Atrial fibrillation: comorbidities, lifestyle, and patient factors

Comorbidity patterns and mortality in atrial fibrillation: a latent class analysis of the EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF)

BACKGROUND

Most older patients with atrial fibrillation (AF) have comorbidities. However, it is unclear whether specific comorbidity patterns are associated with adverse outcomes. We identified comorbidity patterns and their association with mortality in multimorbid older AF patients with different multidimensional frailty.

METHODS

Hospitalised adults aged ≥65 years with non-valvular AF were followed for 12 months in the multicentre EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF). Demographic characteristics, coexisting medical conditions, use of medications including anticoagulants, and the Multidimensional Prognostic Index (MPI) were captured on discharge. We used latent class analysis (LCA) to identify comorbidity phenotypes and Cox regression to determine associations between identified phenotypes and 12-month mortality.

RESULTS

Amongst n = 2,019 AF patients (mean ± SD age 82.9 ± 7.5 years), a 3-class LCA solution was considered optimal for phenotyping. The model identified phenotype 1 (hypertensive, other circulatory conditions, metabolic diseases; 33%), phenotype 2 (digestive diseases, infection, injury, non-specific clinical and laboratory abnormalities; 26%), and phenotype 3 (heart failure, respiratory diseases; 41%). Overall, 512 patients (25%) died within 12 months. Compared to phenotype 1, after adjusting for age, sex, use of anticoagulants, cardiovascular medications, and proton pump inhibitors, and individual MPI domains, phenotype 3 had a significantly higher risk of mortality (adjusted hazard ratio = 1.27, 95% CI = 1.01 to 1.60). In contrast, the risk of mortality in phenotype 2 was not different to phenotype 1.

CONCLUSION

We observed an association between comorbidity phenotypes identified using LCA and mortality in older AF patients. Further research is warranted to identify the mechanisms underpinning such associations.

Economic burden of disease and mortality of intracranial haemorrhage under oral FXai: a German claims data analysis

BACKGROUND

Intracranial haemorrhage (ICH) is one of the most serious complications of anticoagulant therapy with oral factor Xa inhibitors (FXai). To meet an urgent medical need of optimising treatment pathways, we assessed the frequency of ICH during oral FXai treatment, as well as the associated burden on the German healthcare system.

METHODS

Our study was based on a claims database comprising over 4 million people with statutory health insurance in Germany. The study included people initiating oral FXai treatment for the first time between 2016 and 2021, and who experienced ICH during a three-year treatment period. For a balanced comparison of hospitalisations, costs, and mortality, propensity score matching between patients with and without ICH was performed.

RESULTS

During the study period, 78,086 patients had started oral FXai therapy, of which 530 experienced ICH during the therapy. The incidence rate of ICH was highest within the first 90 days after the start of oral FXai therapy during follow-up with 0.64 events per 100 patient-years (PY; 95% CI: 0.52-0.77%). Three-month mortality rates were significantly higher among patients who had experienced an ICH event (39.4%; 95% CI: 35.4-43.8%), as opposed to patients without ICH (5.9%; 95% CI: 4.2-8.3%). This difference prevailed during follow-up, while mortality increased at roughly equal rates in both patient groups. Patients with ICH were on average hospitalised for 40.4 days/PY (95% CI: 35.7 days - 45.2 days) in the first year after the event; comparable patients without ICH were hospitalised for 10.8 days/PY (95% CI: 8.3 days - 13.2 days). Annual total costs per patient were €37,328 (95% CI: €32,243-€42,412) for patients with ICH, and €10,564 (95% CI: €9,298-€11,831) for patients without ICH. Hospitalisation costs were the main driver with 86.1% versus 50.8%, respectively.

CONCLUSIONS

Incidence rates of ICH during oral FXai therapy were within the range of other published real-world data. Duration of hospitalisations, associated costs, and mortality were high and significantly higher for patients with ICH than for comparable patients without ICH. The high burden on the healthcare system highlights the need for preventive measures and more efficient treatment pathways for patients with ICH under oral FXai therapy.

The Elderly Patient with Atrial Fibrillation: Optimal Treatment Strategies

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with its prevalence expected to rise significantly due to global population aging [...].

Exercise-based cardiac rehabilitation for patients with atrial fibrillation: a narrative review

The role of physical activity (i.e. any bodily movement that requires energy expenditure) and exercise (i.e. planned, structured, and repetitive physical activity to improve/maintain fitness) in the primary and secondary prevention of atrial fibrillation (AF) is increasingly recognized. Physical activity has been associated with lower risks to develop AF and associated complications (e.g. stroke, heart failure, and myocardial infarction). Exercise-based cardiac rehabilitation (ExCR) is increasingly examined in the treatment of AF and sometimes combined with rhythm control strategies (e.g. catheter ablation). Nonetheless, several important clinical, practical, and mechanistic questions remain not fully understood. This state-of-the-art review first provides a contemporary update on the evidence base for the clinical effects of ExCR in AF. Despite the ongoing need for high-quality studies, existing randomized controlled trials and cohort studies suggest ExCR reduces AF burden, lowers risks for major adverse cardiovascular events, and improves health-related quality of life. Second, to facilitate implementation of ExCR, we have observed comparable effects of distinct exercise protocols (e.g. type of training and centre-/home-based) and discussed similarity of effectiveness across patient characteristics (e.g. age, sex, and AF subtype). Critically, we have discussed potential barriers that may prohibit the uptake of ExCR for patients with AF, categorized at clinician- (e.g. referral and training), patient- (e.g. motivation, transportation, and psychosocial factors), and system-levels (e.g. insurance and resources). Third, we have summarized the potential mechanisms underlying these effects of ExCR, classified by their potential role in reducing AF burden (e.g. atrial/ventricular function, autonomic balance, and inflammation) and lowering risks for adverse events (e.g. modifiable risk factors, vascular function, and thrombogenesis). Based on the increasing evidence for clinical benefits, e.g. improved health-related quality of life and better clinical outcomes, we advocate stronger focus on regular physical activity and referral to multidisciplinary ExCR for sustainable lifestyle changes within the ESC AF-CARE pathway for the prevention and treatment of AF.

Cardiovascular health and risks of atrial fibrillation and its prognosis

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia around the world with an increased risk of a broad spectrum of adverse comorbidities and death. Whether cardiovascular health (CVH) is associated with AF development remains unclear.

Methods

238,420 participants without cardiovascular disease at baseline were selected from the UK Biobank study cohort from 2006 to 2010. CVH was defined based on "Life's Essential 8″ scores. Sex-specific multi-state Markov and flexible parametric survival models were used to estimate the hazard ratio (HR) and 95 % confidence intervals (95 % CI) for the associations of CVH with incident AF and its prognosis.

Results

In fully-adjusted models, CVH is significantly associated with a reduced risk of incident AF among both men and women, after accounting for the potential impact of death. Among AF patients without other evaluated diseases, a higher CVH score was generally linked with a reduced risk of death in both sexes. Among AF patients with incident prognostic diseases, only CVH associated with death following heart failure (0.78, 0.63-0.97) was observed among men, whereas CVH was significantly associated with death following coronary heart disease (0.80, 0.69-0.93), stroke (0.73, 0.61-0.89) and dementia (0.79, 0.71-1.03) among women.

Conclusions

We found significant associations between CVH and the risk reduction of incident AF and its prognostic outcomes, with these associations being more pronounced among women. Findings suggest a potential of screening CVH for both primary prevention of new-onset AF and the secondary prevention to improve AF prognosis.

Prognostic implications of iron deficiency in patients with atrial fibrillation, with and without chronic heart failure

BACKGROUND

Iron deficiency (ID) is common in patients with atrial fibrillation/flutter (AF), but its prognostic implications and optimal diagnostic criteria, particularly in those with and without heart failure (HF), remain unclear. This study assessed the associations between different ID definitions and clinical outcomes in patients with AF.

METHODS

This Danish nationwide cohort study included 10 834 patients with AF who underwent iron studies between 2008 and 2019, stratified by HF status. ID was defined using four criteria: European Society of Cardiology (ESC) guidelines, ferritin <100 ng/mL, transferrin saturation (TSAT) <20% and serum iron ≤13 µmol/L. Associations between ID definitions and all-cause mortality, cardiovascular mortality and all-cause hospitalisation were evaluated using Cox regression models, adjusted for confounders.

RESULTS

Prevalence of ID varied substantially across definitions, ranging from 36.2% to 62.7%. Over a median follow-up of 31 months, TSAT <20% was associated with increased all-cause and cardiovascular mortality in both HF (HR 1.25, 95% CI 1.14 to 1.37 and HR 1.31, 95% CI 1.14 to 1.49, respectively) and patients without HF (HR 1.39, 95% CI 1.18 to 1.64 and HR 1.54, 95% CI 1.18 to 2.00, respectively). Similarly, serum iron ≤13 µmol/L was associated with higher all-cause and cardiovascular mortality in HF (HR 1.44, 95% CI 1.31 to 1.58 and HR 1.42, 95% CI 1.24 to 1.63, respectively) and patients without HF (HR 1.67, 95% CI 1.41 to 1.97 and HR 1.46, 95% CI 1.13 to 1.89, respectively). ID defined by ESC guidelines or ferritin <100 ng/mL was not associated with mortality in either group but was linked to higher all-cause hospitalisation in patients with HF (HR 1.15, 95% CI 1.08 to 1.23 and HR 1.16, 95% CI 1.09 to 1.23, respectively).

CONCLUSIONS

ID defined by TSAT <20% or serum iron ≤13 µmol/L is associated with increased mortality in patients with AF, irrespective of HF status, highlighting these criteria as clinically relevant for risk stratification.

The Role of Early Risk Factor Modification and Ablation in Atrial Fibrillation Substrate Remodeling Prevention

Atrial fibrillation (AF) is the most common sustained arrhythmia, contributing to significant morbidity and healthcare burden worldwide. This review evaluates the role of early risk factor modification and timely catheter ablation in preventing AF progression and improving patient outcomes. A comprehensive literature search was conducted using PubMed, MEDLINE, and Google Scholar, focusing on studies published after the ESC 2020 guidelines for the diagnosis and management of AF up to the release of the updated ESC 2024 guidelines for the management of AF. Keywords included "atrial fibrillation", "catheter ablation", "risk factor management", and "psychological stress". Relevant clinical trials, randomized controlled trials, systematic reviews, and meta-analyses were included, with particular emphasis on novel studies contributing to the ESC 2024 updated recommendations. Traditional risk factors such as obesity, hypertension, diabetes, sleep apnea, alcohol consumption, and physical exertion are well established in AF progression. Early evidence also suggests a role for psychological stress and mood disorders, including depression and post-traumatic stress disorder (PTSD), in increasing AF susceptibility. Psychological stress and mood disorders are linked to AF primarily through behavioral changes such as poor medication adherence, unhealthy lifestyle choices, and increased substance use. Recent guidelines recommend early catheter ablation in selected patients to reduce AF burden, prevent atrial remodeling, and improve quality of life, particularly in those resistant to antiarrhythmic drugs or individuals with AF-induced cardiomyopathy. Furthermore, we highlight the importance of a patient-centered, multidisciplinary approach, integrating electrophysiologists, cardiologists, and primary care providers with structured risk factor interventions and shared decision-making. Despite these advances, gaps remain in defining optimal timing, patient selection, and long-term benefits of catheter ablation in persistent AF, necessitating the need for further research. By integrating early intervention, personalized treatment strategies, and collaborative care models, we may usher in a paradigm shift in AF management, improving long-term cardiovascular outcomes and patient quality of life.

Diagnosis and management of comorbid disease in COPD

COPD is one of the most common chronic respiratory conditions and is associated with high healthcare use, morbidity and mortality. Multimorbidity in COPD is common and confers a worse prognosis. Despite this, there is delayed and often under-diagnosis of comorbid diseases in COPD. Knowledge of the respiratory and non-respiratory pathologies that can coexist with COPD is essential to ensure early detection and appropriate management. This review provides an overview of the comorbidities that have been described in COPD. We discuss their pathogenesis, pitfalls in their diagnosis, and strategies for their prevention and treatment.

Peak left atrial longitudinal strain and incident atrial fibrillation in the general population: a systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is the commonest supraventricular arrhythmia in adults. Timely AF diagnosis seems to ameliorate patients prognosis.

PURPOSE

To investigate the association between peak left atrial longitudinal strain (PALS) and new onset AF in the general population.

OBJECTIVES

We searched major electronic databases for articles assessing the relationship between PALS and incident AF.

RESULTS

Eight studies (11,145 patients) were analysed. Lower levels of PALS were significantly associated with higher risk of incident AF (HR: 0.95; 95%CI: 0.92-0.97, I2: 83%). According to the diagnostic accuracy meta-analysis, PALS <33.4% presents 64% (95%CI: 46-79%) sensitivity and 69% (95%CI: 63-75%) specificity.

CONCLUSIONS

In a relatively healthy population, lower levels of PALS were significantly associated with incident AF. The overall diagnostic accuracy was moderate. Lower levels of PALS seem to justify an opportunistic - rather than a systematic-screening approach. These findings could allow more efficient utilisation of healthcare resources.

2024 Chinese Expert Consensus Guidelines on the Diagnosis and Treatment of Atrial Fibrillation in the Elderly, Endorsed by Geriatric Society of Chinese Medical Association (Cardiovascular Group) and Chinese Society of Geriatric Health Medicine (Cardiovascular Branch): Executive Summary

The consensus guidelines of the Geriatric Society of Chinese Medical Association on the management of atrial fibrillation (AF) in the elderly was first published in 2011 and updated in 2016, with endorsement by Chinese Society of Geriatric Health Medicine. Since then, many important studies regarding the screening and treatment in the elderly population have been reported, necessitating this updated expert consensus guideline. The writing committee members comprehensively reviewed updated evidence pertaining to elderly patients with AF, and formulated this 2024 update. The highlighted issues focused on the following: screening for AF, geriatric comprehensive assessment, use of the Atrial fibrillation Better Care (ABC) pathway for the elderly patients, and special clinical settings related to elderly patients with AF. New recommendations addressing smart technology facilitated AF screening, ABC pathway based management, and optimal anticoagulation were developed, with a focus on the elderly.

Beyond pulmonary vein isolation: approaches to treat patients with persistent atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is the most common arrhythmia. Catheter ablation is a successful rhythm control strategy in paroxysmal AF, but it has demonstrated dramatically lower AF-free survival rates in patients with persistent AF. In recent years, myriad novel rhythm control strategies have been developed, each with the promise of improved persistent AF ablation success.

AREAS COVERED

This review discusses multiple novel techniques and approaches to persistent AF. Authors identified relevant papers by searching PubMed and Google Scholar databases and considered all papers identified, regardless of publication date. It begins by discussing recent advances in electrogram analysis that yielded improved AF-free survival following persistent AF catheter ablation. Next, it discusses several trials revealing the shortcomings of MRI in guiding persistent AF ablation. Finally, it discusses one nascent technique (Vein of Marshall ablation) and technology (AI-assisted electrogram analysis) who have shown promise in improving persistent AF ablation.

EXPERT OPINION

In the authors' expert opinions, upcoming persistent AF ablations will utilize a stepwise approach of (1) ensuring PV isolation, (2) Vein of Marshall ablation and (3) AI-assisted ablation to optimize future persistent AF ablation outcomes. This approach systematically addresses arrhythmogenic sources beyond the pulmonary veins, the historical treatment target.

Multidisciplinary Approach in Atrial Fibrillation: As Good as Gold

Atrial fibrillation (AF) represents the most common sustained arrhythmia necessitating dual focus: acute complication management and sustained longitudinal oversight to modulate disease progression and ensure comprehensive patient care over time. AF is a multifaceted disorder; due to such a great number of potential exacerbating conditions, a multidisciplinary team (MDT) should manage AF patients by cooperating with a cardiologist. Effective management of AF patients necessitates the implementation of a well-coordinated and tailored care pathway aimed at delivering optimized treatment through collaboration among various healthcare professionals. Management of AF should be carefully evaluated and mutually agreed upon in consultation with healthcare providers. It is crucial to recognize that treatment may evolve due to the emergence of new risk factors, symptoms, disease progression, and advancements in treatment modalities. In the context of multidisciplinary AF teams, a coordinated approach involves assembling a diverse team tailored to meet individual patients' unique needs based on local services' availability.

Bidirectional two-sample Mendelian randomization study of association between smoking initiation and atrial fibrillation

INTRODUCTION

The relationship between smoking and heart disease has been frequently reported. Therefore, we aimed to explore the association between smoking initiation and atrial fibrillation.

METHODS

Genetic association data pertaining to smoking initiation and atrial fibrillation were obtained from genome-wide association studies (GWAS). Phenotypically related single nucleotide polymorphisms (SNPs) were selected as instrumental variables. Inverse-variance weighted (IVW), weighted median, Mendelian randomization (MR), Egger regression, simple mode, and weighted mode methods were employed to perform the MR study. The association between smoking initiation and atrial fibrillation was evaluated using odds ratios (OR) and 95% confidence intervals (CI). Cochran's Q test was employed to assess heterogeneity among instrumental variables, utilizing the IVW and MR-Egger methods. The Egger-intercept method was employed to test for horizontal pleiotropy, and the 'leave-one-out' method was utilized for sensitivity analysis.

RESULTS

The MR results for the effect of smoking initiation on atrial fibrillation (IVW, OR=1.11; 95% CI: 1.02-1.20, p=0.013) supported an association between smoking initiation and an increased likelihood of atrial fibrillation. In total, 85 SNPs were extracted from the GWAS pooled data as instrumental variables. The MR-Egger method indicated an intercept close to 0 (Egger intercept= -0.005, p=0.371), suggesting no horizontal pleiotropy in the selected instrumental variables. The 'leave-one-out' sensitivity analysis demonstrated that the results were robust and that no instrumental variables significantly influenced the results. Reverse MR analysis indicated no effect of atrial fibrillation on smoking initiation (IVW, OR=1.00; 95% CI: 0.99-1.02, p=0.684).

CONCLUSIONS

Smoking initiation has a significant impact on atrial fibrillation. However, atrial fibrillation did not influence smoking initiation. This study provides novel insights into the genetic relationships between smoking initiation and atrial fibrillation.

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.