Left atrial enlargement is an independent predictor of stroke and systemic embolism in patients with non-valvular atrial fibrillation

Impact of left ventricular diastolic function and direct oral anticoagulant use for predicting embolic events in patients with heart failure and atrial fibrillation

Background

Patients with atrial fibrillation (AF) and heart failure (HF) have high stroke risk owing to left atrial dysfunction. However, anticoagulation is a concern in patients with high bleeding risk. We aimed to identify independent predictors of stroke in HF patients with AF.

Methods

We retrospectively examined 320 patients (mean age 79 ± 12 years, 163 women) hospitalized with acute HF complicated by AF between January 2014 and December 2018. Patients were followed from admission until ischemic stroke or systemic embolism (SSE) onset or death or were censored at the last contact date or September 2023.

Results

SSE occurred in 40 patients (median follow-up of 528 days). Multivariate Cox regression analysis identified age (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.00-1.07, p = .034), direct oral anticoagulant (DOAC) use (HR 0.26, 95% CI 0.11-0.60, p = .002), and early diastolic peak flow velocity to early diastolic peak annular velocity (E/e'; HR 1.05, 95% CI 1.02-1.08, p < .001) to be independent predictors of SSE, whereas left atrial reservoir strain was not. After determining an appropriate E/e' cutoff by receiver-operating characteristic curve analysis and adjusting the multivariate Cox model, E/e' ≥17.5 (HR 3.30, 95% CI 1.56-6.83, p = .001) independently predicted SSE. The results were consistent with no interaction in the subanalysis except for gender.

Conclusion

Elderly patients not on DOACs with elevated E/e' may be at higher risk of stroke, suggesting that DOACs should be the first choice for patients with elevated E/e' and aggressive additional prophylaxis and careful follow-up are needed.

Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis

BACKGROUND

New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation.

METHODS

MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates.

RESULTS

We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke.

CONCLUSION

These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.

Enhancing the evaluation of acute ischemic stroke risk in individuals with non-valvular atrial fibrillation by including laboratory indicators

To investigate the clinical significance of the CHA2DS2-VASc-60 score, lipoprotein (a) [Lp(a)], red blood cell distribution width (RDW), and their combined effect in patients with non-valvular atrial fibrillation (NVAF) who experience acute ischemic stroke (AIS). This retrospective analysis was conducted on the clinical data of hospitalized patients with NVAF at the Third Affiliated Hospital of Anhui Medical University between April 1, 2020, and April 1, 2023. Based on the diagnosis of acute ischemic stroke (AIS), the patients were divided into two groups: the AIS group (150 cases of NVAF patients with comorbid AIS) and the non-AIS group (163 cases of NVAF patients without AIS). We performed CHA2DS2-VASc-60 scoring for all patients and collected their laboratory indicators and echocardiographic indicators during hospitalization. The study comprised 313 individuals with NVAF in total. There is a statistically significant difference (P < 0.05) in the comparison of CHA2DS2-VASc-60 score (5.68 ± 1.12 vs. 3.67 ± 1.47), Lp(a) [23.98 (13.28, 42.22) vs. 14.32 (7.96, 21.91)] and RDW (13.67 ± 1.25 vs. 12.94 ± 0.76) between NVAF patients with and without concomitant AIS. The results of the Spearman correlation analysis demonstrate a positive association between Lp(a) and RDW levels and both the CHA2DS2-VASc score and the CHA2DS2-VASc-60 score in patients with NVAF. Multivariate logistic regression analysis revealed that CHA2DS2-VASc-60 score [OR = 6.549, 95% CI: 4.110-10.433, P < 0.05], Lp(a) [OR = 1.023, 95% CI: 1.005-1.041, P < 0.05], and RDW [OR = 1.644, 95% CI: 1.071-2.525, P < 0.05] were independent risk factors for AIS in patients with non-valvular atrial fibrillation (NVAF). The receiver operator characteristic (ROC) curves showed that the area under the curve of CHA2DS2-VASc-60 score, Lp(a), RDW, and CHA2DS2-VASc-60 score combined with Lp(a) and RDW predicted that NVAF patients with AIS were 0.881 [95% CI: 0.804-0.906], 0.685 [95% CI: 0.626-0.744], 0.695 [95% CI: 0.637-0.754], and 0.906 [95% CI: 0.845-0.921], respectively. The CHA2DS2-VASc-60 score, Lp(a), and RDW were significantly increased in NVAF patients with AIS, which were independent risk factors for NVAF patients with AIS. The combination of the three has a high predictive capacity for NVAF patients with AIS.

Association of left atrial enlargement with heart failure events in non-valvular atrial fibrillation patients with preserved left ventricular ejection fraction

Aims

Atrial fibrillation (AF) increases the risk of heart failure (HF); however, little is known regarding the risk stratification for incident HF in AF patients, especially with preserved left ventricular ejection fraction (LVEF).

Methods and results

The Fushimi AF Registry is a community-based prospective survey of AF patients. From the registry, 3002 non-valvular AF patients with preserved LVEF and with the data of antero-posterior left atrial diameter (LAD) at enrolment were investigated. Patients were stratified by LAD (<40, 40-44, 45-49, and ≥50 mm) with backgrounds and HF hospitalization incidences compared between groups. Of 3002 patients [mean age, 73.5 ± 10.7 years; women, 1226 (41%); paroxysmal AF, 1579 (53%); and mean CHA2DS2-VASc score, 3.3 ± 1.7], the mean LAD was 43 ± 8 mm. Patients with larger LAD were older and less often paroxysmal AF, with a higher CHA2DS2-VASc score (all P < 0.001). Heart failure hospitalization occurred in 412 patients during the median follow-up period of 6.0 years. Larger LAD was independently associated with a higher HF hospitalization risk [LAD ≥ 50 mm: hazard ratio (HR), 2.36; 95% confidence interval (CI), 1.75-3.18; LAD 45-49 mm: HR, 1.84; 95% CI, 1.37-2.46; and LAD 40-44 mm: HR, 1.34; 95% CI, 1.01-1.78, compared with LAD < 40 mm) after adjustment by age, sex, AF type, and CHA2DS2-VASc score. These results were also consistent across major subgroups, showing no significant interaction.

Conclusion

Left atrial diameter is significantly associated with the risk of incident HF in AF patients with preserved LVEF, suggesting the utility of LAD regarding HF risk stratification for these patients.

Automated Atrial Fibrillation Diagnosis by Echocardiography without ECG: Accuracy and Applications of a New Deep Learning Approach

BACKGROUND

Automated rhythm detection on echocardiography through artificial intelligence (AI) has yet to be fully realized. We propose an AI model trained to identify atrial fibrillation (AF) using apical 4-chamber (AP4) cines without requiring electrocardiogram (ECG) data.

METHODS

Transthoracic echocardiography studies of consecutive patients ≥ 18 years old at our tertiary care centre were retrospectively reviewed for AF and sinus rhythm. The study was first interpreted by level III-trained echocardiography cardiologists as the gold standard for rhythm diagnosis based on ECG rhythm strip and imaging assessment, which was also verified with a 12-lead ECG around the time of the study. AP4 cines with three cardiac cycles were then extracted from these studies with the rhythm strip and Doppler information removed and introduced to the deep learning model ResNet(2+1)D with an 80:10:10 training-validation-test split ratio.

RESULTS

634 patient studies (1205 cines) were included. After training, the AI model achieved high accuracy on validation for detection of both AF and sinus rhythm (mean F1-score = 0.92; AUROC = 0.95). Performance was consistent on the test dataset (mean F1-score = 0.94, AUROC = 0.98) when using the cardiologist's assessment of the ECG rhythm strip as the gold standard, who had access to the full study and external ECG data, while the AI model did not.

CONCLUSIONS

AF detection by AI on echocardiography without ECG appears accurate when compared to an echocardiography cardiologist's assessment of the ECG rhythm strip as the gold standard. This has potential clinical implications in point-of-care ultrasound and stroke risk stratification.

Predictive value of lipoprotein(a) for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA2DS2-VASc scores: a cross-sectional study

OBJECTIVE

Current guidelines are debated when it comes to starting anticoagulant therapy in patients with non-valvular atrial fibrillation (NVAF) and low CHA2DS2-VASc scores (1-2 in women and 0-1 in men). However, these individuals still have a high likelihood of developing left atrial thrombus/spontaneous echo contrast (LAT/SEC) and experiencing subsequent thromboembolism. Recent research has demonstrated that lipoprotein(a) [Lp(a)] may increase the risk of thrombosis, but the relationship between Lp(a) and LAT/SEC in NVAF patients is not clearly established. Therefore, this study sought to evaluate the predictive ability of Lp(a) for LAT/SEC among NVAF patients with low CHA2DS2-VASc scores.

METHODS

NVAF patients with available transesophageal echocardiography (TEE) data were evaluated. Based on the TEE results, the subjects were classified into non-LAT/SEC and LAT/SEC groups. The risk factors for LAT/SEC were examined using binary logistic regression analyses and were validated by using 1:1 propensity score matching (PSM). Subsequently, novel predictive models for LAT/SEC were developed by integrating the CHA2DS2-VASc score with the identified factors, and the accuracy of these models was tested using receiver operating characteristic (ROC) analysis.

RESULTS

In total, 481 NVAF patients were enrolled. The LAT/SEC group displayed higher Lp(a) concentrations. It was found that enlarged left atrial diameter (LAD), high concentrations of Lp(a), and a history of coronary heart disease (CHD) were independent predictors of LAT/SEC. Lp(a) and LAD still had predictive values for LAT/SEC after adjusting for PSM. In both the highest quartile groups of Lp(a) (>266 mg/L) and LAD (>39.5 mm), the occurrence of LAT/SEC was higher than that in the corresponding lowest quartile. By incorporating Lp(a) and the LAD, the predictive value of the CHA2DS2-VASc score for LAT/SEC was significantly improved.

CONCLUSION

Elevated Lp(a) and enlarged LAD were independent risk factors for LAT/SEC among NVAF patients with low CHA2DS2-VASc scores. The prediction accuracy of the CHA2DS2-VASc score for LAT/SEC was significantly improved by the addition of Lp(a) and LAD. When evaluating the stroke risk in patients with NVAF, Lp(a) and LAD should be taken into account together with the CHA2DS2-VASc score.

TRIAL REGISTRATION

Retrospectively registered.

Atrial Fibrillation Detection and Load: Knowledge Gaps Related to Stroke Prevention

Atrial fibrillation is a major cause of ischemic stroke. Technological advances now support prolonged cardiac rhythm monitoring using either surface electrodes or insertable cardiac monitors. Four major randomized controlled trials show that prolonged cardiac monitoring detects subclinical paroxysmal atrial fibrillation in 9% to 16% of patients with ischemic stroke, including in patients with potential alternative causes such as large artery disease or small vessel occlusion; however, the optimal monitoring strategy, including the target patient population and the monitoring device (whether to use an event monitor, insertable cardiac monitor, or stepped approach) has not been well defined. Furthermore, the clinical significance of very short duration paroxysmal atrial fibrillation remains controversial. The relevance of the duration of monitoring, burden of device-detected atrial fibrillation, and its proximity to the acute ischemic stroke will require more research to define the most effective methods for stroke prevention in this patient population.

Renin-angiotensin-aldosterone system inhibitors and mortality risk in elderly patients with atrial fibrillation. Insights from the nationwide START registry

BACKGROUND

Arterial hypertension is the most common cardiovascular comorbidity in atrial fibrillation (AF). Few studies investigated management strategies of hypertension in AF.

MATERIALS AND METHODS

We included 5769 AF patients on oral anticoagulants from the nationwide ongoing Italian START registry. We investigated the prescription of antihypertensive drugs and mortality risk. Subgroup analyses according to sex and major cardiovascular comorbidities were performed.

RESULTS

Mean age was 80.8 years, 46.1% were women; 80.3% of patients were hypertensive. Furosemide (30.1%) was the most frequent diuretic followed by hydrochlorothiazide (15.4%) and potassium canrenoate (7.9%). 61.1% received β-blockers: 34.2% bisoprolol, 6.2% atenolol. Additionally, 36.9% were on angiotensin converting enzyme inhibitors (ACE-I): ramipril (20.9%), enalapril (5.3%) and perindopril (2.8%); 31.7% were on angiotensin receptors blockers (ARBs): valsartan (7.6%) and irbesartan (6.4%). Amlodipine and lercanidipine were prescribed in 14.0% and 2.3%, respectively. ACE-I (p < 0.001), α-blockers (p = 0.020) and Dihydropyridines calcium channel blockers (p = 0.004) were more common in men, while ARBs (p = 0.008), thiazide diuretics (p < 0.001) and β-blockers (p < 0.001) in women. During 22.61 ± 17.1 months, 512 patients died. Multivariable Cox regression analysis showed that ACE-I (Hazard ratio [HR] 0.758, 95% Confidence Interval [95%CI] 0.612-0.940, p = 0.012) and ARBs (HR 0.623, 95%CI 0.487-0.796, p < 0.001) inversely associated with mortality. ACE-I/ARBs inversely associated with mortality in both sexes and in patients with diabetes. This associastion was evident for ACE-I in patients with previous cardiovascular disease, and for ARBs in HF.

CONCLUSION

A lower mortality risk was found in AF patients on ACE-I/ARBs. Different prescription patterns of antihypertensive drugs between men and women do exist.

Bidirectional Association Among the Type of Atrial Fibrillation, Sleep-Disordered Breathing Severity, Heart Failure Progression, and Left Atrial Enlargement, in Patients with Atrial Fibrillation

This study aimed to clarify (1) the association among the atrial fibrillation (AF) type, sleep-disordered breathing (SDB), heart failure (HF), and left atrial (LA) enlargement, (2) the independent predictors of LA enlargement, and (3) the effects of ablation on those conditions in patients with AF. The study's endpoint was LA enlargement (LA volume index [LAVI] ≥ 78 mL/m2).Of 423 patients with nonvalvular AF, 236 were enrolled. We evaluated the role of the clinical parameters such as the AF type, SDB severity, and HF in LA enlargement. Among them, 141 patients exhibiting a 3% oxygen desaturation index (ODI) of ≥ 10 events/hour underwent polysomnography to evaluate the SDB severity measured by the apnea-hypopnea index (AHI). The LA enlargement and HF were characterized by the LA diameter/LAVI, an increase in the B-type natriuretic peptide level, and a lower left ventricular ejection fraction.This study showed that non-paroxysmal AF (NPAF) rather than paroxysmal AF (PAF), the SDB severity, LA enlargement, and HF progression had bidirectional associations and exacerbated each other, which generated a vicious cycle that contributed to the LA enlargement. NPAF (OR = 4.55, P < 0.001), an AHI of ≥ 25.10 events/hour (OR = 1.55, P = 0.003), and a 3% ODI of ≥ 15.43 events/hour (OR = 1.52, P = 0.003) were independent predictors of an acceleration of the LA enlargement. AF ablation improved the HF and LA enlargement.To break this vicious cycle, AF ablation may be the basis for suppressing the LA enlargement and HF progression subsequently eliminating the substrates for AF and SDB in patients with AF.

Impact of left atrial diameter on all-cause mortality of patients with STEMI undergoing primary percutaneous coronary intervention

OBJECTIVES

To evaluating the predictive significance of the left atrial diameter in acute ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).

METHODS

The STEMI population came from 2 retrospective cohorts with 1097 patients, cohorts A (YongChuan Hospital) and cohorts B (Taizhou First People's Hospital). Within 3 days (cohort A) or 5 days (cohort B) post-PCI, patients underwent ultrasound evaluations. Cohort A was segmented into quartile categories based on eft atrial diameter (LAd) (Q1 to Q4). The odds ratios (ORs) for overall mortality were assessed using logistic regression. Cohort B was used for sensitivity analysis.

RESULTS

During follow-up period, 226 (20.6%) patients experienced endpoint. In cohort A, univariable odds ratios were 2.68 (95%CI 1.11~6.89), 5.32 (95%CI 2.46~12.83) and 11.92 (95%CI 5.78~27.92), while multivariate ORs were 2.25 (95%CI 0.82~6.55), 5.09 (95%CI 2.12~13.56), and 15.05 (95%CI 6.58~39.09) in Q2 to Q4 group, respectively, compared with Q1 group (p for trend <0.001). Upon subgroup evaluation, the correlation between LAd and the likelihood of overall mortality was more pronounced in patients having a left ventricular ejection fraction (LVEF) between 40% and 50%, and those with LVEF ≥50%, in contrast to those with LVEF <40% (p for interaction <0.001).

CONCLUSION

Left atrial diameter is indicative of the long-term overall mortality risk in STEMI patients post-PCI, particularly in those with an LVEF ≥ 40%.

Markers of Atrial Myopathy in the General Population: Prevalence, Predictors, and Inter-Relations

BACKGROUND

Atrial myopathy refers to structural and functional cardiac abnormalities associated with atrial fibrillation and stroke, but appropriate diagnostic criteria are lacking.

OBJECTIVES

This study aimed to assess prevalence, clinical correlates, and overlap between potential atrial myopathy markers.

METHODS

The population-based SCAPIS (Swedish CArdioPulmonary bioImage Study) prospectively included 6,013 subjects without atrial fibrillation with 24-hour electrocardiograms. Resting electrocardiograms measuring P-wave indices were collected at 1 screening site (n = 1,201), and a random sample (n = 385) had echocardiographic left atrial volume index (LAVi). Atrial myopathy markers were defined as ≥500 premature atrial complexes/24 h, LAVi ≥34 mL/m2, P-wave duration >120 milliseconds, or P-wave terminal force in V1 >4,000 ms·s. Clinical correlates included age, sex, body mass index, height, smoking, physical activity, coronary artery disease, diabetes, systolic blood pressure, antihypertensive medication, and low education.

RESULTS

Atrial myopathy was common; 42% of the sample with all diagnostic modalities available had ≥1 atrial myopathy marker, but only 9% had 2 and 0.3% had ≥3. Only P-wave duration and LAVi were correlated (ρ = 0.10; P = 0.04). Clinical correlates of premature atrial complexes, P-wave indices, and LAVi differed; current smoking (34% increase; P < 0.001), systolic blood pressure (4%/mm Hg increase; P = 0.01), diabetes (35% increase; P = 0.001), and coronary artery disease (71% increase; P = 0.003) were associated with premature atrial complexes, physical activity ≥2 h/wk was associated with increased LAVi (β-coefficient = 3.1; P < 0.0001) and body mass index was associated with P-wave duration (β-coefficient = 0.4/kg/m2; P < 0.0001).

CONCLUSIONS

In the general population, indirect markers of atrial myopathy are common but only weakly correlated, and their risk factor patterns are different. More studies are needed to accurately identify individuals with atrial myopathy with diagnostic methods.

Association between left atrial enlargement and poor cerebral collaterals in large vessel occlusion

OBJECTIVES

Left atrial enlargement (LAE) is a known risk factor for atrial fibrillation, a common cause of large vessel occlusion (LVO) leading to ischemic stroke. While robust cerebral collaterals protect penumbral tissue from infarction, the effect of structural heart disease on cerebral collaterals remains uncertain. This study aims to investigate the association between LAE and cerebral collaterals in patients with acute LVO stroke.

MATERIALS AND METHODS

We conducted a retrospective study of consecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 to 2020. Consecutive patients with echocardiography and computed tomography angiography (CTA) of the head were included. Multivariate logistic regression analysis was performed to evaluate the relationship between LAE and poor cerebral collaterals, adjusting for demographics (age, sex, race) and vascular risk factors (hypertension, diabetes and smoking).

RESULTS

The study included 235 patients with mean age of 69±15 years and an initial mean National Institutes of Health Stroke Scale score of 18. Of these, 89 (37.9 %) had LAE, and 105 (44.7 %) had poor collaterals. Patients with LAE were more likely to have poor collaterals compared to those without LAE (58.4 % vs 36.3 %, P = 0.001). LAE was independently associated with higher odds of poor collaterals (odds ratio, 2.47; P = 0.001), even after adjusting for covariables (odds ratio 1.84, P = 0.048).

CONCLUSIONS

Our study demonstrated a significant association between LAE and poor cerebral collaterals in patients with LVO stroke undergoing EVT. Further research is warranted to explore potential shared mechanisms, such as endothelial dysfunction, underlying this heart-brain association.

Left ventricular hypertrophy and left atrial size are associated with ischemic strokes among non-vitamin K antagonist oral anticoagulant users

BACKGROUND

Ischemic strokes (IS) occurring in patients taking non-vitamin K antagonist oral anticoagulants (NOACs) are becoming increasingly more frequent. We aimed to determine the clinical, echocardiographic, and neuroimaging markers associated with developing IS in patients taking NOACs for atrial fibrillation.

METHODS

From a quaternary care center, clinical/radiologic data were collected from consecutive NOAC users with IS and age-matched controls without IS. Brain MRIs were reviewed for markers of cerebral small vessel disease. Variables with significant differences between groups were entered into a multivariable regression model to determine predictors of IS. Among IS patients, a Cox regression analysis was constructed to determine predictors of IS recurrence during follow-up.

RESULTS

112 patients with IS and 94 controls were included in the study. Variables significantly different between groups included apixaban use, dabigatran use, prior cerebrovascular events, hemoglobin A1c (HbA1c), left ventricular hypertrophy, left atrial volume index, and severe white matter hyperintensities. After multivariable adjustment, prior cerebrovascular events (aOR 23.86, 95% CI [6.02-94.48]), HbA1c levels (aOR 2.36, 95% CI [1.39-3.99]), left ventricular hypertrophy (aOR 2.73, 95% CI [1.11-6.71]) and left atrial volume index (aOR 1.05, 95% CI [1.01-1.08]) increased the risk of stroke, whereas apixaban use appeared to decrease the risk (aOR 0.38, 95% CI [0.16-0.92]). Malignancy was associated with IS recurrence (aHR 4.90, 95% CI [1.35-18.42]) after adjustment for age and chronic renal failure.

CONCLUSIONS

Prior cerebrovascular events, diabetes, left ventricular hypertrophy, and increased left atrial size are risk factors for developing an IS among NOAC users.

Relationship between postoperative atrial fibrillation and its recurrence after lung resection

PURPOSE

Atrial fibrillation (AF) frequently occurs after pulmonary resection and is commonly referred to as postoperative atrial fibrillation (POAF). This study explored whether or not POAF is related to the recurrence of AF in the chronic phase.

METHODS

A total of 1311 consecutive patients without a history of AF who underwent lung resection based on a diagnosis of lung tumor were retrospectively analyzed.

RESULTS

POAF occurred in 46 patients (3.5%), and a logistic regression analysis revealed that the age (p < 0.05), history of hyperthyroidism (p < 0.05), and major lung resection (p < 0.05) were independent predictors of POAF. AF events in the chronic phase were observed in 15 (32.6%) and 45 (3.6%) patients with and without POAF, respectively. A Cox regression analysis revealed that POAF was the only independent predictor of AF development in the chronic phase (p < 0.01). The Kaplan-Meier curve and log-rank test revealed that the cumulative incidence of AF in the chronic phase was significantly higher in patients with POAF than in those without POAF (p < 0.01).

CONCLUSION

POAF was an independent predictor for AF in the chronic phase after lung resection. Further investigations including cases of catheter ablation and optimal medical therapy for patients with POAF after lung resection are needed.

Predictive Values of the CHA2DS2-VASc Score and Left Atrial Diameter for Cerebral Small Vessel Disease in Geriatric Patients With Atrial Fibrillation

Objective The objective of this study was to determine whether the CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex) score and left atrial diameter (LAD) could predict the presence of cerebral small vessel disease (cSVD) in patients older than 65 years with atrial fibrillation as the cause of ischemic stroke. Materials and methods In this study, we included patients over 65 years of age who had suffered an ischemic stroke caused by atrial fibrillation within 30 days after the onset of symptoms. The data recorded included demographics, electrocardiograms, Holter monitors, and echocardiography reports. The anteroposterior LAD, determined by transthoracic echocardiography, was analyzed. Each patient's CHA2DS2-VASc score was calculated. Brain magnetic resonance imaging (MRI) assessed white matter hyperintensities (WMH) on fluid-attenuated inversion recovery (FLAIR) images and cerebral microbleeds (CMBs) on susceptibility-weighted sequences. The Fazekas score, based on WMH on MRI, was used to grade the severity of gliosis. Participants were categorized into three groups according to their quantitative CMB burden. Findings The study included 60 participants, with a mean age of 80 years (range 65-99), and 43.3% (n = 26) were male. The CHA2DS2-VASc score had a mean value of 4.21 (range 2-8), and the mean LAD was 4.17 (range 2.6-5.3) cm. The CHA2DS2-VASc score did not predict CMBs (OR, 1.389; 95% CI, 0.961-2.008, p = 0.08) in geriatric stroke patients with atrial fibrillation. However, in the subgroup of patients with diabetes mellitus, the CHA2DS2-VASc score was higher in those with CMB 1-4 and CMB ≥ 5 than in those without CMB. Additionally, the risk of CMBs 1-4 increased with higher LAD compared to patients without LAD. Conclusion The LAD and CHA2DS2-VASc scores were not significantly associated with CMB prediction in elderly stroke patients with atrial fibrillation. In a diabetes mellitus subgroup, the CHA2DS2-VASc score was indicative of CMB. An increased LAD elevates the risk of CMBs in patients with coronary artery disease.

Multimodality Imaging in Patients with Hypertrophic Cardiomyopathy and Atrial Fibrillation

Ventricular hypertrophy is associated with diastolic dysfunction, resulting in increased left atrial (LA) pressure, enlargement, fibrosis, and decreased LA function. Hypertrophic cardiomyopathy (HCM) is characterized by myocyte disarray, myocardial fibrosis, and hypertrophy. Notably, a thickened and noncompliant LV results in the impairment of diastolic function. These conditions promote LA remodeling and enlargement, which contribute to developing and maintaining atrial fibrillation (AF). AF is an atrial arrhythmia that occurs frequently in HCM, and evaluating the morphology and physiology of the atrium and ventricle is important for treatment and prognosis determination in HCM patients with AF. In addition, it provides a clue that can predict the possibility of new AF, even in patients not previously diagnosed with AF. Cardiac magnetic resonance (CMR), which can overcome the limitations of transthoracic echocardiography (TTE), has been widely used traditionally and even enables tissue characterization; moreover, it has emerged as an essential imaging modality for patients with HCM. Here, we review the role of multimodal imaging in patients with HCM and AF.

Specific inflammatory profile of acute ischemic stroke patients with left atrial enlargement

Background

The inflammatory process underlying atrial myopathy may affect the inflammatory response activated in acute ischemic stroke (AIS).

Objectives

We aimed to assess whether left atrial enlargement (LAE) as a marker of atrial myopathy is associated with a different profile of circulating inflammatory markers in AIS patients.

Methods

HIBISCUS-STROKE is a cohort study including anterior circulation AIS patients treated with mechanical thrombectomy following MRI. Ten circulating inflammatory markers were measured at admission and 6, 24, and 48 h after admission. LAE was defined as a left atrial volume index (LAVi) ≥34 ml/m2. A multiple logistic regression model was performed to detect an independent association between the area under the curve (AUC) of these markers and LAE.

Results

We included 143 patients. Of them, 85 (59.4%) had LAE. On univariable analysis, we found that patients with LAE had higher soluble form suppression of tumorigenicity 2 (sST2), soluble tumor necrosis factor receptor I (sTNFR1), and vascular cellular adhesion molecule-1 (VCAM-1) AUC, were older, mostly female, had a higher National Institutes of Health Stroke Scale (NIHSS) score and blood glucose level at admission, had more often hypertension, and a cardioembolic source of AIS, such as atrial fibrillation, while they were less frequently current smokers and had a lower rate of tandem occlusion than patients without LAE. On multivariable analysis, we found that among circulating inflammatory markers, only high VCAM-1 (OR: 9.13, 95% CI: 3.21-25.9) and sST2 (OR: 3.40, 95% CI: 1.68-6.86) AUC remained associated with LAE.

Conclusions

High VCAM-1 and sST2 levels within the first 48 h are associated with LAE in AIS patients.

Left atrial enlargement and high uric acid level are risk factors for left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate embolic risk assessed by CHA2DS2-VASC score

Aims

To investigate the correlation and predictive value of left atrial diameter and blood uric acid levels with the occurrence of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA₂DS₂-VASc scores.

Methods and results

A total of 849 inpatients diagnosed with atrial fibrillation who had low to moderate CHA₂DS₂-VASc scores and complete transesophageal echocardiography were included in this study. Among them, 66 patients had left atrial thrombus or dense spontaneous echo contrast. When different models were used to correct other known risk factors, acid levels and abnormal left atrial diameter were identified as additional risk factors for left atrial thrombus or dense spontaneous echo contrast. The incidence of left atrial thrombus or dense spontaneous echo contrast was higher in patients with abnormal serum uric acid levels than in the control group (12.4% vs. 5.6%, p < 0.05), and this difference persisted after correcting the baseline data with propensity score matching (10.6% vs. 4.1%, p < 0.05). Abnormal left atrial diameter was another risk factor suggested by regression analysis, with an increased incidence of left atrial thrombus or dense spontaneous echo contrast in the abnormal left atrial diameter group compared to the control group, both before (18.0% vs. 3.5%, p < 0.05) and after (15.5% vs. 5.2%, p < 0.05) propensity score matching. The best predictive value was obtained by adding both abnormal serum uric acid levels and abnormal left atrial diameter.

Conclusion

Left atrial enlargement and high uric acid levels increase the risk of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA₂DS₂-VASc scores.

Predicting a decrease in left atrial appendage flow velocity using left atrial diameter and CHA2DS2-VASc score in patients with non-valvular atrial fibrillation

BACKGROUND

Left atrial (LA) appendage flow velocity (LAAFV) is a classic but invasive predictor of thromboembolic events in patients with atrial fibrillation (AF). We aimed to explore the usefulness of LA diameter (LAD) combined with CHA₂DS₂-VASc score, which is easily available and non-invasive, as a novel score for predicting a decrease in LAAFV in non-valvular AF (NVAF).

METHODS

In total, 716 consecutive NVAF patients who underwent transesophageal echocardiography were divided into the decreased LAAFV (< 0.4 m/s) and preserved LAAFV (≥ 0.4 m/s) groups.

RESULTS

The decreased LAAFV group had a larger LAD and a higher CHA₂DS₂-VASc score than the preserved LAAFV group (P < 0.001). Multivariate linear regression indicated that brain natriuretic peptide (BNP) concentration, persistent AF, LAD, and CHA₂DS₂-VASc score were remained inversely associated with LAAFV. Moreover, multivariate logistic regression revealed that BNP concentration (odds ratio [OR] 1.003, 95% confidence interval [CI] 1.001-1.005, P = 0.003), persistent AF (OR 0.159, 95% CI 0.102-0.247, P < 0.001), and LAD (OR 1.098, 95% CI 1.049-1.149, P < 0.001) were independent factors for a decrease in LAAFV. A novel score, LAD combined with CHA₂DS₂-VASc score, was more accurate for predicting a decrease in LAAFV among NVAF patients (area under the curve was 0.733).

CONCLUSION

Enlarged LAD was independent risk factor for a decrease in LAAFV among NVAF patients. LAD combined with CHA₂DS₂-VASc score enhanced the predictive ability for a decrease in LAAFV among NVAF patients.

Comparison of Biplane Area-Length Method and 3D Volume Quantification by Using Cardiac MRI for Assessment of Left Atrial Volume in Atrial Fibrillation

Purpose

To compare maximum left atrial (LA) volume (LAV) from the routinely used biplane area-length (BAL) method with three-dimensional (3D)-based volumetry from late gadolinium-enhanced MRI (3D LGE MRI) and contrast-enhanced MR angiography (3D CE-MRA) in patients with atrial fibrillation (AF).

Materials and Methods

Sixty-four patients with AF (mean age, 63 years ± 9 [SD]; 40 male patients) were retrospectively included from a prospective cohort acquired between October 2018 and February 2021. All patients underwent a research MRI examination that included standard two- and four-chamber cine acquisitions, 3D CE-MRA, and 3D LGE MRI performed prior to the atrial kick. Contour delineation on cine imaging and LA 3D segmentations were performed by a radiologist. Maximum LAV (BALmax) was extracted from the BAL volume-time curve and compared with LAV from 3D CE-MRA and 3D LGE MRI. The Kruskal-Wallis test was performed, followed by the Dunn post hoc test and Bland-Altman analyses. Interobserver variability was assessed in 10 patients.

Results

BALmax underestimated LAV compared with 3D CE-MRA (bias: -23.5 mL ± 46.2, P < .001) and 3D LGE MRI (bias: -31.3 mL ± 58.3, P < .001), whereas 3D LGE MRI volumes showed no evidence of a difference from 3D CE-MRA (bias: 7.8 mL ± 45.7, P = .38). Interobserver variability yielded excellent agreement for each method (intraclass correlation coefficient, 0.96-0.98).

Conclusion

BALmax underestimated LAV in patients with AF compared with 3D LGE MRI and 3D CE-MRA, suggesting that the geometric assumption of an ellipsoidal LA shape in BAL does not reflect LA geometry in patients with AF.Keywords: Left Atrial Volume, Biplane Area-Length, Late Gadolinium-enhanced 3D MRI, Contrast-enhanced 3D MR Angiography, Atrial Fibrillation Supplemental material is available for this article. © RSNA, 2023.

Left atrial CT volume and CHA2DS2-VASc score predict early pulmonary vein stump thrombus after left upper lobectomy

The purpose of this study is to clarify the feasibility of left atrial (LA) volume measurement and CHA₂DS₂-VASc score for predicting the development of pulmonary vein (PV) stump thrombus after left upper lobectomy (LUL). The study population comprised 50 patients who underwent LUL for pulmonary lesions. All patients were evaluated for the development of PV stump thrombus at 7 days after LUL. LA volume was measured using preoperative CT and the CHA₂DS₂-VASc score was evaluated. LA volume and CHA₂DS₂-VASc score were compared between patients with and without the development of PV stump thrombus using the Mann-Whitney U test. Receiver-operating characteristic (ROC) curve analysis was performed to evaluate the accuracy of prediction of PV stump thrombus development. PV stump thrombus was detected in 17 (33.4%) of the 50 patients. LA volume was significantly greater in patients who developed PV stump thrombus than in those without thrombus (79.7 ± 19.4 vs. 66.6 ± 17.0 mL, p = 0.040). CHA₂DS₂-VASc score was significantly higher in patients with PV stump thrombosis than in those without thrombus (3.4 ± 1.5 vs. 2.5 ± 1.5, p = 0.039). Area under the ROC curve values for predicting PV stump thrombus were 0.679, 0.676, and 0.714 for LA volume, CHA₂DS₂-VASc score, and their combination, respectively. In conclusion, LA volume measured using preoperative CT and CHA₂DS₂-VASc score may help predict the development of PV stump thrombus after LUL.

Factors associated with left atrial appendage filling defects on early-phase cardiac computed tomography in patients with nonvalvular atrial fibrillation: a case-control study

Background

The significance of left atrial appendage (LAA) filling defects on early-phase cardiac computed tomography (CCT) remains uncertain. This study retrospectively investigated predictive factors of LAA filling defects on early-phase CCT.

Methods

A total of 68 patients with nonvalvular atrial fibrillation (AF) and early filling defect on CCT who underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were enrolled [48 males, 20 females; mean ± standard deviation (SD) age 62.72±8.13 years]. Additionally 68 sex- and age-matched patients with normal LAA filling were included as the control group. CCT, ultrasound, clinical and laboratory data were analyzed. Baseline data between groups were analyzed using t-, Mann-Whitney, and chi-squared tests. Multivariable logistic regression analysis was used to adjust for confounders. Pearson correlation analysis was used to confirm correlations between variables.

Results

Decreased LAA flow velocity [LAAFV; odds ratio (OR) =0.918; 95% confidence interval (CI): 0.883-0.954; P<0.001] and increased left atrial volume index (LAVI; OR =1.055; 95% CI: 1.012-1.099; P=0.011) were significantly associated with early-phase CCT LAA filling defects. The LAAFV threshold for predicting early LAA filling defects was 40.5 cm/s, with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.905 (sensitivity 82.4%, specificity 91.2%); the LAVI predictive threshold was 58.77 mL/m² (AUC =0.840, sensitivity 85.3%, specificity 72.1%). A significant positive correlation was detected between LAAFV and the Hounsfield unit (HU) ratio of the LAA to ascending aorta on early-phase CCT (r=0.614; P<0.001), as well as the HU difference in LAA between early and delayed phase CCT (r=0.591; P<0.001). There were significant (P<0.05) differences in LAAFV between different filling defects.

Conclusions

Decreased LAAFV and increased LAVI are independent factors associated with LAA filling defects only on early-phase CCT. Early-phase CCT LAA filling defect is associated with LAA emptying dysfunction. These findings contribute to thrombosis risk stratification in patients with AF.

Atrial fibrillation and stroke

INTRODUCTION

Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified.

AREAS COVERED

This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract).

EXPERT OPINION

The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.

Left Atrial Diameter and the Risk of Thromboembolism in Patients with Left Ventricular Noncompaction

Aims: Patients with left ventricular noncompaction (LVNC) are at risk of thromboembolism. The relationship between left atrial diameter (LAD), a robust predictor for thrombosis, and LVNC is unclear. The purpose of this study was to explore the effect of LAD on the thrombotic risk in LVNC. Methods: In this retrospective cohort study, 320 patients with imaging characteristics of LVNC were included for statistical analysis. The primary endpoint was a composite event of intracardiac thrombi and stroke or transient ischemic attack (TIA). The secondary endpoints were intracardiac thrombi and stroke/TIA. Results: The 320 included patients (211 [65.9%] men, median age: 45 years [interquartile range: 30−57]) were divided into LAD1 (<43 mm, n = 157) and LAD2 (≥43 mm, n = 163) groups based on the median LAD. Throughout the median follow-up of 34 months, the incidence of thromboembolism among them was 7.2%: 11 (3.4%) patients had stroke/TIA and 14 (4.4%) had intracardiac thrombi. The rate of thromboembolism in the LAD2 group was higher than that of patients in the LAD1 group (11.0% vs. 3.2%, p = 0.007). Kaplan−Meier survival curves suggested that a LAD ≥ 43 mm was associated with a higher risk of thromboembolism and intracardiac thrombi (log-rank test, all p < 0.05). After adjusting for potential risk factors, LAD ≥ 43 mm was found to be an independent risk factor for thromboembolism (p = 0.013) and stroke (p = 0.024). The area under the receiver operating characteristic curve of LAD for predicting thromboembolism reached 0.696 at 1 year, 0.635 at 2 years, and 0.660 at 3 years. Conclusions: A larger LAD was related to a higher risk of thromboembolism in patients with LVNC. The LAD may be a useful predictor for thrombotic risk stratification among such patients.

Age-dependent risk for thromboembolism in atrial fibrillation: The Fushimi AF registry

Background

The risk for thromboembolism depending on the different age subgroups in patients with atrial fibrillation (AF) has not been fully elucidated.

Methods

The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto. Follow-up data were available for 4,466 patients by the end of 2019. Clinical determinants and the description of variables which interact and lead to the incidence of thromboembolism (the composite of ischemic stroke and systemic embolism [SE]) were identified in overall population and in age subgroups (≤64, 65–74, and ≥ 75 years).

Results

A total of 314 patients developed thromboembolism during the median follow-up of 1,610 days (1.56 per 100 person-years). The independent determinants were age advance (per 10 years, hazard ratio [HR]: 1.51, 95% confidence interval [CI]: 1.22–1.86, P < 0.001), low body weight (HR: 1.91, 95% CI: 1.35–2.70, P < 0.001), history of stroke or SE (HR: 2.06, 95% CI: 1.54–2.76, P < 0.001), chronic kidney disease (HR: 1.34, 95% CI: 1.01–1.78, P = 0.043), and left atrial enlargement (HR: 1.57, 95% CI: 1.18–2.10, P = 0.0021). With regard to the age subgroup analysis, diabetes mellitus (P = 0.043), vascular disease (P = 0.005), male sex (P = 0.022), and sustained AF (P = 0.014) indicated significantly relevant interactions between the age subgroups and thromboembolism.

Conclusion

The risk and the impact of baseline characteristics on thromboembolism in patients with AF varied depending on the age subgroups.

Multimodal Approach for the Prediction of Atrial Fibrillation Detected After Stroke: SAFAS Study

Background

Intensive screening for atrial fibrillation (AF) has led to a better recognition of this cause in stroke patients. However, it is currently debated whether AF Detected After Stroke (AFDAS) has the same pathophysiology and embolic risk as prior-to-stroke AF. We thus aimed to systematically approach AFDAS using a multimodal approach combining clinical, imaging, biological and electrocardiographic markers.

Methods

Patients without previously known AF admitted to the Dijon University Hospital (France) stroke unit for acute ischemic stroke were prospectively enrolled. The primary endpoint was the presence of AFDAS at 6 months, diagnosed through admission ECG, continuous electrocardiographic monitoring, long-term external Holter during the hospital stay, or implantable cardiac monitor if clinically indicated after discharge.

Results

Of the 240 included patients, 77 (32%) developed AFDAS. Compared with sinus rhythm patients, those developing AFDAS were older, more often women and less often active smokers. AFDAS patients had higher blood levels of NT-proBNP, osteoprotegerin, galectin-3, GDF-15 and ST2, as well as increased left atrial indexed volume and lower left ventricular ejection fraction. After multivariable analysis, galectin-3 ≧ 9 ng/ml [OR 3.10; 95% CI (1.03–9.254), p = 0.042], NT-proBNP ≧ 290 pg/ml [OR 3.950; 95% CI (1.754–8.892, p = 0.001], OPG ≥ 887 pg/ml [OR 2.338; 95% CI (1.015–5.620), p = 0.046) and LAVI ≥ 33.5 ml/m2 [OR 2.982; 95% CI (1.342–6.625), p = 0.007] were independently associated with AFDAS.

Conclusion

A multimodal approach combining imaging, electrocardiography and original biological markers resulted in good predictive models for AFDAS. These results also suggest that AFDAS is probably related to an underlying atrial cardiopathy.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT03570060].

Predicting cerebral infarction in patients with atrial fibrillation using machine learning: The Fushimi AF registry

The CHADS₂ and CHA₂DS₂-VASc scores are widely used to assess ischemic risk in the patients with atrial fibrillation (AF). However, the discrimination performance of these scores is limited. Using the data from a community-based prospective cohort study, we sought to construct a machine learning-based prediction model for cerebral infarction in patients with AF, and to compare its performance with the existing scores. All consecutive patients with AF treated at 81 study institutions from March 2011 to May 2017 were enrolled (n = 4396). The whole dataset was divided into a derivation cohort (n = 1005) and validation cohort (n = 752) after excluding the patients with valvular AF and anticoagulation therapy. Using the derivation cohort dataset, a machine learning model based on gradient boosting tree algorithm (ML) was built to predict cerebral infarction. In the validation cohort, the receiver operating characteristic area under the curve of the ML model was higher than those of the existing models according to the Hanley and McNeil method: ML, 0.72 (95%CI, 0.66-0.79); CHADS₂, 0.61 (95%CI, 0.53-0.69); CHA₂DS₂-VASc, 0.62 (95%CI, 0.54-0.70). As a conclusion, machine learning algorithm have the potential to perform better than the CHADS₂ and CHA₂DS₂-VASc scores for predicting cerebral infarction in patients with non-valvular AF.

Left atrial booster-pump function as a predictive parameter for atrial fibrillation in patients with severely dilated left atrium

BACKGROUND

Left atrial (LA) dimension ≥50 mm had approximately four times the risk of developing atrial fibrillation (AF). The aim of this study was to investigate whether the application of clinical and echocardiographic parameters could differentiate between the patients having severely dilated left atrium with and without AF.

METHODS

This retrospective cross-sectional study enrolled consecutive patients with LA dimension ≥50 mm and divided them into three groups: no AF (no-AF), paroxysmal AF (PAF) and non-paroxysmal AF (non-PAF) groups. For PAF and non-PAF groups, all patients underwent radiofrequency ablation, and the echocardiographic parameters were obtained on the next day after ablation.

RESULTS

Our study population comprised 160 patients, including 80, 53, and 27 patients in the non-AF, PAF and non-PAF groups, respectively. The no-AF group had a significantly higher body mass index (kg/m2) (29.31±6.27, 27.58±4.12 and 26.57±2.81, P=0.01), and a higher prevalence of diabetes mellitus (DM) [31 (38.80%), 13 (25.00%) and 4 (14.80%), P=0.01] and hypertension [67 (83.80%), 34 (65.40%), and 19 (70.40%), P=0.04], but a lower prevalence of rheumatic heart disease (RHD) [3 (3.80%), 6 (11.50%) and 5 (18.50%), P=0.02] and sick sinus syndrome [0 (0.00%), 6 (11.50%) and 4 (14.80%), P=0.045]. Echocardiographic studies showed that the non-AF group had significantly smaller LA minimal volume index (24.89±9.74, 34.06±19.38 and 42.83±17.44 mL/m2, P<0.01), higher LA emptying fraction (51.99%±13.97%, 38.40%±15.96% and 33.89%±10.73%, P<0.01), longitudinal strain (23.87%±7.72%, 17.11%±8.52% and 12.38%±4.28%, P<0.01) and strain rate than the AF groups. The multivariate analysis showed that the late diastolic component of LA strain rate was the only independent factor associated with the presence of AF (odds ratio, 21.69; 95% CI, 9.77-48.13, P<0.01).

CONCLUSIONS

LA function plays an important role in the absence of AF in patients with LA dimension ≥50 mm; the late diastolic component of LA strain rate was the only independent variable on multivariate analysis.

Left Atrial Diameter in the Prediction of Thromboembolic Event and Death in Atrial Fibrillation

Background: This study aimed to determine the predictive value of left atrial diameter (LAD), and the incremental prognostic value of LAD in combination with CHA2DS2-VASc score for predicting thromboembolic event and all-cause death in patients with non-valvular atrial fibrillation (AF). Methods: This is a prospective study from 27 hospitals during 2014−2017. LADi is LAD data indexed by body surface area, and LADi in the 4th quartile (LADi Q4) was considered high. Results: A total of 2251 patients (mean age 67.4 years, 58.6% male) were enrolled. Mean follow-up duration was 32.3 months. Rates of thromboembolic events and all-cause death were significantly higher in LADi Q4 patients than in LADi Q1−3 patients (2.89 vs. 1.11 per 100 person-years, p < 0.001, and 7.52 vs. 3.13 per 100 person-years, p < 0.001, respectively). LADi Q4 is an independent predictor of thromboembolic events and all-cause death with an adjusted hazard ratio and 95% confidence interval of 1.94 (1.24−3.05) and 1.81 (1.38−2.37), respectively. LADi has incremental prognostic value on top of the CHA2DS2-VASc score with the increase in global chi-square for thromboembolism (p = 0.005) and all-cause death (p < 0.001). Conclusions: LADi is an independent predictor of thromboembolic event and has incremental prognostic value in combination with CHA2DS2-VASc score in AF patients.

Refinement of CHADS2 and CHA2DS2-VASc scores predict left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation patients

Objective

To investigate the risk factors of left atrial thrombus (LAT)/spontaneous echo contrast (SEC) in patients with nonvalvular atrial fibrillation (AF).

Methods

This retrospective study analysed the data from consecutive patients with nonvalvular AF that underwent transoesophageal echocardiography. Logistic regression analysis was performed to identify risk factors of LAT/SEC. Receiver operating characteristic curve analysis was undertaken compare the new scales with CHADS2 and CHA2DS2-VASc scores.

Results

A total of 558 patients with AF were included in the study. LAT/SEC was detected in 137 (24.6%) patients. The independent risk factors of LAT/SEC beyond CHADS2 or CHA2DS2-VASc scores included non-paroxysmal AF and left atrial diameter >37.5 mm. These two variables were added into the CHADS2 or CHA2DS2-VASc score to build new scales. Areas under the curve for the new scales based on CHADS2 and CHA2DS2-VASc scores were significantly higher than the CHADS2 or CHA2DS2-VASc score both in the overall study cohort and in patients at a high risk of thromboembolism.

Conclusions

Non-paroxysmal AF and increased left atrial diameter beyond the CHADS2 or CHA2DS2-VASc score were independent risk factors of LAT/SEC and may help to improve the current risk stratification, especially for patients with nonvalvular AF at a high risk of thromboembolism.

Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation before Catheter Ablation and Cardioversion: Risk Factors beyond the CHA2DS2-VASc Score

Left atrial appendage thrombus (LAAT) is a surrogate of thromboembolic events in patients with nonvalvular atrial fibrillation (NVAF). We aimed to investigate the risk factors for LAAT formation before catheter ablation and cardioversion beside the CHA2DS2-VASc score. In this case-control study, patients with NVAF who underwent transesophageal echocardiography (TEE) were included. Demographic data, laboratory results, and echocardiographic measurements were retrospectively collected. Logistic regression analysis was performed to determine risk factors predicting LAAT. Of the 543 included patients, LAAT was identified in 50 patients (9.2%). Multivariable logistic regression analysis for the entire cohort showed that NT-proBNP (per 500 ng/L increase, OR (95% CI): 1.09 (1.00–1.19), p = 0.038) and LDL-C (per 1 mmol/L increase, OR (95% CI): 1.70 (1.05–2.77), p = 0.032) were independently correlated with the presence of LAAT after the adjustment for CHA2DS2-VASc score and anticoagulant therapy. The subgroup analysis of patients without anticoagulant therapy also yielded similar results. Regarding patients with CHA2DS2-VASc scores ≤ 1, a higher level of LDL-C (per 1 mmol/L increase, OR (95% CI): 6.31 (2.38–16.74), p < 0.001) independently correlated with the presence of LAAT. The present study suggests that beyond CHA2DS2-VASc score, raised NT-proBNP and LDL-C are additional predictors for LAAT in NVAF patients.

Clinical impact of left atrial enlargement in Korean patients with atrial fibrillation

We sought to evaluate the clinical implication of LAE based on left atrial anterior–posterior (LA AP) dimension or LA volume index (LAVI) in Korean patients with atrial fibrillation (AF). We enrolled 8159 AF patients from the CODE-AF registry. The primary outcome was rate of stroke or systemic embolism (SSE). The prevalence of mild, moderate, and severe LAE by LA AP dimension was 30.6%, 18.5%, and 21.4%, and by LAVI (available in 5808 patients) was 15.7%, 12.5% and 37.8%, respectively. Compared with no or mild LAE, patients with significant LAE (moderate to severe LAE, n = 3258, 39.9%) were associated with a higher rate of SSE (2.5% vs. 1.4%, P = 0.001). Multivariable analysis suggested presence of significant LAE by LA AP dimension was associated with a higher risk of SSE in the overall population (HR 1.57, 95% CI: 1.14–2.17, P = 0.005) and in patients using anticoagulants (n = 5836, HR 1.79, 95% CI: 1.23–2.63, P = 0.002). Patients with significant LAE by LAVI were also at higher risk of SSE (HR 1.58, 95% CI: 1.09–2.29, P = 0.017). In conclusion, significant LAE by LA dimension or LAVI was present in 39.9% and 50.2% of AF patients, respectively, and was associated with a higher rate of SSE.

Heart failure with preserved ejection fraction: An alternative paradigm to explain the clinical implications of atrial fibrillation

Atrial fibrillation (AF) is associated with exercise intolerance, stroke, and all-cause mortality. However, whether this can be solely attributable to the arrhythmia itself or alternative mechanisms remains controversial. Heart failure with preserved ejection (HFpEF) commonly coexists with AF and may contribute to the poor outcomes associated with AF. Indeed, several invasive hemodynamic studies have confirmed that patients with AF are at increased risk of underlying HFpEF and that the presence of HFpEF may have important prognostic implications in these patients.

Mechanistically, AF and HFpEF are closely linked. Both conditions are driven by the presence of common cardiovascular risk factors and are associated with left atrial (LA) myopathy, characterized by mechanical and electrical dysfunction. Progressive worsening of this left atrial (LA) myopathy is associated with both increased AF burden and worsening HFpEF. In addition, there is growing evidence to suggest that worsening LA myopathy is associated with poorer outcomes in both conditions and that reversal of the LA myopathy could improve outcomes. In this review article, we will present the epidemiologic and mechanistic evidence underlying the common coexistence of AF and HFpEF, discuss the importance of a progressive LA myopathy in the pathogenesis of both conditions, and review the evidence from important invasive hemodynamic studies. Finally, we will review the prognostic implications of HFpEF in patients with AF and discuss the relative merits of AF burden reduction vs HFpEF reduction in improving outcomes of patients with AF and HFpEF.

Impact of renin-angiotensin system inhibitors on long-term clinical outcomes of patients with rheumatic heart disease

AIMS

Rheumatic heart disease (RHD) remains a major global health problem. Renin-angiotensin-aldosterone system inhibitors (RAASi) are commonly administered in the treatment of cardiovascular disease, but its role in RHD patients is still limited. We performed a retrospective study to determine the effect of RAASi on long-term outcomes for RHD patients.

METHODS AND RESULTS

A 1:1 propensity score matching was implemented to balance baseline characteristics between groups RAASi and non-RAASi. Cox proportional hazards regression model was used to investigate the associations of RAASi with the risks of all-cause mortality, cardiovascular death (CVD), and cerebrovascular death. Binary logistic regression analysis was used to evaluate the associations of RAASi with the risks of 1, 3, and 5 year heart failure (HF) rehospitalization, new-onset atrial fibrillation (AF), and new-onset stroke. A total of 734 RHD patients were enrolled as study participants; nearly half of these participants had combined valve damage (54.4%), worse New York Heart Association functional class status (III and IV, 55.2%), surgical treatment (54.2%), and AF (65.0%). After propensity score matching, 514 RHD patients were finally analysed. RAASi treatment was associated with decreased risks of all-cause mortality [adjusted hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.37-0.73, P < 0.001], CVD (adjusted HR = 0.48, 95% CI: 0.30-0.76, P = 0.002), and cerebrovascular death (adjusted HR = 0.22, 95% CI: 0.08-0.60, P = 0.003). Further subgroup analysis showed that RAASi treatment was associated with decreased risks of all-cause mortality (adjusted HR = 0.50, 95% CI: 0.31-0.79, P = 0.004), CVD (adjusted HR = 0.48, 95% CI: 0.25-0.91, P = 0.025), and cerebrovascular death (adjusted HR = 0.19, 95% CI: 0.05-0.65, P = 0.008) in RHD patients without surgical treatment, and better effect was observed in RHD patients with surgical treatment on the risks of all-cause mortality (adjusted HR = 0.47, 95% CI: 0.26-0.85, P = 0.012) and CVD (adjusted HR = 0.43, 95% CI: 0.21-0.90, P = 0.024) except cerebrovascular death (adjusted HR = 0.52, 95% CI: 0.08-3.36, P = 0.491). RAASi treatment was associated with decreased HF rehospitalization risk of 1 year [adjusted odds ratio (OR) = 0.38, 95% CI: 0.23-0.61, P < 0.001], 3 year (adjusted OR = 0.43, 95% CI: 0.28-0.68, P < 0.001), and 5 year (adjusted OR = 0.48, 95% CI: 0.30-0.77, P = 0.002) as well as new-onset AF risk (adjusted OR = 0.38, 95% CI: 0.21-0.68, P = 0.001). RAASi treatment had nothing to do with new-onset stroke risk (adjusted OR = 0.80, 95% CI: 0.47-1.38, P = 0.428).

CONCLUSION

Renin-angiotensin-aldosterone system inhibitor treatment was significantly associated with decreased risks of mortality, HF rehospitalization, and new-onset AF in RHD patients in median 5.9 year follow-up.

Left atrial appendage orifice area and morphology is closely associated with flow velocity in patients with nonvalvular atrial fibrillation

Background

Thromboembolic events are the most serious complication of atrial fibrillation (AF), and the left atrial appendage (LAA) is the most important site of thrombosis in patients with AF. During the period of COVID-19, a non-invasive left atrial appendage detection method is particularly important in order to reduce the exposure of the virus. This study used CT three-dimensional reconstruction methods to explore the relationship between LAA morphology, LAA orifice area and its mechanical function in patients with non-valvular atrial fibrillation (NVAF).

Methods

A total of 81 consecutive patients with NVAF (36 cases of paroxysmal atrial fibrillation and 45 cases of persistent atrial fibrillation) who were planned to undergo catheter radiofrequency ablation were enrolled. All patients were examined by transthoracic echocardiography (TTE), TEE, and computed tomography angiography (CTA) before surgery. The LAA orifice area was obtained according to the images of CTA. According to the left atrial appendage morphology, it was divided into chicken wing type and non-chicken wing type. At the same time, TEE was performed to determine left atrial appendage flow velocity (LAAFV), and the relationship between the left atrial appendage orifice area and LAAFV was analyzed.

Results

The LAAFV in Non-chicken wing group was lower than that in Chicken wing group (36.2 ± 15.0 cm/s vs. 49.1 ± 22.0 cm/s, p-value < 0.05). In the subgroup analysis, the LAAFV in Non-chicken wing group was lower than that in Chicken wing group in the paroxysmal AF (44.0 ± 14.3 cm/s vs. 60.2 ± 22.8 cm/s, p-value < 0.05). In the persistent AF, similar results were observed (29.7 ± 12.4 cm/s vs. 40.8 ± 17.7 cm/s, p-value < 0.05). The LAAFV in persistent AF group was lower than that in paroxysmal AF group (34.6 ± 15.8 cm/s vs. 49.9 ± 20.0 cm/s, p-value < 0.001). The LAAFV was negatively correlated with left atrial dimension (R = − 0.451, p-value < 0.001), LAA orifice area (R= − 0.438, p-value < 0.001) and left ventricular mass index (LVMI) (R= − 0.624, p-value < 0.001), while it was positively correlated with LVEF (R = 0.271, p-value = 0.014). Multiple linear regression analysis showed that LAA morphology (β = − 0.335, p-value < 0.001), LAA orifice area (β = −  0.185, p-value = 0.033), AF type (β = − 0.167, p-value = 0.043) and LVMI (β = − 0.465, p-value < 0.001) were independent factors of LAAFV.

Conclusions

The LAA orifice area is closely related to the mechanical function of the LAA in patients with NVAF. The larger LAA orifice area and LVMI, Non-chicken wing LAA and persistent AF are independent predictors of decreased mechanical function of LAA, and these parameters might be helpful for better management of LA thrombosis.

Comparison of the Safety and Effectiveness of Four Direct Oral Anticoagulants in Japanese Patients with Nonvalvular Atrial Fibrillation Using Real-World Data

Direct oral anticoagulants (DOACs) are widely used for the prevention of ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). However, the differences in safety and effectiveness among four DOACs, dabigatran, rivaroxaban, apixaban, and edoxaban, in Japanese patients have not been clarified. Therefore, we conducted a retrospective cohort study to directly compare the safety and effectiveness among the four DOACs using the Japan Medical Data Center (JMDC) claims database. We identified 3823 patients with NVAF who started receiving a DOAC between March 2011 and June 2017. The safety outcome was major bleeding (a composite outcome of intracranial, gastrointestinal, respiratory, or renal/urinary tract bleeding) and the effectiveness outcome was the composite of ischemic stroke including transient ischemic attack (TIA) or systemic embolism. We constructed a Cox proportional hazard model to calculate the hazard ratio (HR) for all four DOAC combinations. The risk of major bleeding was significantly lower in the dabigatran group than in the apixaban group (HR, 0.55; 95% confidence interval (CI), 0.31-0.93; p = 0.03). In contrast, there was no significant difference in the risk of major bleeding among the other DOACs. In the composite risk of ischemic stroke including TIA or systemic embolism, there was no significant difference among the four DOACs. This study suggested that in the current use of DOACs in Japanese patients with NVAF, dabigatran had a significantly lower risk of major bleeding than apixaban, but there was no significant difference in effectiveness among the four DOACs.

Risk factors for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA2DS2-VASc score

OBJECTIVE

Risk factors of left atrial thrombus (LAT) or spontaneous echo contrast (LASEC) in non-valvular atrial fibrillation (NVAF) had been reported. However, information in the subgroup of NVAF patients with low CHA₂DS₂-VASc scores was limited. Here, we evaluated the risk factors of LAT/LASEC in NVAF patients with low CHA₂DS₂-VASc scores.

METHODS

Transesophageal echocardiography (TEE) file of NVAF patients with low CHA₂DS₂-VASc scores was reviewed (between June 2009 and Feb 2019) in this retrospective observational study. Binary logistic regression analysis was performed to identify risk factors other than the CHA₂DS₂-VASc score. Propensity score matching (PSM) was used to further evaluate independent risk markers for LAT/LASEC. The newly discovered factors were added to the CHA₂DS₂-VASc score, and receiver operating characteristic analysis was used to evaluate the ability of the model to predict LAT/LASEC.

RESULTS

TEE files of 3056 NVAF patients with low CHA₂DS₂-VASc scores were reviewed. Regression analysis revealed elevated fibrinogen and enlarged left atrium (LA) were risk factors for LAT/LASEC. Further PSM analysis confirmed that elevated fibrinogen and enlarged LA were independent risk factors for LAT/LASEC. After including fibrinogen and left atrial diameter (LAD), the CHA₂DS₂-VASc score was more accurate for LAT/LASEC prediction in NVAF patients with low CHA₂DS₂-VASc scores (area under the curve difference is 0.241, 95% confidence interval (CI) 0.188-0.294, Z = 8.890, P < 0.0001).

CONCLUSIONS

Elevated fibrinogen and enlarged LA were independent risk factors for LAT/LASEC in NVAF patients with low CHA₂DS₂-VASc scores. Taking fibrinogen and LAD into consideration may help improve LAT/LASEC risk evaluation, which warrants further validation studies.

A bi-atrial statistical shape model for large-scale in silico studies of human atria: Model development and application to ECG simulations

Large-scale electrophysiological simulations to obtain electrocardiograms (ECG) carry the potential to produce extensive datasets for training of machine learning classifiers to, e.g., discriminate between different cardiac pathologies. The adoption of simulations for these purposes is limited due to a lack of ready-to-use models covering atrial anatomical variability. We built a bi-atrial statistical shape model (SSM) of the endocardial wall based on 47 segmented human CT and MRI datasets using Gaussian process morphable models. Generalization, specificity, and compactness metrics were evaluated. The SSM was applied to simulate atrial ECGs in 100 random volumetric instances. The first eigenmode of our SSM reflects a change of the total volume of both atria, the second the asymmetry between left vs. right atrial volume, the third a change in the prominence of the atrial appendages. The SSM is capable of generalizing well to unseen geometries and 95% of the total shape variance is covered by its first 24 eigenvectors. The P waves in the 12-lead ECG of 100 random instances showed a duration of 109.7±12.2 ms in accordance with large cohort studies. The novel bi-atrial SSM itself as well as 100 exemplary instances with rule-based augmentation of atrial wall thickness, fiber orientation, inter-atrial bridges and tags for anatomical structures have been made publicly available. This novel, openly available bi-atrial SSM can in future be employed to generate large sets of realistic atrial geometries as a basis for in silico big data approaches.

[Independent risk factors of atrial thrombosis in patients with nonvalvular atrial fibrillation and low CHA2DS2-VASc scores]

OBJECTIVE

To explore the risk factors of atrial thrombosis in patients with nonvalvular atrial fibrillation(NVAF)with low CHA₂DS₂-VASc scores at admission (≤1 for male and ≤2 for female patients).

METHODS

We retrospectively analyzed the clinical data of 10 382 patients with NVAF undergoing transesophageal echocardiography in our hospital from 2009 to 2019, and enrolled 48 NVAF patients with thrombosis as the observation group and another 240 NVAF patients without thrombosis as the control group.The baseline characteristics, biochemical indicators, and echocardiographic findings of the patients were analyzed using univariate analysis, multivariate logistic regression analysis and Pearson correlation analysis.

RESULTS

The baseline data did not differ significantly between the two groups (P > 0.05).Compared with those in the control group, the patients with atrial thrombosis had an increased left atrial diameter (LAD; P < 0.001), a greater likelihood of hypertrophic cardiomyopathy (HCM; P < 0.001), significantly higher levels of C-reactive protein (CRP; P < 0.05) and uric acid (P < 0.001), and greater standard deviation of red blood cell distribution width(RDW-SD; P < 0.001).LAD(P < 0.001), HCM(P < 0.05)and CRP(P < 0.05) were identified as the independent factors affecting the occurrence of atrial thrombosis in patients with low CHA₂DS₂-VASc scores.

CONCLUSIONS

LAD enlargement, HCM, and an elevated CRP level are independent risk factors for atrial thrombosis in NVAF patients with low CHA₂DS₂-VASc scores.Active anticoagulation therapy should be administered for these patients once these risk factors are detected to prevent the occurrence of stroke.

Optimizing prognosis in atrial fibrillation: A call to action in Portugal

Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis.

A Novel Risk Stratification System for Ischemic Stroke in Japanese Patients With Non-Valvular Atrial Fibrillation

BACKGROUND

Recently, identification of independent risk factors for ischemic stroke in Japanese non-valvular atrial fibrillation (NVAF) patients was made by analyzing the 5 major Japanese registries: J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and the Hokuriku-Plus AF Registry.Methods and Results:The predictive value of the risk scheme in Japanese NVAF patients was assessed. Of 16,918 patients, 12,289 NVAF patients were analyzed (mean follow up, 649±181 days). Hazard ratios (HRs) of each significant, independent risk factor were determined by using adjusted Cox-hazard proportional analysis. Scoring system for ischemic stroke was created by transforming HR logarithmically and was estimated by c-statistic. During the 21,820 person-years follow up, 241 ischemic stroke events occurred. Significant risk factors were: being elderly (aged 75-84 years [E], HR=1.74), extreme elderly (≥85 years [EE], HR=2.41), having hypertension (H, HR=1.60), previous stroke (S, HR=2.75), type of AF (persistent/permanent) (T, HR=1.59), and low body mass index <18.5 kg/m²(L, HR=1.55) after adjusting for oral anticoagulant treatment. The score was assigned as follows: 1 point to H, E, L, and T, and 2 points to EE and S (HELT-E₂S₂score). The C-statistic, using this score, was 0.681 (95% confidence interval [CI]=0.647-0.714), which was significantly higher than those using CHADS₂(0.647; 95% CI=0.614-0.681, P=0.027 for comparison) and CHA₂DS₂-VASc scores (0.641; 95% CI=0.608-0.673, P=0.008).

CONCLUSIONS

The HELT-E₂S₂score may be useful for identifying Japanese NVAF patients at risk of ischemic stroke.

Association of relative wall thickness of left ventricle with incidence of thromboembolism in patients with non-valvular atrial fibrillation: The Fushimi AF Registry

AIMS

Atrial fibrillation (AF) increases the risk of thromboembolism, such as ischaemic stroke or systemic embolism (SE). The aim of this study was to investigate the relationship between left ventricular relative wall thickness (RWT) and the risk of thromboembolism in patients with non-valvular AF.

METHODS AND RESULTS

The Fushimi AF Registry is a community-based prospective survey of the patients with AF in Japan. Analyses were performed on 3067 non-valvular AF patients, in which RWT values determined by transthoracic echocardiography were available at the baseline. The high-RWT group (RWT above the median) was more often female, older, and had higher systolic blood pressure, CHADS2 and CHA2DS2-VASc scores, as compared with low-RWT group. During the median follow-up period of 1309 days, there was a higher incidence of ischaemic stroke/SE in the high-RWT group [unadjusted hazard ratio (HR), 1.91; 95% confidence interval (CI), 1.42-2.59]. On multivariate Cox regression analysis, including the components of CHA2DS2-VASc score, left atrial diameter, oral anticoagulant prescription at baseline, and type of AF, high RWT was independently associated with ischaemic stroke/SE (adjusted HR, 1.81; 95% CI, 1.34-2.47). Stratified analysis demonstrated no significant interaction for any subgroups. In Kaplan-Meier analysis, ordinal RWT quartiles stratified the incidence of ischaemic stroke/SE. Finally, addition of RWT to CHA2DS2-VASc score increased the performance of risk stratification for the incidence of stroke/SE.

CONCLUSION

Relative wall thickness was independently associated with ischaemic stroke/SE among Japanese patients with non-valvular AF, suggesting the importance of left ventricular morphology in contributing to adverse outcomes, particularly thromboembolism.

Possible protective effect of resolvin D1 on inflammation in atrial fibrillation: involvement of ER stress mediated the NLRP3 inflammasome pathway

Atrial fibrillation (AF) is the most common type of cardiac rhythm disturbance. At the cellular level, excessive ROS generation during AF is associated with ER stress, which induces an inflammatory response by activating the unfolded protein response (UPR) pathway and the nuclear factor-kappa B (NF-kB) signaling pathway. Activation of the NLR family pyrin domain containing 3 (NLRP3) inflammasome has been linked to the pathogenesis of AF through NF-kB activation and inflammatory cytokine secretion. It has been shown that NLRP3 inflammasome activation by endoplasmic reticulum (ER) stress is dependent on NF-kB activation. The anti-inflammatory role of resolvin D1 (RvD1), a pro-resolving mediator derived from omega-3 fatty acids, has demonstrated that the NF-κB/NLRP3 inflammasome pathway in different tissues is attenuated after treatment with RvD1. However, the mechanism of the anti-inflammatory activity of RvD1 in AF has not been clarified. This review suggests that RvD1 may inhibit ER stress-induced NLRP3 inflammasome through suppressing NF-κB in cardiac tissue and, thus ameliorate AF.

Different Determinants of the Recurrence of Atrial Fibrillation and Adverse Clinical Events in the Mid-Term Period After Atrial Fibrillation Ablation

BACKGROUND

It is unclear whether there are differences in the clinical factors between atrial fibrillation (AF) recurrence and adverse clinical events (AEs), including stroke/transient ischemic attack (TIA), major bleeding, and death, after AF ablation.Methods and Results:We examined the data from a retrospective multicenter Japanese registry conducted at 24 cardiovascular centers between 2011 and 2017. Of the 3,451 patients (74.1% men; 63.3±10.3 years) who underwent AF ablation, 1,046 (30.3%) had AF recurrence and 224 (6.5%) suffered AEs (51 strokes/TIAs, 71 major bleeding events, and 36 deaths) over a median follow-up of 20.7 months. After multivariate adjustment, female sex, persistent and long-lasting persistent AF (vs. paroxysmal AF), and stepwise increased left atrial diameter (LAd) quartiles were significantly associated with post-ablation recurrences. A multivariate analysis revealed that an age ≥75 years (vs. <65 years), body weight <50 kg, diabetes, vascular disease, left ventricular (LV) ejection fraction <40% (vs. ≥50%), Lad ≥44 mm (vs. <36 mm), and creatinine clearance <50 mL/min were independently associated with AE incidences, but not with recurrences.

CONCLUSIONS

This study disclosed different determinants of post-ablation recurrence and AEs. Female sex, persistent AF, and enlarged LAd were determinants of post-ablation recurrence, whereas an old age, comorbidities, and LV and renal dysfunction rather than post-ablation recurrence were AEs determinants. These findings will help determine ablation indications and post-ablation management.

A Review of Biomarkers for Ischemic Stroke Evaluation in Patients With Non-valvular Atrial Fibrillation

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and results in a significantly increased ischemic stroke (IS) risk. IS risk stratification tools are widely being applied to guide anticoagulation treatment decisions and duration in patients with non-valvular AF (NVAF). The CHA₂DS₂-VASc score is largely validated and currently recommended by renowned guidelines. However, this score is heavily dependent on age, sex, and comorbidities, and exhibits only moderate predictive power. Finding effective and validated clinical biomarkers to assist in personalized IS risk evaluation has become one of the promising directions in the prevention and treatment of NVAF. A number of studies in recent years have explored differentially expressed biomarkers in NVAF patients with and without IS, and the potential role of various biomarkers for prediction or early diagnosis of IS in patients with NVAF. In this review, we describe the clinical application and utility of AF characteristics, cardiac imaging and electrocardiogram markers, arterial stiffness and atherosclerosis-related markers, circulating biomarkers, and novel genetic markers in IS diagnosis and management of patients with NVAF. We conclude that at present, there is no consensus understanding of a desirable biomarker for IS risk stratification in NVAF, and enrolling these biomarkers into extant models also remains challenging. Further prospective cohorts and trials are needed to integrate various clinical risk factors and biomarkers to optimize IS prediction in patients with NVAF. However, we believe that the growing insight into molecular mechanisms and in-depth understanding of existing and emerging biomarkers may further improve the IS risk identification and guide anticoagulation therapy in patients with NVAF.