ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation—Executive Summary

Patients with Atrial Fibrillation are Unlikely to Benefit from Aspirin Monotherapy

Background

Aspirin (ASA), the mainstay antiplatelet treatment in patients with cardiovascular disease (CVD), has been received by a considerable number of AF patients. This study sought to examine the association between ASA monotherapy and the risk of major adverse cardiac and cerebrovascular events (MACCE) in patients with atrial fibrillation (AF).

Methods

A total of 850 patients with AF were identified from a community-based Kailuan study. All patients were assigned to two groups according to their medicine history: an aspirin therapy group (ASA group) (n = 174), and a non-aspirin therapy group (non-ASA group) (n = 676). The clinical endpoints are MACCE, including myocardial infarction (MI), ischemic stroke (IS), and hemorrhagic stroke (HS). Incidence curves for MACCE were plotted using the Kaplan-Meier method, and the Log rank test was used to assess the differences in incidence rates. The hazard ratios (HR) and 95% confidence intervals (CI) for MACCE were analyzed using Cox proportional-hazards analysis regression models.

Results

During the 7.2-year follow-up, 30 MACCE occurred in the ASA group, and 101 in the non-ASA group, with a cumulative incidence of 19.88% vs 17.27%, P = 0.511; 3 cases of MI occurred in the ASA group, and 18 cases in the non-ASA group, with a cumulative incidence of 1.78% vs 2.90%, P = 0.305. Twenty-seven cases of IS occurred in the ASA group, and 84 cases in the non-ASA group, with a cumulative incidence of 1.78% vs 2.90%, P = 0.305. Eight cases of HS occurred in the ASA group, and 13 cases in the non-ASA group, with a cumulative incidence of 5.01% vs 2.34%, P = 0.045. Multivariate regression analysis showed that ASA therapy was not associated with MACCE (HR: 1.130, 95% CI: 0.747-1.710, P = 0.562). In addition, ASA therapy was not associated with IS (HR: 1.309, 95% CI: 0.843-2.034, P = 0.231). However, ASA therapy was significantly associated with HS (HR: 2.563, 95% CI: 1.024-6.418, P = 0.044).

Conclusion

ASA monotherapy is not associated with a lower risk of ischemic events, while significantly associated with a higher risk of bleeding events. Patients with AF are unlikely to benefit from aspirin monotherapy.

Association of Serum Uric Acid with Non-Valvular Atrial Fibrillation: A Retrospective Study in China

Purpose

The association between serum uric acid (SUA) and atrial fibrillation (AF) has been widely focused on and studied in recent years. However, the exact association between SUA and AF is unclear, and the effect of gender on the association between SUA levels and AF has been controversial. This study aimed to investigate the association between SUA levels and non-valvular AF (NVAF) and the potential effect of gender on it.

Patients and Methods

A total of 866 NVAF patients (463 males, age 69.44 ± 8.07 years) and 646 sex-matched control patients in sinus rhythm, with no history of arrhythmia were included in this study. t-test, ANOVA, and chi-square test were used for baseline data analysis. The receiver operating characteristic curve, logistic regression and Pearson correlation analysis were used for correlation analysis.

Results

Compared to controls, NVAF patients exhibited higher SUA (P<0.001). After adjusting for confounders of NVAF, SUA remained significantly associated with NVAF, regardless of gender (OR= 1.31, 95% CI 1.18-1.43, P<0.001). SUA demonstrated higher predictability and sensitivity in predicting the occurrence of female NVAF compared to male (area under the curve was 0.68 (95% CI 0.64-0.72, P<0.001), sensitivity 87.3%), with the optimal cut-off point identified as 5.72 mg/dL. Furthermore, SUA levels correlated with APOA1, Scr and NT-proBNP in NVAF patients. SUA levels varied significantly among NVAF subtypes.

Conclusion

High SUA levels were independently associated with NVAF, regardless of gender. SUA exhibited higher predictability and sensitivity in predicting the occurrence of NVAF in females compared to males. High SUA levels may affect other NVAF-related factors and participate in the pathophysiological process of NVAF.

Oral anticoagulation therapy initiation in patients with atrial fibrillation in relation to world region of origin: a register-based nationwide study

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia and results in a high risk of stroke. The number of immigrants is increasing globally, but little is known about potential differences in AF care across migrant populations.

AIM

To investigate if initiation of oral anticoagulation therapy (OAC) differs for patients with incident AF in relation to country of origin.

METHODS

A nationwide register-based study covering 1999-2017. AF was defined as a first-time diagnosis of AF and a high risk of stroke. Stroke risk was defined according to guidelines from the European Society of Cardiology (ESC). Poisson regression adjusted for sex, age, socioeconomic position and comorbidity was made to compute incidence rate ratios (IRR) for initiation of OAC.

RESULTS

The AF population included 254 586 individuals of Danish origin, 6673 of Western origin and 3757 of non-Western origin. Overall, OAC was initiated within -30/+90 days relative to the AF diagnosis in 50.3% of individuals of Danish origin initiated OAC, 49.6% of Western origin and 44.5% of non-Western origin. Immigrants from non-Western countries had significantly lower adjusted IRR of initiating OAC according to all ESC guidelines compared with patients of Danish origin. The adjusted IRRs ranged from 0.73 (95% CI: 0.66 to 0.80) following the launch of the 2010 ESC guideline to 0.89 (95% CI: 0.82 to 0.97) following the launch of the 2001 ESC guideline.

CONCLUSION

Patients with AF with a high risk of stroke of non-Western origin have persistently experienced a lower chance of initiating OAC compared with patients of Danish origin during the last decades.

[Survey on blood thinning therapy in patients with age-related macular degeneration]

BACKGROUND

Patients with age-related macular degeneration (AMD) often receive concomitant systemic blood thinning medications. These are known to increase the risk of severe hemorrhage also in connection with AMD, which can lead to extensive subretinal hemorrhaging.

OBJECTIVE

The purpose of this study was to investigate the proportion of patients with AMD and concomitant blood thinning treatment, including the type and reason for blood thinning treatment.

METHODS

This survey was prospectively conducted at the University Eye Hospital, Bonn, Germany. Volunteers were recruited during retinal consultations and the consultations for intravitreal injections (IVOM).

RESULTS

The questionnaire was completed by 178 patients. The mean age was 81.7 years (58-100) and 101 patients (57.7%) were undergoing blood thinning treatment. The majority of patients were taking antiplatelet agents (n = 59; 58.4%), especially ASA (n = 55; 54.5%). Direct oral anticoagulants (DOAC) were taken by 33 patients (32.7%), including most frequently apixaban (17.8%). Vitamin K antagonists (VKA) was taken by 4 patients (4%). The most common reason for blood thinning treatment was atrial fibrillation (n = 32, 31.7%), followed by stent implantation (n = 20, 19.8%) and stroke (n = 12, 11.9%) but 13 patients (12.9%) did not know why they were undergoing blood thinning treatment. No clear indications for the use of blood thinners were found in 31 patients (30.7%).

CONCLUSION

A large proportion of patients with AMD undergo blood thinning treatment; however, not every patient has a clear indication. Due to the increased risk of bleeding, the use of blood thinners should be critically evaluated in close cooperation with primary care physicians and cardiologists.

Chronic kidney disease promotes atrial fibrillation via inflammasome pathway activation

Chronic kidney disease (CKD) is associated with a higher risk of atrial fibrillation (AF). The mechanistic link between CKD and AF remains elusive. IL-1β, a main effector of NLR family pyrin domain-containing 3 (NLRP3) inflammasome activation, is a key modulator of conditions associated with inflammation, such as AF and CKD. Circulating IL-1β levels were elevated in patients with CKD who had AF (versus patients with CKD in sinus rhythm). Moreover, NLRP3 activity was enhanced in atria of patients with CKD. To elucidate the role of NLRP3/IL-1β signaling in the pathogenesis of CKD-induced AF, Nlrp3-/- and WT mice were subjected to a 2-stage subtotal nephrectomy protocol to induce CKD. Four weeks after surgery, IL-1β levels in serum and atrial tissue were increased in WT CKD (WT-CKD) mice versus sham-operated WT (WT-sham) mice. The increased susceptibility to pacing-induced AF and the longer AF duration in WT-CKD mice were associated with an abbreviated atrial effective refractory period, enlarged atria, and atrial fibrosis. Genetic inhibition of NLRP3 in Nlrp3-/- mice or neutralizing anti-IL-1β antibodies effectively reduced IL-1β levels, normalized left atrial dimensions, and reduced fibrosis and the incidence of AF. These data suggest that CKD creates a substrate for AF development by activating the NLRP3 inflammasome in atria, which is associated with structural and electrical remodeling. Neutralizing IL-1β antibodies may be beneficial in preventing CKD-induced AF.

The Experiences of Endurance Athletes With Atrial Fibrillation: Tensions and Takeaways

BACKGROUND

Growing evidence indicates that chronic high-intensity endurance exercise predisposes male, middle-aged athletes to increased risk of atrial fibrillation (AF). The aetiology of AF in endurance athletes is multifactorial and remains incompletely understood. Despite their unique training demands, AF care in athletes remains largely based on evidence derived from the general population. Understanding the experiences of athletes with AF provides a necessary foundation for addressing challenges in managing their condition and identifying gaps in care.

AIM

The purpose of this interpretive descriptive qualitative study was to describe the experiences and perspectives of endurance athletes living with AF.

METHOD

Masters athletes diagnosed with AF and aged between 35 and 60 years were recruited internationally through cardiology practices and social media. Ten middle-aged, male endurance athletes with AF and >1,500 lifetime training hours participated in individual, semi-structured interviews. Data were analysed using inductive thematic analysis.

RESULTS

Three key themes were constructed: (1) tensions with training, (2) tensions with treatment plans, and (3) tensions with clinicians. Participants experienced a wide range of symptoms from AF that significantly affected their ability to train, and reacted negatively to medical treatment strategies that affected their exercise capacity and training performance. Athletes experienced tensions with providers who failed to acknowledge their athletic needs.

CONCLUSIONS

Our results highlight the unique difficulties that male athletes with AF face in navigating between training and their disease, treatment, and clinicians. Shared decision-making between the athlete and provider is likely necessary for effective management of athletic AF.

Edoxaban treatment in atrial fibrillation in routine clinical care: One-year outcomes of the prospective observational ETNA-AF study in South Korean patients

BACKGROUND

The real-world outcomes of edoxaban treatment in patients with atrial fibrillation (AF) were analyzed in the ETNA-AF (Edoxaban Treatment in Routine Clinical Practice) study involving data from multiple regional registries. This report addresses effectiveness and safety of edoxaban in the Korean ETNA-AF population.

METHODS

One-year data from 1887 Korean ETNA-AF participants were analyzed according to edoxaban dose and patient age and compared with results of other ETNA-AF registries.

RESULTS

Approximately 70% of patients received the recommended doses of edoxaban (60 mg/30 mg); non-recommended 60 mg and 30 mg doses were prescribed to 9.6% and 19.8% of the patients, respectively. The proportions of reference age (<65 years), youngest-old (65-74 years) and middle-old/oldest-old (≥75 years) groups were 21.4%, 40.2%, and 38.4%, respectively. Incidence of major or clinically relevant nonmajor bleeding was similar within dose (0.57%-1.71%) and age subgroups (1.26%-1.63%). Incidence of net clinical outcome, a composite of stroke, systemic embolic event, major bleeding, and all-cause mortality, was also comparable among dose subgroups (1.14%-3.10%) and age subgroups (2.28%-2.78%). The percentage of Korean patients receiving non-recommended 30 mg (19.8%) was over twice that of the European population (8.4%). However, the clinical outcomes were generally similar among different populations included in the ETNA-AF study.

CONCLUSIONS

The outcomes in the Korean ETNA-AF population are like those in the global ETNA-AF population, with overall low event rates of stroke, major bleeding and all-cause mortality across age and dose subgroups. Edoxaban can be used effectively and safely in specific populations of Korean AF patients, including the elderly.

Temporal Trends in Antithrombotic Therapy for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention From 2014 to 2022 in Japan

Background: Recent revisions of clinical guidelines by the Japanese Circulation Society, American Heart Association/American College of Cardiology, and European Society of Cardiology updated the management of antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, the extent to which these guidelines have been implemented in real-world daily clinical practice is unclear. Methods and Results: We conducted surveys on the status of antithrombotic therapy for patients with AF undergoing PCI every 2 years from 2014 to 2022 in 14 cardiovascular centers in Japan. The primary use of drug-eluting stents increased from 10% in 2014 to 95-100% in 2018, and the use of direct oral anticoagulants increased from 15% in 2014 to 100% in 2018, in accordance with the revised practice guidelines. In patients with acute coronary syndrome, the duration of triple therapy within 1 month was approximately 10% until 2018, and increased to >70% from 2020. In patients with chronic coronary syndrome, the duration of triple therapy within 1 month was approximately 10% until 2016, and >75% from 2018. Since 2020, the most common timing of discontinuation of dual antiplatelet therapy to transition to anticoagulation monotherapy during the chronic phase of PCI has been 1 year after PCI. Conclusions: Japanese interventional cardiologists have updated their treatment strategies for patients with AF undergoing PCI according to revisions of clinical practice guidelines.

The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture)

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.

The effect of contrast agents on the anticoagulant properties of oral factor Xa inhibitors

BACKGROUND

Contrast agents may affect the anticoagulant properties of novel oral anticoagulants.

PURPOSE

To evaluate the effect of iohexol as a contrast agent on the anticoagulant activity of oral factor Xa inhibitors.

MATERIAL AND METHODS

The study included 65 individuals who underwent contrast computed tomography(CT). Group 1 comprised 20 patients using rivaroxaban, Group 2, 20 patients using apixaban, and Group 3, 20 patients using edoxaban. Group 4 was the control group of five healthy volunteers. Iohexol (60 mL) was used as a contrast agent. Blood samples of 2 mL were withdrawn into two tubes at 4 h after the drug dose and 1 h after the contrast CT (CT was performed 3 h after the drug was taken) from all the patients, and for the control group, at any time before and 1 h after contrast CT. The anticoagulant properties of rivaroxaban, apixaban, and edoxaban were evaluated using anti-factor Xa levels.

RESULTS

The anti-factor Xa level was increased after using the contrast agent in the rivaroxaban group (0.66 ± 0.32 U/mL vs. 0.67 ± 0.32 U/mL; P = 0.01) and the edoxaban group (0.74 ± 0.35 U/mL vs. 0.76 ± 0.36 U/mL; P = 0.006). No significant difference was observed in the apixaban group (0.66 ± 0.33 U/mL vs. 0.66 ± 0.32 U/mL; P = 0.21) and control group (0.02 ± 0.01 U/mL vs. 0.03 ± 0.01 U/mL; P = 0.33).

CONCLUSION

The anticoagulant properties of rivaroxaban and edoxaban tended to increase significantly, but there was no statistically significant difference in the anticoagulant properties of apixaban after the administration of contrast agent. To determine whether the small laboratory difference has a clinical effect, there is a need for larger clinical trials (NCT04611386).

Comparison of ANN and ANFIS Models for AF Diagnosis Using RR Irregularities

Classification of normal sinus rhythm (NSR), paroxysmal atrial fibrillation (PAF), and persistent atrial fibrillation (AF) is crucial in order to diagnose and effectively plan treatment for patients. Current classification models were primarily developed by electrocardiogram (ECG) signal databases, which may be unsuitable for local patients. Therefore, this research collected ECG signals from 60 local Thai patients (age 52.53 ± 23.92) to create a classification model. The coefficient of variance (CV), the median absolute deviation (MAD), and the root mean square of the successive differences (RMSSD) are ordinary feature variables of RR irregularities used by existing models. The square of average variation (SAV) is a newly proposed feature that extracts from the irregularity of RR intervals. All variables were found to be statistically different using ANOVA tests and Tukey’s method with a p-value less than 0.05. The methods of artificial neural network (ANN) and adaptive neuro-fuzzy inference system (ANFIS) were also tested and compared to find the best classification model. Finally, SAV showed the best performance using the ANFIS model with trapezoidal membership function, having the highest system accuracy (ACC) at 89.33%, sensitivity (SE), specificity (SP), and positive predictivity (PPR) for NSR at 100.00%, 94.00%, and 89.29%, PAF at 88.00%, 90.57%, and 81.48%, and AF at 80.00%, 96.00%, and 90.91%, respectively.

Feasibility and safety of a novel blunt tip concealed needle device for pericardial access in porcine models

BACKGROUND

Percutaneous pericardial access is the cornerstone of various procedures in clinical cardiology. The two commonly used methods utilizing large bore (LB) and smaller micropuncture (MP) needles often lead to inadvertent RV punctures. As both of these techniques push the pericardium inward, the novel blunt tip concealed needle device (BTCND) introduces the concept of bringing a small portion of the pericardium into a tube, where needle puncture and guidewire can be passed into the pericardial space all within the safety of the tube.

METHODS

The BTCND (Via One®, CardioVia, Nazareth, Israel) is a tool designed to allow for safe percutaneous subxiphoid pericardial access. In this preclinical study, a total of 18 procedures were performed in 5 female pigs. All procedures were performed under general anesthesia and under fluoroscopic guidance with a team of veterinarians and cardiac electrophysiologists. A laparoscopic camera was used to demonstrate and record the procedure. The Institutional Animal Care and Use Committees approved all preclinical experiments.

RESULTS

A total of 18 procedures were performed on five female pigs. In all procedures, the physicians safely introduced guidewire into the pericardial space. Device operation was not associated with any adverse events or bleeding, nor was any damage seen to the pericardium, the heart, or other organs during the procedure.

CONCLUSION

The result of our preclinical report demonstrates that the device is intuitive, easy to use, and effective for its intended use. Large preclinical studies are needed to validate the results of the study.

Temporal trends in anticoagulation management for US active duty personnel with atrial fibrillation

ObjectivesThis study aims to investigate US active duty (AD) military members diagnosed with atrial fibrillation (AF) and the temporal trends of systemic anticoagulation (AC). Our secondary objective is to study the AC prescriptions in AD military members diagnosed with AF and associated military dispositions and deployment rates.

DESIGN AND SETTING

A retrospective investigation of Tricare pharmacy AC prescriptions within the San Antonio Military Health System from January 2004 to July 2019 for AD individuals diagnosed with AF was performed.

PARTICIPANTS

386 AD personnel with non-valvular AF were analysed (mean age 35.0±9.4 years; mean body mass index, 28.3±4.3 kg/m²; 93% male; 57% Caucasian, 94% paroxysmal AF).

OUTCOMES

The temporal trends of systemic AC prescriptions were the primary outcome measures. The association between AC prescriptions and military dispositions and deployments were secondary outcomes of interest.

STATISTICAL ANALYSIS

The association between AC management, future deployments and military disposition was analysed using χ² and Fisher's exact test for categorical variables. The t-test was used for comparison of continuous variables.

RESULTS

CHA₂DS₂-VASc and HAS-BLED scores were low (0.39±0.65 and 0.86±0.63, respectively). 127 (33%) members received warfarin and 58 (15%) received direct oral anticoagulants (DOACs). Rates of military retention were not different between AC histories (no AC (64%) vs warfarin (75%) vs DOAC (65%); p=0.425). There was a significant trend of more recent utilisation of DOACs compared with warfarin (p<0.0001). When adjusted for temporal changes in deployment rates, there was no significant difference in deployment between AC groups (no AC (39%) vs warfarin (49%) vs DOAC (27%); p=0.9472).

CONCLUSIONS

This is the first report describing AC utilisation in US AD military members with AF. Young AD personnel with low stroke and bleeding risks do not commonly receive AC prescriptions. DOAC prescription rates are increasing and predominate over warfarin for AC indications.

The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture)

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.

Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease

Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.

Prediction of Atrial Fibrillation in Hospitalized Elderly Patients With Coronary Heart Disease and Type 2 Diabetes Mellitus Using Machine Learning: A Multicenter Retrospective Study

Background

The objective of this study was to use machine learning algorithms to construct predictive models for atrial fibrillation (AF) in elderly patients with coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM).

Methods

The diagnosis and treatment data of elderly patients with CHD and T2DM, who were treated in four tertiary hospitals in Chongqing, China from 2015 to 2021, were collected. Five machine learning algorithms: logistic regression, logistic regression+least absolute shrinkage and selection operator, classified regression tree (CART), random forest (RF) and extreme gradient lifting (XGBoost) were used to construct the prediction models. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and accuracy were used as the comparison measures between different models.

Results

A total of 3,858 elderly patients with CHD and T2DM were included. In the internal validation cohort, XGBoost had the highest AUC (0.743) and sensitivity (0.833), and RF had the highest specificity (0.753) and accuracy (0.735). In the external verification, RF had the highest AUC (0.726) and sensitivity (0.686), and CART had the highest specificity (0.925) and accuracy (0.841). Total bilirubin, triglycerides and uric acid were the three most important predictors of AF.

Conclusion

The risk prediction models of AF in elderly patients with CHD and T2DM based on machine learning algorithms had high diagnostic value. The prediction models constructed by RF and XGBoost were more effective. The results of this study can provide reference for the clinical prevention and treatment of AF.

Cost-effectiveness of a photopethysmographic procedure for screening for atrial fibrillation in 6 European countries

BACKGROUND

Strokes cause an estimated annual health care burden of 170 billion euros across Europe. Atrial fibrillation is one of the major risk factors for stroke and increases the individual risk 4.2-fold. But prevention with anticoagulants may reduce this risk by 70%. Screening methods are employed to detect previously undetected atrial fibrillation. Screening studies in various European countries show a high degree of undetected atrial fibrillation. This study aims to assess the cost-effectiveness of systematic screening with a smartphone application, named Preventicus Heartbeats. It is a hands-on screening tool for use on smartphone to diagnose AF with high sensitivity and specificity.

METHODS

A previously published model for calculating screening cost-effectiveness was extended to 6 European countries covering a wide range in terms of treatment costs and epidemiologic parameters.

RESULTS

The use of screening lowers the cost per case in countries with comparatively high levels of health care costs (Switzerland: -€75; UK: -€7). Moderate higher costs per case were observed in 4 countries (Greece: €6; Netherlands: €15). Low levels of health care costs result in less or no potential for further cost reduction (Poland: €20; Serbia: €33). In all countries considered, the model showed an increase in effectiveness measures both in the number of strokes avoided and the quality adjusted life years. The number of strokes avoided per 1000 participants ranged from 2.52 (Switzerland) to 4.44 (Poland). Quality-adjusted life-years per case gained from screening ranged from 0.0105 (Switzerland) to 0.0187 (Poland). The screening procedure dominated in two countries (Switzerland, UK). For the remaining countries, the incremental cost effectiveness ratio ranged from €489/QALY (Greece) to €2548/QALY (Serbia).

CONCLUSION

The model results showed a strong dependence of the results on the country-specific costs for stroke treatment. The use of the investigated screening method is close to cost-neutral or cost-reducing in the Western European countries and Greece. In countries with low price levels, higher cost increases due to AF screening are to be expected. Lower costs of anticoagulation, which are expected due to the upcoming patent expiry of direct anticoagulants, have a positive effect on the cost result.

Changes in anticoagulant prescription in a general hospital in 2008-2018

Aim. To study the structure of anticoagulant prescription in a general hospital to identify trends and contributing factors.

Materials and methods. The study was conducted in an urban general hospital. According to retrospective retrieval from electronic health records, total 17,129 patients received anticoagulants from 2008 to 2018. Formal appropriateness of oral anticoagulants (OАС) prescriptions for 6,638 patients with atrial fibrillation (AF) was analyzed with CHA2-DS2-VASc score.

Results. Appearance of recommendations for the direct oral anticoagulants (DOAC) prescription in clinical guidelines for venous thromboembolism (VTE) and AF management contributed to steady increase in the DOAC taking and decrease in the proportion of warfarin prescription. From 2011 to 2018, the proportion of patients with DOACs prescription increased from 1.7% to 81.5%. The most common indications for anticoagulant were ischemic stroke prevention in AF and VTE with mean rate 75.3% and 23.2%, respectively for the 2011-2018 period. Steady increase in low-molecular-weight heparin (LMWH) prophylactic prescriptions was also shown (Chi-square for linear trend=1340, df=1, p<0.0001). Since 2014, the prescription of LMWH in prophylactic doses increased dramatically, probably related to implementation of computerized decision support system (CDSS) for VTE prevention in the hospital.

Conclusion. The study showed that in a general hospital anticoagulants were prescribed in 19% of hospitalized patient. Not only the new clinical recommendations based on the results of the recent studies on anticoagulants efficacy and safety (external factors), but also implementation standard operating protocols and CDSS, providing physicians current information about the relevant clinical recommendations (internal changes), could influence the appropriateness of anticoagulants prescription.

Clinical outcomes of atrial fibrillation with hyperthyroidism

BACKGROUND

Atrial fibrillation (Afib) is a common cardiac manifestation of hyperthyroidism. The data regarding outcomes of Afib with and without hyperthyroidism are lacking.

HYPOTHESIS

We hypothesized that patients with Afib and hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism.

METHODS

We queried the National Inpatient Sample database for years 2015-2017 using Validated ICD-10-CM codes for Afib and hyperthyroidism. Patients were separated into two groups, Afib with hyperthyroidism and without hyperthyroidism.

RESULTS

The study was conducted with 68 095 278 patients. A total of 9 727 295 Afib patients were identified, 90 635 (0.9%) had hyperthyroidism. The prevalence of hyperthyroidism was higher in patients with Afib (0.9% vs 0.4%, P < .001), compared with patients without Afib. Using multivariate regression analysis adjusting for various confounding factors, the odds ratio of Afib with hyperthyroidism was 2.08 (CI 2.07-2.10; P < .0001). Afib patients with hyperthyroidism were younger (71 vs 75 years, P < .0001) and more likely to be female (64% vs 47%; P < .0001) as compared with Afib patients without hyperthyroidism. Afib patients with hyperthyroidism had lower prevalence of CAD (36% vs 44%, P < .0001), cardiomyopathy (24.1% vs 25.9%, P < .0001), valvular disease (6.9% vs 7.4%, P < .0001), hypertension (60.7% vs 64.4%, P < .0001), diabetes mellitus (29% vs 32%, P < .0001) and obstructive sleep apnea (10.5% vs 12.2%, P < .0001). Afib with hyperthyroidism had lower hospitalization cost ($14 968 ± 21 871 vs $15 955 ± 22 233, P < .0001), shorter mean length of stay (5.7 ± 6.6 vs 5.9 ± 6.6 days, P < .0001) and lower in-hospital mortality (3.3% vs 4.8%, P < .0001. The disposition to home was higher in Afib with hyperthyroidism patients (51% vs 42; P < .0001).

CONCLUSION

Hyperthyroidism is associated with Afib in both univariate and multivariate analysis. Afib patients with hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism.

Thromboembolic events following cardioversion of acute atrial fibrillation and flutter: a systematic review and meta-analysis

BACKGROUND

Recent studies have presented concerning data on the safety of cardioversion for acute atrial fibrillation and flutter. We conducted this meta-analysis to evaluate the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter patients of < 48 h in duration.

METHODS

We searched MEDLINE, Embase, and Cochrane from inception through February 6, 2020 for studies reporting thromboembolic events post-cardioversion of acute atrial fibrillation and flutter. Main outcome was thromboembolic events within 30 days post-cardioversion. Primary analysis compared thromboembolic events based on oral anticoagulation use versus no oral anticoagulation use. Secondary analysis was based on baseline thromboembolic risk. We performed meta-analyses where 2 or more studies were available, by applying the DerSimonian-Laird random-effects model. Risk of bias was assessed with the Quality in Prognostic Studies tool.

RESULTS

Of 717 titles screened, 20 studies met inclusion criteria. Primary analysis of seven studies with low risk of bias demonstrated insufficient evidence regarding the risk of thromboembolic events associated with oral anticoagulation use (RR = 0.82 where RR < 1 suggests decreased risk with oral anticoagulation use; 95% CI 0.27 to 2.47; I² = 0%). Secondary analysis of 13 studies revealed increased risk of thromboembolic events with high baseline thromboembolic risk (RR = 2.25 where RR > 1 indicates increased risk with higher CHADS₂ or CHA₂DS₂-VASc scores; 95% CI 1.25 to 4.04; I² = 0%).

CONCLUSION

Primary analysis revealed insufficient evidence regarding the effect of oral anticoagulation use on thromboembolic events post-cardioversion of low-risk acute atrial fibrillation and flutter, though the event rate is low in contemporary practice. Our findings can better inform patient-centered decision-making when considering 4-week oral anticoagulation use for acute atrial fibrillation and flutter patients.

Comparative Analysis of Risk Stratification Scores in Atrial Fibrillation

BACKGROUND

Atrial Fibrillation (AF) has become a major global health concern and is associated with an increased risk of poor outcomes. Identifying risk factors in patients with AF can be challenging, given the high burden of comorbidities in these patients. Risk stratification schemes appear to facilitate accurate prediction of outcomes and assist therapeutic management decisions.

OBJECTIVE

To summarize current evidence on risk stratification scores for patients with AF.

RESULTS

Traditional risk models rely heavily on demographics and comorbidities, while newer tools have been gradually focusing on novel biomarkers and diagnostic imaging to facilitate more personalized risk assessment. Several studies have been conducted to compare existing risk schemes and identify specific patient populations in which the prognostic ability of each scheme excels. However, current guidelines do not appear to encourage the implementation of risk models in clinical practice, as they have not incorporated new ones in their recommendations for the management of patients with AF for almost a decade.

CONCLUSION

Further work is warranted to analyze new reliable risk stratification schemes and optimally implement them into routine clinical life.

Laboratory predictors of clinical outcomes in patients with atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice that affects intracardiac hemodynamics and is accompanied by increased mortality due to the risk of stroke and systemic thromboembolism. In recent years, numerous studies, evaluating the use of biomarkers in AF patients, have been conducted to expand the possibility of stratification the complications risks.

The aim of the review is to evaluate the possible isolated and combined predictive significance of NT-proBNP, troponin T (TnT) and D-dimer levels in the development and progression of AF and its thromboembolic complications according to published data. Determining the level of NT-proBNP can be used to diagnose cardioembolic stroke in latent forms of AF. Patients with a cardioembolic stroke have been shown to have higher BNP/NT-proBNP levels than patients with an atherothrombotic stroke and venous thromboembolism. Elevated TnT level is independently associated with AF detection as a cause of stroke. The assessment on the CHADS2 scale significantly correlates with the level of troponin I (TnI). However, it is equally important to take into account TnI level even with a low score of CHADS2. Patients with the level of TnI ≥ 0.040 pg/L are considered to be prescribed anticoagulants in the same way as the patients with high CHADS2 score. Similar results were obtained analyzing high-sensitivity cardiac troponin T (hs-cTnT) data. The level of D-dimer 0.315 mg/L was determined to be the optimal limit level for predicting the adverse functional outcome of stroke owing to AF. Patients with a high level of D-dimer have shown a high risk of developing thromboembolic and cardiovascular complications despite their taking anticoagulant drugs. D-dimer levels positively correlate with the CHA2DS2 and CHA2DS2-VASC scales of stroke risk stratification. The analysis of the biomarkers combination has revealed the increase of hs-cTnT and BNP associated with stroke in AF patients (p<0.05). However, ABC scale, including hs-cTnT and NT- pro BNP, hasn't given more accurate result in stroke predicting than CHA2DS2-VASc scale. The integration of biomarkers in predicting the risk of AF occurrence, progression and appearance of thromboembolic complications is a promising direction. An isolated level of biomarkers (hs-cTnT, NT-proBNP, D-dimer) and their combination with clinical risk factors can improve the quality of cardioembolic strokes prognosis.

Sex-Specific Prevalence, Incidence, and Mortality Associated With Atrial Fibrillation in Heart Failure

OBJECTIVES

This study sought to investigate the mortality associated with atrial fibrillation (AF) in men and women with heart failure (HF) according to the sequence of presentation and rhythm versus rate control.

BACKGROUND

The sex-specific epidemiology of AF in HF is sparse.

METHODS

Using the Danish nationwide registries, all first-time cases of HF were identified and followed for all-cause mortality from 1998 to 2018.

RESULTS

Among 252,988 patients with HF (mean age: 74 ± 13 years, 45% women), AF presented before HF in 54,064 (21%) and on the same day in 27,651 (11%) individuals, similar in women and men. Among patients without AF, the cumulative 10-year incidence of AF was 18.7% (95% confidence interval [CI]: 18.2% to 19.1%) in women and 21.3% (95% CI: 21.0% to 21.6%) in men. On follow-up (mean: 6.2 ± 5.8 years), adjusted mortality rate ratios were 3.33 (95% CI: 3.25 to 3.41) in women and 2.84 (95% CI: 2.78 to 2.90) in men if AF antedated HF, 3.45 (95% CI: 3.37 to 3.56) in women versus 2.76 (95% CI: 2.69 to 2.83) in men when AF and HF were diagnosed concomitantly, and 4.85 (95% CI: 4.73 to 4.97) in women versus 3.89 (95% CI: 3.80 to 3.98) in men when AF developed after HF. Compared with rate control for AF, a rhythm-controlling strategy was associated with lowered mortality in inverse probability-weighted models across all strata and in both sexes (hazard ratios: 0.75 to 0.83), except for women who developed AF after HF onset (hazard ratio: 1.03).

CONCLUSIONS

More than half of all men and women with HF will develop AF during their clinical course, with prognosis associated with AF being worse in women than men. Further studies are needed to understand the underlying mechanisms.

Current Drug Treatment Strategies for Atrial Fibrillation and TASK-1 Inhibition as an Emerging Novel Therapy Option

Atrial fibrillation (AF) is the most common sustained arrhythmia with a prevalence of up to 4% and an upwards trend due to demographic changes. It is associated with an increase in mortality and stroke incidences. While stroke risk can be significantly reduced through anticoagulant therapy, adequate treatment of other AF related symptoms remains an unmet medical need in many cases. Two main treatment strategies are available: rate control that modulates ventricular heart rate and prevents tachymyopathy as well as rhythm control that aims to restore and sustain sinus rhythm. Rate control can be achieved through drugs or ablation of the atrioventricular node, rendering the patient pacemaker-dependent. For rhythm control electrical cardioversion and pharmacological cardioversion can be used. While electrical cardioversion requires fasting and sedation of the patient, antiarrhythmic drugs have other limitations. Most antiarrhythmic drugs carry a risk for pro-arrhythmic effects and are contraindicated in patients with structural heart diseases. Furthermore, catheter ablation of pulmonary veins can be performed with its risk of intraprocedural complications and varying success. In recent years TASK-1 has been introduced as a new target for AF therapy. Upregulation of TASK-1 in AF patients contributes to prolongation of the action potential duration. In a porcine model of AF, TASK-1 inhibition by gene therapy or pharmacological compounds induced cardioversion to sinus rhythm. The DOxapram Conversion TO Sinus rhythm (DOCTOS)-Trial will reveal whether doxapram, a potent TASK-1 inhibitor, can be used for acute cardioversion of persistent and paroxysmal AF in patients, potentially leading to a new treatment option for AF.

Cortisol on Circadian Rhythm and Its Effect on Cardiovascular System

The synthesis and secretion of cortisol are controlled by the hypothalamic–pituitary–adrenal axis. Cortisol exhibits a proper 24-h circadian rhythm that affects the brain, the autonomic nervous system, the heart, and the vasculature that prepares the cardiovascular system for optimal function during these anticipated behavioral cycles. A literature search was conducted using databases such as Google Scholar, PubMed, and Scopus. Relevant search terms included “circadian rhythm and cardiovascular”, “cortisol”, “cortisol and acute coronary syndrome”, “cortisol and arrhythmias”, “cortisol and sudden cardiac death”, “cortisol and stroke”, and “cardioprotective agents”. A total of 120 articles were obtained on the basis of the above search. Lower levels of cortisol were seen at the beginning of sleep, while there was a rise towards the end of sleep, with the highest level reached at the moment the individual wakes up. In the present review, we discuss the role of 11β-hydroxysteroid dehydrogenase (11β-HSD1), which is a novel molecular target of interest for treating metabolic syndrome and type-2 diabetes mellitus. 11β-HSD1 is the major determinant of cortisol excess, and its inhibition alleviates metabolic abnormalities. The present review highlights the role of cortisol, which controls the circadian rhythm, and describes its effect on the cardiovascular system. The review provides a platform for future potential cardioprotective therapeutic agents.

Challenges in the Management of Atrial Fibrillation With Subclinical Hyperthyroidism

Subclinical thyroid disorders have a high prevalence among older individuals and women. Subclinical hypothyroidism is diagnosed by elevated serum levels of thyroid-stimulating hormone (TSH) with thyroxine levels within the reference range, and subclinical hyperthyroidism is diagnosed by low TSH in conjunction with thyroxine and triiodothyronine levels within reference ranges. Atrial fibrillation is the most commonly diagnosed cardiac arrhythmia and has been associated with an increased risk of mortality, heart failure, stroke, and depression. Mechanistic data from animal and human physiology studies as well as observational data in humans support an association of subclinical hyperthyroidism with atrial fibrillation. Guidelines recommend the measurement of TSH in the evaluation of new-onset atrial fibrillation. All patients with overt hyperthyroidism should be treated, and treatment of subclinical hyperthyroidism should be considered in patients older than 65 years with TSH < 0.4 mlU/L, or in younger patients with TSH < 0.1 mlU/L. Guidelines also recommend screening for AF in patients with known hyperthyroidism. Wearable devices that measure the heart electrical activity continuously may be a novel strategy to detect atrial fibrillation in patients at risk. In this review, we explore the interplay between thyroid hormones and atrial fibrillation, management controversies in subclinical hyperthyroidism, and potential strategies to improve the management of atrial fibrillation in patients with subclinical hyperthyroidism.

Does Warfarin or Rivaroxaban at Low Anticoagulation Intensity Provide a Survival Benefit to Asian Patients With Atrial Fibrillation?

Background: Low-dose rivaroxaban and low-intensity warfarin are widely used in Asia for patients with atrial fibrillation (AF). However, in Asians, it is unclear whether low-dose rivaroxaban and low-intensity warfarin can improve the prognosis of AF. In this study, we investigate the survival benefits of low-dose rivaroxaban and low-intensity warfarin in Asian patients with AF in clinical practice. Methods: This cohort study used medical records in a single tertiary hospital in China, between 2019 and 2020, to identify patients with AF who used rivaroxaban or warfarin, or had no anticoagulant therapy. Follow-ups were performed through telephone contact or medical record review. Cox proportional hazards models were used to compare the risk of mortality of patients in the anticoagulant-untreated group vs. warfarin-treated groups and rivaroxaban-treated groups. Results: A total of 1727 AF patients, discharged between 2019 and 2020, were enrolled in this cohort, of which 873 patients did not use any anticoagulant, 457 patients received warfarin and 397 patients used rivaroxaban. Multivariable analysis showed that, of all the warfarin groups, patients with an international normalized ratio (INR) below 2, good INR control, or poor INR control had a significantly lower risk of mortality compared with that of patients without anticoagulants (HR 0.309, p = 0.0001; HR 0.387, p = 0.0238; HR 0.363, p < 0.0001). Multivariable Cox proportional hazard analyses also demonstrated that, compared with the no anticoagulant group, all rivaroxaban dosage groups (≤10 mg, HR 0.456, p = 0.0129; 15 mg, HR 0.246, p = 0.0003; 20 mg, HR 0.264, p = 0.0237) were significantly associated with a lower risk of mortality. Conclusion: Despite effects being smaller than observed with recommended optimal anticoagulation, the use of warfarin with an INR below 2, poor INR control and the use of low-dose rivaroxaban may still provide survival benefits, suggesting viable alternatives that enable physicians to better resolve decisional conflicts concerning the risks and benefits of anticoagulant therapies, as well as for patients in need of but unable to receive standard anticoagulant therapy due to bleeding risk or other factors, such as financial burden, concerns of adverse outcomes, as well as low treatment compliance and persistence.

Risk factors for new-onset atrial fibrillation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

New-onset atrial fibrillation (AF) in patients with chronic obstructive pulmonary disease (COPD) is associated with an accelerated decline in lung function, and a significant increase in mortality rate. A deeper understanding of the risk factors for new-onset AF during COPD will provide insights into the relationship between COPD and AF and guide clinical practice. This systematic review and meta-analysis is designed to identify risk factors for new-onset AF in patients with COPD, and to formulate recommendations for preventing AF in COPD patients that will assist clinical decision making.

METHODS

PubMed, Embase, Web of Science and Cochrane Library databases were searched for studies, which reported the results of potential risk factors for new-onset AF in COPD patients.

RESULTS

Twenty studies involving 8,072,043 participants were included. Fifty factors were examined as potential risk factors for new-onset AF during COPD. Risk factors were grouped according to demographics, comorbid conditions, and COPD- and cardiovascular-related factors. In quantitative analysis, cardiovascular- and demographic-related factors with a greater than 50% increase in the odds of new-onset AF included age (over 65 years and over 75 years), acute care encounter, coronary artery disease, heart failure and congestive heart failure. Only one factor is related to the reduction of odds by more than 33.3%, which is black race (vs white). In qualitative analysis, the comparison of the risk factors was conducted between COPD-associated AF and non-COPD-associated AF. Cardiovascular-related factors for non-COPD-associated AF were also considered as risk factors for new-onset AF during COPD; however, the influence tended to be stronger during COPD. In addition, comorbid factors identified in non-COPD-associated AF were not associated with an increased risk of AF during COPD.

CONCLUSIONS

New-onset AF in COPD has significant demographic characteristics. Older age (over 65 years), males and white race are at higher risk of developing AF. COPD patients with a history of cardiovascular disease should be carefully monitored for new-onset of AF, and appropriate preventive measures should be implemented. Even patients with mild COPD are at high risk of new-onset AF. This study shows that risk factors for new-onset AF during COPD are mainly those associated with the cardiovascular-related event and are not synonymous with comorbid factors for non-COPD-associated AF. The pathogenesis of COPD-associated AF may be predominantly related to the cardiac dysfunction caused by the chronic duration of COPD, which increases the risk of cardiovascular-related factors and further increases the risk of AF during COPD.

PROSPERO REGISTRATION NUMBER

CRD42019137758.

A Real-world Experience of the Safety and Efficacy of Non-vitamin K Oral Anticoagulants Versus Warfarin in Patients with Non-valvular Atrial Fibrillation— A Single-centre Retrospective Cohort Study in Singapore

Introduction: Non-vitamin K oral anticoagulants (NOACs) were shown to have better outcomes than warfarin for non-valvular atrial fibrillation (NVAF). Given limited local real-world data, this study aims to evaluate the safety and efficacy of NOACs versus warfarin for NVAF in Singapore. Methods: This single-centre retrospective cohort study included 439 patients ≥ 21 years old that were newly prescribed with oral anticoagulants (OACs) for NVAF in 2015. Follow-ups for patients upon OAC initiation lasted either for 2 years or until the occurrence of bleeding or thromboembolism event or death (whichever was earlier). Primary endpoints included major bleeding and stroke, while secondary endpoints included overall bleeding and thromboembolic events. Time-to-events was evaluated via Kaplan-Meier survival analysis. Data on time in therapeutic range (TTR) and compliance were analysed. Results: Patients were assigned to 4 groups: warfarin (157, 35.8%), rivaroxaban (154, 35.1%), apixaban (98, 22.3%) and dabigatran (30, 6.8%). With a mean age of 70.8 (±10.8) years old, the population were predominantly males (56.5%) and comprised Chinese (73.8%), Malays (18.7%) and others (7.5%). The rates of stroke per year were 0.7%, 1.7%, 2.2% and 0% for warfarin, rivaroxaban, apixaban and dabigatran, respectively (P=0.411), whereas those of major bleeding were 2.7%, 1.4%, 2.2% and 0% (P=0.560). As compared to warfarin, no significant differences were observed for risks of stroke and of major bleeding for rivaroxaban (adjusted hazard ratio (HR) 4.19, 95% confidence interval (CI) 0.68–26.05, P=0.124 and adjusted HR 0.43, 95% CI 0.12–1.59, P=0.207) and apixaban (adjusted HR 5.33, 95% CI 0.85–33.34, P=0.074 and adjusted HR 1.54, 95% CI 0.39–6.15, P=0.538). Mean TTR was 68.8% (±24.3%) for warfarin. Compliance rates for rivaroxaban, apixaban, and dabigatran were 56.6%, 59.2%, and 44.8% respectively (P=0.177). Conclusion: NOACs were associated with similar stroke and major bleeding rates as warfarin for NVAF. Keywords: Anticoagulant, Asian, atrial fibrillation, compliance, haemorrhage, thrombosis

Evaluating the cost-effectiveness of catheter ablation of atrial fibrillation

Background

The pursuit of a clearer understanding of the pathogenesis of atrial fibrillation (AFib) and the development of new technology has resulted in a surge of interest in the surgical ablation for AFib. Here, we report our 8-year experience in the surgical treatment and management of AFib alongside, evaluating the cost-effectiveness in southern Mainland China over a 1-year follow-up.

Methods

Data of 3,068 patients from March 2011 through June 2019 was retrospectively extracted from The Provincial National Cardiac Database of Xiangya Second Hospital. The activities considered (and costs calculated) were outpatient consultations, hospital admissions, and drug treatment. Quality of life (QoL) questionnaires were also carried out to assess whether concomitant AFib correction procedures increase risk in patients, or improve patient's QoL.

Results

A total of 3,068 patients completed the questionnaires at a minimum of one time-point during the follow-up. The total cost was combined to obtain incremental costs per quality-adjusted life-years (QALYs). The total costs of the AFib catheter ablation group were remarkably higher compared to surgery as usual group. The incremental cost-effectiveness ratio was $76,513,227 (¥542,287,667) per QALY, with an acceptability line graph for cost at 43%.

Conclusions

AFib is an extraordinarily costly and worrisome public health problem. Precision medicine is vital as it provides a platform for the clinical translation of targeted interventions that are designed to help treat and prevent AFib. Thus, to improve the QoL expectancy outcome(s), both therapeutic and surgical interventions should be aimed at addressing the underlying heart disease rather than restoring sinus rhythm.

Revisiting Antiarrhythmic Drug Therapy for Atrial Fibrillation: Reviewing Lessons Learned and Redefining Therapeutic Paradigms

Since the clinical use of digitalis as the first pharmacological therapy for atrial fibrillation (AF) 235 years ago in 1785, antiarrhythmic drug therapy has advanced considerably and become a cornerstone of AF clinical management. Yet, a preventive or curative panacea for sustained AF does not exist despite the rise of AF global prevalence to epidemiological proportions. While multiple elevated risk factors for AF have been established, the natural history and etiology of AF remain incompletely understood. In the present article, the first section selectively highlights some disappointing shortcomings and current efforts in antiarrhythmic drug therapy to uncover reasons why AF is such a clinical challenge. The second section discusses some modern takes on the natural history of AF as a relentless, progressive fibro-inflammatory "atriomyopathy." The final section emphasizes the need to redefine therapeutic strategies on par with new insights of AF pathophysiology.

Healthcare costs of NVAF patients treated with rivaroxaban and apixaban in the US

OBJECTIVES

To provide the most current assessment of real-world healthcare resource utilization (HRU) and costs among patients with non-valvular atrial fibrillation (NVAF) who newly initiated rivaroxaban and apixaban using a large US database.

MATERIAL AND METHODS

A retrospective weighted cohort design was used with healthcare insurance claims from the Optum Clinformatics Data Mart databases (January 2012-December 2018). The index date was defined as the first dispensing of rivaroxaban or apixaban. Adult NVAF patients with an index date on or after 1 January 2016, ≥ 12 months of continuous eligibility before the index date and ≥ 1 month after, and without prior use of oral anticoagulant were included. The observation period spanned from the index date to the earliest of the end of data availability, end of insurance coverage, or death. Inverse probability of treatment weighting (IPTW) was used to adjust for differences in baseline characteristics between cohorts. All-cause healthcare resource utilization (HRU), including hospitalization, emergency room, and outpatient visits, and healthcare costs, including medical and pharmacy costs, were evaluated from the payer's perspective during the observation period up to 18 and 24 months, separately.

RESULTS

In total, 23,822 rivaroxaban and 53,666 apixaban users were included. After weighting, all baseline characteristics were well balanced between cohorts (mean age: 73.8 years, female: 46.6% in both cohorts). Up to 18 months of follow-up, rivaroxaban users incurred significantly lower total healthcare costs compared to apixaban users (cost difference = -$1,121; p = 0.020), driven by significantly lower rates of outpatient hospital visits and associated costs (cost difference = -$1,579; p < 0.001). Similar results were found in the analysis conducted for up to 24 months of follow-up (total cost difference = ‒$1,111; p = 0.020).

CONCLUSIONS

In this large retrospective analysis, patients with NVAF initiated on rivaroxaban incurred significantly lower healthcare costs compared to those initiated on apixaban, which were primarily driven by significantly lower outpatient visits and costs during the 18- and 24-month follow-up periods.

[Cardiac CT-Scan: Utility for the management of chest pain, cardiovascular screening and before atrial fibrillation ablation procedure]

Cardiac CT-scan is recommended for sorting patients presenting with stable or acute chest pain with low to intermediate risk of coronary artery disease (CAD). Recent studies have shown its reliability for diagnosing CAD in high-risk patients, notably those with acute coronary syndrome (ACS) without ST-elevation. Coronary CT-scan also represents a great opportunity for the screening of atherosclerosis in patients at risk and allows a better prevention of coronary artery disease by introduction of preventive treatments in patients with abnormal coronary CT-scan, especially statins. It is useful for the follow-up of patients who underwent a coronary arteries revascularization with either stents or bypasses. Coronary arteries calcium scoring appears to be an independent predictive factor of cardiovascular and total mortality and its use is recommended for stratifying the cardiovascular risk. However, its interpretation remains unobvious and the patient management is poorly improved by the results. Anyway, if the score is above zero, atherosclerosis is present and therefore a lipid lowering treatment should be discussed. Cardiac CT-scan has become the Gold Standard exam before an aortic valve replacement, for the measurement of the aortic root notably, allowing the best prothesis selection. Before atrial fibrillation ablation procedure by pulmonary vein isolation, the cardiac CT-scan allows a 3-D visualization of the two atria, especially the left atrium, and rules out any suspicion of cardiac thrombus. It allows the research of an anomalous pulmonary venous connection. The 3-D support will also enable the operator to navigate in the heart during the ablation procedure.

Evaluation of late atrial enhancement by cardiac magnetic resonance imaging in patients with obstructive sleep apnea

INTRODUCTION

Atrial fibrillation (AF) is a growing public health problem especially due to its association with thromboembolic phenomena. Among its risk factors, obstructive sleep apnea (OSA) has increased in incidence and is often under diagnosed. OSA increases the risk of AF by mechanisms not fully known, but it may lead to remodeling and structural alteration of the atria. Cardiac magnetic resonance (CMR), in addition to assessing heart morphology, allows the identification of areas of fibrosis, including the atrium, by the late gadolinium enhancement technique (LGE) and could identify cases of OSA with potential atrial instability.

OBJECTIVE

To evaluate the relationship of LGE atrial by CMR in patients with atrial fibrillation with OSA.

METHODS

We selected 81 patients who were divided into four groups: Group 1: 20 OSA patients without AF, Group 2: 20 OSA and AF patients, Group 3: 21 patients with only atrial fibrillation without OSA and Group 4: 20 healthy patients without associated comorbidities. All underwent CMR for morphofunctional evaluation and LGE research.

RESULTS

The average age was 57.1+-10.59 years. Clinical variables such as hypertension (p = 0.24) and Diabetes Mellitus (p = 0.20) were not predictors of AF in OSA patients. Of the 40 cases with OSA, 18, 45% had severe obstructive disorder, and in this group AF was more prevalent. The mean left ventricular ejection fraction was 62.9% (+-7.46) and it did not differ between groups (p = 0.2). Patients with concomitant OSA and AF had significantly larger left atria (p < 0.001). Cases of OSA with AF showed significantly more atrial LGE (95% vs. 30%, p < 0.001), being an independent predictor in multivariate analysis (P < 0,001).

CONCLUSION

Atrial LGE is independently associated with the presence of AF in patients with OSA. These elements may help to identify cases of higher risk for developing AF in OSA patients in clinical practice.

Anticoagulant Therapy in Initially Low-Risk Patients With Nonvalvular Atrial Fibrillation Who Develop Risk Factors

Background

The CHA₂DS₂‐VASc score has been validated for stroke risk prediction in patients with atrial fibrillation (AF). Antithrombotic therapy is not recommended for low‐risk patients with AF (CHA₂DS₂‐VASc 0 [male] or 1 [female]). We studied a cohort of initially low‐risk patients with AF in relation to their development of incident comorbidities and their treatment on oral anticoagulation therapy.

Methods and Results

We assessed data from 14 441 low‐risk patients with AF (CHA₂DS₂‐VASc score of 0 [male] or 1 [female]) using the Korean National Health Insurance Service database, in relation to their development of incident stroke risk factors and adverse outcomes. The clinical end point was the occurrence of ischemic stroke, major bleeding, all‐cause death, or the composite outcome (ischemic stroke + major bleeding + all‐cause death). In our cohort, 2615 (29.1%) male and 1650 (30.3%) female patients acquired at least 1 new stroke risk factor during a mean follow‐up of 2.0 years. Among the patients with an increasing CHA₂DS₂‐VASc score ≥1, male and female patients treated with oral anticoagulants had a significantly lower risk of ischemic stroke (male: hazard ratio [HR], 0.62 [95% CI, 0.44–0.82; P=0.003]; female: HR, 0.65 [95% CI, 0.47–0.84; P=0.007]), all‐cause death (male: HR, 0.67 [95% CI, 0.49–0.88; P=0.009]; female: HR, 0.82 [95% CI, 0.63–1.02; P=0.185]), and composite outcomes (male: HR, 0.78 [95% CI, 0.61–0.95; P=0.042]; female: HR, 0.79 [95% CI, 0.62–0.96; P=0.045]) than patients not treated with oral anticoagulants.

Conclusions

Approximately 30% of patients acquired ≥1 stroke risk factor over a 2‐year follow‐up period. Low‐risk patients with AF should be regularly reassessed to adequately identify those with incident stroke risk factors that would merit thromboprophylaxis for the prevention of stroke and the composite outcome.

Cerebrovascular Disease and Cognition in Chronic Kidney Disease Patients

Chronic kidney disease (CKD) affects both brain structure and function. Patients with CKD have a higher risk of both ischemic and hemorrhagic strokes. Age, prior disease history, hypertension, diabetes, atrial fibrillation, smoking, diet, obesity, and sedimentary lifestyle are most common risk factors. Renal-specific pathophysiologic derangements, such as oxidative stress, chronic inflammation, endothelial dysfunction, vascular calcification, anemia, gut dysbiosis, and uremic toxins are important mediators. Dialysis initiation constitutes the highest stroke risk period. CKD significantly worsens stroke outcomes. It is essential to understand the risks and benefits of established stroke therapeutics in patients with CKD, especially in those on dialysis. Subclinical cerebrovascular disease, such as of silent brain infarction, white matter lesions, cerebral microbleeds, and cerebral atrophy are more prevalent with declining renal function. This may lead to functional brain damage manifesting as cognitive impairment. Cognitive dysfunction has been linked to poor compliance with medications, and is associated with greater morbidity and mortality. Thus, understanding the interaction between renal impairment and brain is important in to minimize the risk of neurologic injury in patients with CKD. This article reviews the link between chronic kidney disease and brain abnormalities associated with CKD in detail.

A cost-effectiveness analysis model of Preventicus atrial fibrillation screening from the point of view of statutory health insurance in Germany

BACKGROUND

With atrial fibrillation (AF) the risk of stroke is 4.2-fold increased to a comparable population without AF. This risk decreases by up to 70% if AF is detected early enough and effective stroke preventive measures are taken as recommended by international guidelines. Long-term studies found large number of subjects with undiagnosed AF. Preventicus Heartbeats" is a hands-on screening tool for use on smartphone to diagnose AF with high sensitivity and specificity. The aim of this study is to research the cost-effectiveness of systematic screening for AF with this smartphone application.

METHOD

Employing a Markov model we analysed the cost-effectiveness of the "Preventicus Heartbeats" screening for Germany, i.e. from the perspective of German statutory sick funds.

RESULTS

For a cohort of 10,000 insured 75-year-old the use of the diagnostic app could avoid 60 strokes in the remaining lifetime thereof 32 strokes in the next four years. Former models have applied similar cohorts. The same cohort showed an increase in quality-adjusted life years (QALY) in the remaining lifetime of 165 QALYs in the scenario with screening versus. without screening and a decrease in discounted lifetime costs (including risk compensation effects) of €129 per participant (€148 for male, €114 for female participants).

CONCLUSIONS

The modelling demonstrates the health benefits and economic effects of an implementation of a systematic screening on AF with "Preventicus Heartbeats", given the perspective of the German payer, the statutory health care system.

Apixaban: An Update of the Evidence for Its Place in the Prevention of Stroke in Patients with Atrial Fibrillation

Oral anticoagulant therapy for stroke prevention in atrial fibrillation patients has been remarkably changed by the introduction of non-vitamin k oral anticoagulants (NOAC). Apixaban was the third NOAC introduced to clinical practice. Aim was to outline the current evidence for Apixaban in stroke prevention in atrial fibrillation patients in the randomized trials and real-world data. Apixaban has been shown to be superior to warfarin in preventing stroke and systemic embolism and causes significantly less major bleeding based on large randomized trials. These data are confirmed in real-world studies. Apixaban has been shown to be safe and effective in atrial fibrillation patients in acute coronary syndrome or undergoing PCI in combination with a P2Y₁₂ inhibitor. Regarding expanded use of apixaban also in valvular heart disease patients, there is still missing knowledge in relation to the safety and efficacy of apixaban which is being addressed by ongoing randomized clinical trials.

Latent Classes of Adherence to Oral Anticoagulation Therapy Among Patients With a New Diagnosis of Atrial Fibrillation

Importance

Less than half of US patients with a diagnosis of atrial fibrillation (AF) receive oral anticoagulation.

Objectives

To identify patients with similar patterns of adherence to regimens of warfarin and direct oral anticoagulants (DOACs) in the first year after AF diagnosis and to evaluate associations between patient characteristics and membership in latent classes of adherence.

Design, Setting, and Participants

This retrospective cohort study used 2013 to 2016 Medicare claims data to identify 7491 patients with a new diagnosis of AF in 2014 to 2015 who initiated warfarin after AF diagnosis and 9478 patients with a new diagnosis of AF in 2014 to 2015 who initiated DOAC treatment after AF diagnosis, for a total of 16 969 Medicare beneficiaries. Participants were followed up for 12 months after AF diagnosis. Statistical analysis was performed from February 1 to November 30, 2018.

Exposures

Treatment with warfarin or DOAC after AF diagnosis.

Main Outcomes and Measures

The main outcome was the proportion of days that patients received warfarin or DOAC, measured in 30-day intervals after AF diagnosis. Independent variables included patient demographic characteristics, socioeconomic status, region of residence, and clinical characteristics. Latent class mixed models were used to identify latent classes of warfarin and DOAC adherence, and polytomous logistic regression was used to assess the association between patient characteristics and membership in each latent class.

Results

Among the 7491 patients receiving warfarin (4348 women), the mean (SD) age was 76.0 (10.0) years; among the 9478 patients receiving DOAC (5496 women), the mean (SD) age was 77.0 (8.5) years. Four latent classes of patients were identified based on warfarin adherence: late initiators (980 [13%]), early initiators who discontinued therapy at months 1 to 3 (1297 [17%]) or at months 5 to 10 (735 [10%]), and continuously adherent patients (4479 [60%]). Four latent classes of patients were also identified based on DOAC adherence: patients who initiated DOAC in months 1 to 5 (1368 [14%]) or months 6 to 11 (800 [8%]), patients with suboptimal and decreasing adherence (2267 [24%]), and continuously adherent patients (5043 [53%]). Membership in latent classes of warfarin adherence was significantly associated with sex, eligibility for Medicaid and income subsidy, region of residence, CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) risk score, and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, and drugs or alcohol) score. Membership in latent classes of DOAC adherence was significantly associated with race/ethnicity, region of residence, HAS-BLED score, and use of antiarrhythmic medications.

Conclusions and Relevance

This study found that, among patients who initiated anticoagulation therapy, 40% of those who initiated warfarin therapy and 47% of those who initiated DOAC treatment did not continuously adhere to therapy in the first year after AF diagnosis. Identifying longitudinal patterns of warfarin and DOAC adherence and the factors associated with them provides suggestions for the design of targeted strategies to mitigate suboptimal oral anticoagulation use.

Significant cardiac disease complicating Graves' disease in previously healthy young adults

SUMMARY

Graves' disease is associated with tachydysrythmia, cardiac ischaemia and cardiomyopathy - all uncommon in young adults without previous cardiac disease. We present three young individuals who developed cardiac complications after periods of uncontrolled Graves' disease. Subject 1: A 34-year-old female had severe thyrotoxic symptoms for weeks. Investigations showed fT4: 98.4 (11-25 pmol/L), fT3: 46.9 (3.1-6.8 pmol/L), TSH <0.01 (0.27-4.2 mU/L) and thyrotrophin receptor antibody (TRAb): 34.8 (<0.9 U//l). She had appropriate treatment but several weeks later she became breathless despite improving thyroid function. Echocardiography showed a pericardial effusion of 2.9 cm. She responded well to steroids and NSAIDs but developed active severe Graves' orbitopathy after early total thyroidectomy. Subject 2: A 28-year-old male developed thyrotoxic symptoms (fT4: 38 pmol/L, fT3: 13.9 pmol/L, TSH <0.01 (for over 6 months) and TRAb: 9.3 U/L). One month after starting carbimazole, he developed acute heart failure (HF) due to severe dilated cardiomyopathy - EF 10-15%. He partially recovered after treatment - EF 28% and had early radioiodine treatment. Subject 3: A 42-year-old woman who had been thyrotoxic for several months (fT4: 54.3; fT3 >46.1; TSH <0.01; TRAb: 4.5) developed atrial fibrillation (AF) and heart failure. Echocardiography showed cardiomegaly - EF 29%. She maintains sinus rhythm following early total thyroidectomy (EF 50%). Significant cardiac complications may occur in previously fit young adults, who have had uncontrolled Graves' disease for weeks to months. Cardiac function recovers in the majority, but early definitive treatment should be discussed to avoid Graves' disease relapse and further cardiac decompensation.

LEARNING POINTS

Cardiac complications of Graves' disease are uncommon in young adults without previous cardiac disease. These complications may however occur if Graves' disease had been poorly controlled for several weeks or months prior to presentation. Persistent symptoms after adequate control should alert clinicians to the possibility of cardiac disease. Specific treatment of Graves' disease and appropriate cardiac intervention results in complete recovery in the majority and carries a good prognosis. Early definitive treatment should be offered to them to prevent cardiac decompensation at times of further relapse.

Rate Control Management of Atrial Fibrillation With Rapid Ventricular Response in the Emergency Department

BACKGROUND

There exists limited evidence on managing atrial fibrillation (AF) with rapid ventricular response in the emergency department. We sought to better understand the burden of disease in patients with AF for whom rhythm control was not successful or not attempted and identify opportunities for improved care.

METHODS

We conducted a health records review of consecutive visits of patients with AF at 2 academic emergency departments. We included patients ≥ 18 years with AF, heart rate ≥ 100 beats per minute (bpm), and who were not successfully cardioverted or not attempted cardioversion. Outcomes were: (1) incidence given rate control, (2) management practices, (3) adverse events, (4) compliance with guidelines, and (5) outcomes. We performed descriptive statistics.

RESULTS

We included 665 visits, with mean age ± standard deviation 77.4 ± 12.9, female 51.6%, mean ± standard deviation heart rate 121.6 ± 17.4 bpm, AF status (permanent 53.4%; paroxysmal 29.5%; persistent 17.1%), admitted 61.4%. Of all cases, 147 (22.1%) had primary AF and 518 (77.9%) had a rapid rate secondary to a medical cause (heart failure 12.8%; pneumonia 11.7%; sepsis 8.4%). In 117 with primary AF given rate control, 59.0% had a final rate ≤ 100 bpm and 7.7% suffered adverse events. Suboptimal use of rate control occurred in 47.0% (agent 2.6%; route 27.4%; dosage 9.4%; timing 7.7%). At discharge, 11.5% with CHADS-65 risk factors were still not anticoagulated.

CONCLUSIONS

Most patients had a rapid rhythm secondary to a medical cause. There were a concerning number of adverse events related to suboptimal use of rate control. Better awareness of guidelines will ensure safer use of rate control.

Drug-eluting versus bare-metal stents for first myocardial infarction in patients with atrial fibrillation: A nationwide population-based cohort study

BACKGROUND

Acute myocardial infarction (AMI) complicates the clinical management of atrial fibrillation (AF) because coronary stenting may influence subsequent antithrombotic therapy. We investigated the use of a bare-metal stent (BMS) or a drug-eluting stent (DES) and associated outcomes in patients with pre-existing AF and first AMI undergoing percutaneous coronary intervention.

METHODS AND RESULTS

Patient records in this population-based study were retrospectively collected from the Taiwan National Health Insurance Research Database. Using propensity score matching (PSM), we used 1:2 ratio stratification into a DES group of 436 and a BMS group of 785 patients from 2007 to 2011. The mean follow-up of matched cohorts was 1.7 years. After PSM, DESs were associated with lower rates of cardiovascular death (7.8%, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.86 and 10.1%, HR 0.64, 95% CI 0.45-0.90) and primary composite outcome (35.1%, HR 0.76, 95% CI 0.63-0.92 and 48.2%, HR 0.81, 95% CI 0.69-0.96) than BMSs within the first year and at the end of follow-up. Although the greatest benefit from DESs, irrespective of the first- and second- generation DESs, implantation was observed within the first year only, this benefit was not observed in patients with diabetes, chronic kidney disease, or dialysis.

CONCLUSIONS

Use of DESs in AMI patients with pre-existing AF is associated with significantly lower rates of cardiovascular death and primary composite outcome within the first year follow-up. However, the effect is not apparent in patients with diabetes, chronic kidney disease or dialysis.

Atrial Fibrillation Post Coronary Artery Graft Surgery: A Review Of Literature

Atrial fibrillation (AF) is a failure that is observed in heart disease and is also known to be the most common heart rhythm disturbance post coronary artery bypass surgery. Although AF is considered a transient problem, it is usually accompanied with a variety of complications and morbidity for patients and may result in death. In the present study, pre- and post-operative considerable factors which may increase the risk and mortality of AF, and possible treatments have been concisely reviewed.