data analysis and model calculations indicate that the best result was shown by gradient boosting with mean accuracy cross-validation score = 0.96. f1-score = 98, weighted avg precision = 93, recall = 96, f1-score = 94. The highest correlation coefficient for G40 and different clinical conditions was achieved with fibrillation, hypertension, stenosis or occlusion of the precerebral arteries (0.16), cerebral sinus thrombosis (0.089), arterial hypertension (0.17), age (0.03), non-traumatic intracranial hemorrhage (0.07), atrial fibrillation (0.05), delta absolute neutrophil count (0.05), platelet count at discharge (0.04), transfusion volume for stem cell transplantation (0.023). From the clinical point of view, the identified differences in the importance of predictors in a broader patient model are consistent with a practical algorithm for organic brain damage. Atrial fibrillation is one of the leading factors in the development of both ischemic and hemorrhagic strokes. At the same time, brain infarction can be accompanied both by the development of epileptic seizures in the acute period and by unprovoked epileptic seizures and development of epilepsy in the early recovery and in a longer period. In addition, a microembolism of the left heart chambers can lead to multiple microfocal lesions of the brain, which is one of the pathogenetic aspects of epilepsy in elderly patients. The presence of precordial fibrillation requires anticoagulant therapy, the use of which increases the risk of both spontaneous and traumatic intracranial hemorrhage.

Risk Factors, Subsequent Disease Onset, and Prognostic Impact of Myocardial Infarction and Atrial Fibrillation

Background Although myocardial infarction (MI) and atrial fibrillation (AF) are frequent comorbidities and share common cardiovascular risk factors, the direction and strength of the association of the risk factors with disease onset, subsequent disease incidence, and mortality are not completely understood. Methods and Results In pooled multivariable Cox regression analyses, we examined temporal relations of disease onset and identified predictors of MI, AF, and all-cause mortality in 108 363 individuals (median age, 46.0 years; 48.2% men) free of MI and AF at baseline from 6 European population-based cohorts. During a maximum follow-up of 10.0 years, 3558 (3.3%) individuals were diagnosed exclusively with MI, 1922 (1.8%) with AF but no MI, and 491 (0.5%) individuals developed both MI and AF. Association of sex, systolic blood pressure, antihypertensive treatment, and diabetes appeared to be stronger with incident MI than with AF, whereas increasing age and body mass index showed a higher risk for incident AF. Total cholesterol and daily smoking were significantly related to incident MI but not AF. Combined population attributable fraction of cardiovascular risk factors was >70% for incident MI, whereas it was only 27% for AF. Subsequent MI after AF (hazard ratio [HR], 1.68; 95% CI, 1.03-2.74) and subsequent AF after MI (HR, 1.75; 95% CI, 1.31-2.34) both significantly increased overall mortality risk. Conclusions We observed different associations of cardiovascular risk factors with both diseases indicating distinct pathophysiological pathways. Subsequent diagnoses of MI and AF significantly increased mortality risk.

Atrial fibrillation detected at screening is not a benign condition: outcomes in screen-detected versus clinically detected atrial fibrillation. Results from the Prevention of Renal and Vascular End-stage Disease (PREVEND) study

AIMS

It is unknown whether screen-detected atrial fibrillation (AF) carries cardiovascular risks similar to clinically detected AF. We aimed to compare clinical outcomes between individuals with screen-detected and clinically detected incident AF.

METHODS

We studied 8265 participants (age 49 ± 13 years, 50% women) without prevalent AF from the community-based Prevention of Renal and Vascular End-stage Disease (PREVEND) study. By design of the PREVEND study, 70% of participants had a urinary albumin concentration >10 mg/L. Participants underwent 12-lead ECG screening at baseline and every 3 years. AF was considered screen-detected when first diagnosed during a study visit and clinically detected when first diagnosed during a hospital visit. We analysed data from the baseline visit (1997-1998) up to the third follow-up visit (2008). We used Cox regression with screen-detected and clinically detected AF as time-varying covariates to study the association of screen-detected and clinically detected AF with all-cause mortality, incident heart failure (HF) and vascular events.

RESULTS

During a follow-up of 9.8 ± 2.3 years, 265 participants (3.2%) developed incident AF, of whom 60 (23%) had screen-detected AF. The majority of baseline characteristics were comparable between individuals with screen-detected and clinically detected AF. Unadjusted, both screen-detected and clinically detected AF were strongly associated with mortality, incident HF, and vascular events. After multivariable adjustment, screen-detected and clinically detected AF remained significantly associated with mortality (HR 2.21 (95% CI 1.09 to 4.47) vs 2.95 (2.18 to 4.00), p for difference=0.447) and incident HF (4.90 (2.28 to 10.57) vs 3.98 (2.49 to 6.34), p for difference=0.635). After adjustment, screen-detected AF was not significantly associated with vascular events, whereas clinically detected AF was (1.12 (0.46 to 2.71) vs 1.92 (1.21 to 3.06), p for difference=0.283).

CONCLUSION

Screen-detected incident AF was associated with an increased risk of adverse outcomes, especially all-cause mortality and incident HF. The risk of outcomes was not significantly different between screen-detected AF and clinically detected AF.

Adherence to the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline on the Use of Oral Anticoagulant Agents in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

BACKGROUND

There is a scarcity of studies that evaluate adherence to the utilization of guideline-recommended oral anticoagulant agents (OACs) in patients with atrial fibrillation (AF) in the Middle East. The Jordan Atrial Fibrillation (JoFib) Study evaluated baseline clinical profiles and the utilization of OACs, including vitamin K antagonists (VKAs) and direct OACs (DOACs), in patients with valvular AF (VAF) and nonvalvular AF (NVAF) according to the 2019 focused update of the 2014 AHA/ACC/HRS guidelines.

METHODS

Consecutive patients with AF were enrolled in 29 hospitals and outpatient clinics. The use of OACs was evaluated in patients with VAF and NVAF according to the prespecified guideline.

RESULTS

Of 2000 patients, 177 (8.9%) had VAF and 1823 (91.1%) had NVAF. A VKA was prescribed for 88.1% of the VAF group. In the NVAF group, 1468 (80.5%) of patients had a high CHA2DS2-VASc score, i.e., a score of ≥3 in women and ≥2 in men; 202 (11.1%) patients had an intermediate CHA2DS2-VASc score, i.e., a score of 2 in women and 1 in men; and 153 (8.4%) patients had a low CHA2DS2-VASc score, i.e., a score of 1 in women and 0 in men. Of patients with a high CHA2DS2-VASc score, 1204 (82.0%) received OACs, including DOACs for 784 (53.4%) and VKA for 420 (28.6%) patients. Among patients with an intermediate score, OACs were prescribed for 148 (73.3%) patients, including 107 (53.0%) who received DOACs and 41 (20.3%) patients who received VKA. In patients with a low score, OACs were omitted in 94 (61.4%) patients and prescribed for 59 (38.6%) patients. Multivariate analysis showed that age between 50 and 70 years, CHA2DS2-VASc score of ≥2, a diagnosis of stroke or systemic embolization, and nonparoxysmal AF were significantly associated with increased odds of OAC prescription.

CONCLUSIONS

The current status of the utilization of OACs in Middle Eastern AF patients appears to be promising and is consistent with the 2019 focused update of the 2014 AHA/ACC/HRS guideline. This trial is registered with NCT03917992.

Prevalence and Determinants of Atrial Fibrillation-Associated In-Hospital Ischemic Stroke in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Atrial fibrillation (AF) is an established risk factor ischemic stroke (IS) and is commonly encountered in patient hospitalized with acute myocardial infarction (AMI). Uncommonly, IS can occur as a complication resulting from percutaneous coronary intervention (PCI). There is limited real world data regarding AF-associated in-hospital IS (IH-IS) in patients admitted with AMI undergoing PCI. We queried the National Inpatient Sample database from January 2010 to December 2014 to identify patients admitted with AMI who underwent PCI. In this cohort, we determined the prevalence of AF associated IH-IS and compared risk factors for IH-IS between patients with AF and without AF using multivariable logistic regression models. IH-IS was present in 0.46% (n = 5,938) of the patients with AMI undergoing PCI (n = 1,282,829). Prevalence of IH-IS in patients with AF was higher compared with patients without AF (1.05% vs 0.4%; adjusted odds ratio: 1.634, 95% confidence interval: 1.527 to 1.748, p <0.001). Regardless of AF status, prevalence and risk of IH-IS was higher in females and increased with advancing age. There was significant overlap among risk-factors associated with increased risk of IH-IS in AF and non-AF cohorts, except for obesity in AF patients (adjusted odds ratio: 1.268, 95% confidence interval: 1.023 to 1.572, p = 0.03) in contrast to renal disease, malignancy, and peripheral vascular disease in non-AF patients. In conclusion, IH-IS is a rare complication affecting patients undergoing PCI for AMI and is more likely to occur in AF patients, females, and older adults, with heterogeneity among risk factors in patients with and without AF.

The common characteristics and mutual effects of heart failure and atrial fibrillation: initiation, progression, and outcome of the two aging-related heart diseases

Atrial fibrillation (AF) and heart failure (HF) are common chronic diseases noted in humans. AF and HF share several risk factors, such as age, hypertension, obesity, diabetes, and dyslipidemia. They can interact with each other, while both their morbidity and mortality have been considerably increased. And AF and HF often occur together, suggesting a strong association between the two. However, the underlying mechanism behind this association is not well understood. Among them, aging is the most significant common risk factor, which represents an aging heart and is characterized by fibrosis and decreased number of cardiomyocytes, known as senescence-related cardiac remodeling for both atria and ventricles. Finally, it is proposed that cardiac remodeling is the key link between AF and HF.

Vascular disease in patients with atrial fibrillation. A report from Polish participants in the EORP-AF General Long-Term Registry

AIMS

This study aimed to (1) define the prevalence of vascular disease (VD; coronary (CAD) and/or peripheral artery disease (PAD)) and associated risk factors in patients with atrial fibrillation (AF); (2) establish the relationship of VD and associated treatment patterns on adverse events in AF.

METHODS

Data from 701 Polish AF patients enrolled in the EORP-AF General Long-Term Registry in the years 2013-2016 were included in this analysis. During the one-year follow-up, the occurrence of major adverse events (MAE; all-cause death, thromboembolic event, myocardial infraction) and its components was evaluated.

RESULTS

VD was recorded in 293 (44%) patients and based on multivariate logistic analysis was associated with age >75, diabetes, hypercholesterolemia, heart failure (HF). There was no significant difference in rates of MAE between patients with and without VD based on Fisher's exact test (8.8% vs 5.7%, P = .16), as well as between patients with concomitant CAD and PAD, PAD and CAD alone based on the Chi-square test (21% vs 7.5% vs 6.7%; P = .09). A higher risk of MAE was associated with HF, chronic kidney disease (in all study group), age >75, HF, diabetes (VD group),chronic obstructive pulmonary disease (non-VD group) based on the multivariate logistic analysis. Relative to patients with VD on vitamin K antagonists (VKA), those treated with non-VKA-oral anticoagulants (NOAC) had lower absolute rate of MAE according to Fisher's exact test (1.4% vs 10%, P = .02) but similar risks for thromboembolic and hemorrhagic events. The concomitant use of triple therapy was associated with increased risk of MAE as compared with those on OAC alone or dual therapy based on the Chi-square test (20% vs 4.8%, 3.2%, P = .02).

CONCLUSION

VD was prevalent in almost two-fifths of AF patients. The incidence of MAE was higher in patients with VD on VKA (vs NOAC) and on triple therapy (vs dual therapy, OAC alone) within one-year follow-up.

Cardiac Cell Therapy: Insights into the Mechanisms of Tissue Repair

Stem cell-based cardiac therapies have been extensively studied in recent years. However, the efficacy of cell delivery, engraftment, and differentiation post-transplant remain continuous challenges and represent opportunities to further refine our current strategies. Despite limited long-term cardiac retention, stem cell treatment leads to sustained cardiac benefit following myocardial infarction (MI). This review summarizes the current knowledge on stem cell based cardiac immunomodulation by highlighting the cellular and molecular mechanisms of different immune responses to mesenchymal stem cells (MSCs) and their secretory factors. This review also addresses the clinical evidence in the field.

Proactive screening for symptoms: A simple method to improve early detection of unrecognized cardiovascular disease in primary care. Results from the Lifelines Cohort Study

Cardiovascular disease (CVD) often goes unrecognized, despite symptoms frequently being present. Proactive screening for symptoms might improve early recognition and prevent disease progression or acute cardiovascular events. We studied the diagnostic value of symptoms for the detection of unrecognized atrial fibrillation (AF), heart failure (HF), and coronary artery disease (CAD) and developed a corresponding screening questionnaire. We included 100,311 participants (mean age 52 ± 9 years, 58% women) from the population-based Lifelines Cohort Study. For each outcome (unrecognized AF/HF/CAD), we built a multivariable model containing demographics and symptoms. These models were combined into one 'three-disease' diagnostic model and questionnaire for all three outcomes. Results were validated in Lifelines participants with chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Unrecognized CVD was identified in 1325 participants (1.3%): AF in 131 (0.1%), HF in 599 (0.6%), and CAD in 687 (0.7%). Added to age, sex, and body mass index, palpitations were independent predictors for unrecognized AF; palpitations, chest pain, dyspnea, exercise intolerance, health-related stress, and self-expected health worsening for unrecognized HF; smoking, chest pain, exercise intolerance, and claudication for unrecognized CAD. Area under the curve for the combined diagnostic model was 0.752 (95% CI 0.737-0.766) in the total population and 0.757 (95% CI 0.734-0.781) in participants with COPD and DM. At the chosen threshold, the questionnaire had low specificity, but high sensitivity. In conclusion, a short questionnaire about demographics and symptoms can improve early detection of CVD and help pre-select people who should or should not undergo further screening for CVD.

[Risk of Coronary Events in Atrial Fibrillation]

It has been established that cardiovascular events due to coronary heart disease are highly prevalent in the population of patients with atrial fibrillation. In this review, pathophysiologic mechanisms explaining this association are detailed along with supporting epidemiological evidence. Various methods for the prediction and prevention of coronary events in atrial fibrillation are iscussed, including modification of shared risk factors, antithrombotic therapy and selection of the optimal direct oral anticoagulant in terms of favourable influence on ischemic cardiac outcomes.

Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge

Background

Atrial fibrillation is the most frequent cardiac arrhythmia. It has been estimated that 6–12 million people worldwide will suffer this condition in the US by 2050 and 17.9 million people in Europe by 2060. Atrial fibrillation is a major risk factor for ischemic stroke and provokes important economic burden along with significant morbidity and mortality.

Aim

We provide here comprehensive and updated statistics on worldwide epidemiology of atrial fibrillation.

Methods

An electronic search was conducted for atrial fibrillation. The epidemiologic information was retrieved from the Global Health Data Exchange database, which is regarded as one of the most comprehensive worldwide catalogs of surveys, censuses, vital statistics, and other health-related data.

Results

A total of 3.046 million new cases of atrial fibrillation worldwide were registered in the database during 2017. The estimated incidence rate for 2017 (403/millions inhabitants) was 31% higher than the corresponding incidence in 1997. The worldwide prevalence of atrial fibrillation is 37,574 million cases (0.51% of worldwide population), increased also by 33% during the last 20 years. The highest burden is seen in countries with high socio-demographic index, though the largest recent increased occurred in middle socio-demographic index countries. Future projections suggest that absolute atrial fibrillation burden may increase by >60% in 2050.

Conclusions

Our analyses suggest that atrial fibrillation incidence and prevalence have increased over the last 20 years and will continue to increase over the next 30 years, especially in countries with middle socio-demographic index, becoming one of the largest epidemics and public health challenges.

Association of Body Mass Index With Clinical Outcomes in Patients With Atrial Fibrillation: A Report From the FANTASIIA Registry

Background

Obesity and atrial fibrillation (AF) frequently coexist and independently increase mortality. We sought to assess the association between obesity and adverse events in patients receiving oral anticoagulants for AF.

Methods and Results

Consecutive AF outpatients receiving anticoagulant agents (both vitamin K antagonists and direct oral anticoagulants) were recruited into the FANTASIIA (Atrial fibrillation: influence of the level and type of anticoagulation on the incidence of ischemic and hemorrhagic stroke) registry. This observational, multicenter, and prospective registry of AF patients analyzes the quality of anticoagulation, incidence of events, and differences between oral anticoagulant therapies. We analyzed baseline patient characteristics according to body mass index, normal: <25 kg/m², overweight: 25–30 kg/m², and obese: ≥30 kg/m²), assessing all‐cause mortality, stroke, major bleeding and major adverse cardiovascular events (a composite of ischemic stroke, myocardial infarction, and total mortality) at 3 years’ follow‐up. In this secondary prespecified substudy, the association of weight on prognosis was evaluated. We recruited 1956 patients (56% men, mean age 73.8±9.4 years): 358 (18.3%) had normal body mass index, 871 (44.5%) were overweight, and 727 (37.2%) were obese. Obese patients were younger (P<0.01) and had more comorbidities. Mean time in the therapeutic range was similar across body mass index categories (P=0.42). After a median follow‐up of 1070 days, 255 patients died (13%), 45 had a stroke (2.3%), 146 a major bleeding episode (7.5%) and 168 a major adverse cardiovascular event (8.6%). Event rates were similar between groups for total mortality (P=0.29), stroke (P=0.90), major bleeding (P=0.31), and major adverse cardiovascular events (P=0.24). On multivariate Cox analysis, body mass index was not independently associated with all‐cause mortality, cardiovascular mortality, stroke, major bleeding, or major adverse cardiovascular events.

Conclusions

In this prospective cohort of patients anticoagulated for AF, obesity was highly prevalent and was associated with more comorbidities, but not with poor prognosis.

Gender Differences in Arrhythmias: Focused on Atrial Fibrillation

There are significant differences in clinical presentation and treatment of atrial fibrillation (AF) between women and men. The primary goal of AF management is to restore sinus rhythm and to prevent various complications, including stroke and heart failure. In many areas of AF, such as prevalence, clinical manifestations, morbidity, risk factors, pathophysiology, treatment strategies, and complications, gender-specific variability is observed and needs to be further addressed by large-scale population researches or randomized clinical trials, which help to promote the customization of AF treatment programs, hence to maximize the success rate of AF therapy in both sexes. This review highlights our current understanding of these gender differences in AF and how these differences affect treatment decisions on AF.