Risk of Ischemic Stroke in Asymptomatic Atrial Fibrillation Incidentally Detected in Primary Care Compared with Other Clinical Presentations

Novel stroke prevention strategies following catheter ablation for atrial fibrillation

Stroke prevention following successful catheter ablation of atrial fibrillation remains a controversial topic. Oral anticoagulation is associated with a significant reduction in stroke risk in the general atrial fibrillation population but may be associated with an increased risk of major bleeding, and the benefit: risk ratio must be considered. Improvement in successful catheter ablation and widespread use of cardiac monitoring devices may allow for novel anticoagulation strategies in a subset of patients with atrial fibrillation, which may optimize stroke prevention while minimizing bleeding risk. In this review, we discuss stroke risk in atrial fibrillation and the effects of successful catheter ablation on thromboembolic risk. We also explore novel strategies for stroke prevention following successful catheter ablation.

Global burden of atrial fibrillation/atrial flutter and its attributable risk factors from 1990 to 2021

AIMS

To devise effective preventive measures, a profound understanding of the evolving patterns and trends in atrial fibrillation (AF) and atrial flutter (AFL) burdens is pivotal. Our study was designed to quantify the burden and delineate the risk factors associated with AF and AFL across 204 countries and territories spanning 1990-2021.

METHODS AND RESULTS

Data pertaining to AF and AFL were sourced from the Global Burden of Disease Study 2021. The burden of AF/AFL was evaluated using metrics such as incidence, disability-adjusted life years (DALYs), deaths, and their corresponding age-standardized rates (ASRs), stratified by age, sex, socio-demographic index (SDI), and human development index (HDI). The estimated annual percentage change was employed to quantify changes in ASRs. Population attributable fractions were calculated to determine the proportional contributions of major risk factors to age-standardized AF/AFL deaths. This analysis encompassed the period from 1990 to 2021. Globally, in 2021, there were 4.48 million incident cases [95% uncertainty interval (UI): 3.61-5.70], 8.36 million DALYs (95% UI: 6.97-10.13) and 0.34 million deaths (95% UI: 0.29-0.37) attributed to AF/AFL. The AF/AFL burden in 2021, as well as its trends from 1990 to 2021, displayed substantial variations based on gender, SDI quintiles, and geographical regions. High systolic blood pressure emerged as the leading contributor to age-standardized AF/AFL incidence, prevalence, death, and DALY rate globally among all potential risk factors, followed closely by high body mass index.

CONCLUSION

Our study underscores the enduring significance of AF/AFL as a prominent public health concern worldwide, marked by profound regional and national variations. Despite the substantial potential for prevention and management of AF/AFL, there is a pressing imperative to adopt more cost-effective strategies and interventions to target modifiable risk factors, particularly in areas where the burden of AF/AFL is high or escalating.

The budget impact of implementing atrial fibrillation-screening in European countries

A budget impact analysis estimates the short-term difference between the cost of the current treatment strategy and a new treatment strategy, in this case to implement population screening for atrial fibrillation (AF). The aim of this study is to estimate the financial impact of implementing population-based AF-screening of 75-year-olds compared with the current setting of no screening from a healthcare payer perspective in eight European countries. The net budget impact of AF-screening was estimated in country-specific settings for Denmark, Germany, Ireland, Italy, Netherlands, Serbia, Spain, and Sweden. Country-specific parameters were used to allow for variations in healthcare systems and to reflect the healthcare sector in the country of interest. Similar results can be seen in all countries AF-screening incurs savings of stroke-related costs since AF treatment reduces the number of strokes. However, the increased number of detected AF and higher drug acquisition will increase the drug costs as well as the costs of physician- and control visits. The net budget impact per invited varied from €10 in Ireland to €122 in the Netherlands. The results showed the increased costs of implementing AF-screening were mainly driven by increased drug costs and screening costs. In conclusion, across Europe, though the initial cost of screening and more frequent use of oral anti-coagulants will increase the healthcare payers' costs, introducing population screening for AF will result in savings of stroke-related costs.

Atrial Fibrillation Screening During Routine Automated Office, Home, and Ambulatory Blood Pressure Measurement: A Diagnostic Test Accuracy Systematic Review and Meta-Analysis

BACKGROUND

Atrial fibrillation (AF) is often asymptomatic and undiagnosed. As AF and hypertension often coexist, opportunistic AF detection during routine automated blood pressure (BP) measurement appears to be an attractive screening method.

METHODS

A systematic literature search was conducted to identify studies assessing the diagnostic test accuracy of office, home, or 24-hour ambulatory BP measuring devices with AF detection algorithms versus reference electrocardiography. Analyses were performed per participant (AF status based on several BP readings; most office/home devices) or per reading (AF status based on individual readings; all ambulatory devices). A meta-analysis stratified by device type (office/home/ambulatory) was conducted to calculate pooled measures of diagnostic accuracy. Sensitivity/meta-regression analyses were also performed.

RESULTS

Among 3096 records initially retrieved, 23 diagnostic test accuracy studies were included. Data derived from 11 093 individuals (weighted age 69 years, males 56%, hypertensives 79%, diabetics 24%, and AF prevalence 17%) indicated a pooled sensitivity 0.97 (95% CI, 0.92-0.99), specificity 0.93 (95% CI, 0.90-0.95), and accuracy 0.93 (95% CI, 0.89-0.95), with generally consistent results using office, home, or ambulatory BP devices (slightly lower specificity with the latter). The positive and negative predictive values were 0.70 (95% CI, 0.60-0.80) and 0.99 (95% CI, 0.98-1.00), respectively. Sensitivity analyses indicated lower specificity in studies implementing reading versus participant analyses. Most studies presented a low risk of bias and minor applicability concerns.

CONCLUSIONS

There is considerable and consistent evidence suggesting high diagnostic accuracy of AF detection algorithms implemented in automated BP monitors during routine BP measurements in and out of the office. AF diagnosis requires verification (electrocardiography) before treatment is administered.

Estimating the impact of implementing an integrated care management approach with Atrial fibrillation Better Care (ABC) pathway for patients with atrial fibrillation in England from 2020 to 2040

BACKGROUND

Stroke prevention is central to the management of atrial fibrillation (AF), but there remains a residual risk of adverse outcomes in anticoagulated AF patients. Hence, current guidelines have proposed a more holistic or integrated approach to AF management, based on the Atrial fibrillation Better Care (ABC) pathway, as follows: (A) avoid stroke with anticoagulation; (B) better symptom control with patient-centred symptom directed decisions on rate or rhythm control; and (C) cardiovascular and comorbidity management, including lifestyle factors. There has been no formal healthcare cost analysis from the UK National Health Service (NHS) perspective of ABC pathway implementation to optimize the management of AF. Our aim was to estimate the number of patients with AF in the UK each year up to 2040, their morbidity and mortality, and the associated healthcare costs, and secondly, to estimate improvements in morbidity and mortality of implementing an ABC pathway, and the impact on costs.

RESULTS

In 2020, there were an estimated 1 463 538 AF patients, resulting in £286 million of stroke care and £191 million of care related to bleeds annually. By 2030, it is expected that there will be 2 115 332 AF patients, resulting in £666 million of stroke healthcare and £444 million of healthcare related to bleeds. By 2040, this is expected to rise to 2 856 489 AF patients, with £1096 million of stroke healthcare and £731 million of healthcare related to bleeds for that year. If in 2040 patients are managed on an ABC pathway, this could prevent between 3724 and 18 622 strokes and between 5378 and 26 890 bleeds, and save between 16 131 and 80 653 lives depending on the proportion of patients managed on the pathway. This would equate to cost reductions of between £143.9 million and £719.6 million for the year.

CONCLUSION

We estimate that there will be a substantial healthcare burden in the UK NHS associated with AF, from strokes, bleeds, and mortality over the next decades. If patients are managed with a holistic or integrated care approach based on the ABC pathway, this could prevent strokes and bleeds that equate to substantial NHS healthcare cost reductions, and save lives.

Assessment and management of asymptomatic atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia encountered in practice. It is currently estimated that AF affects approximately 2% of the general population; however, the true prevalence of AF is likely to be at least 3%-4% when asymptomatic AF is considered. For clinically apparent AF, the investigations and management are relatively well established. The identification of minimally symptomatic patients is challenging, and furthermore, the optimal management is less certain. Although there is some debate about the ideal treatment pathway for asymptomatic AF, in most cases, the investigations and comprehensive management follow the same recommendations as clinically apparent AF. In contrast, beyond risk factor optimisation, the ideal management of subclinical or device-detected AF remains undefined. The purpose of the current review is to discuss the assessment and management of asymptomatic AF.

Management of ischaemic stroke survivors in primary care setting: the road to holistic care

The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.

The Report of Community-Based and Government-Endorsed Screening Program of Atrial Fibrillation in Taiwan

BACKGROUND

 Although international guidelines recommended opportunistic screening for atrial fibrillation (AF), the community-based AF screening program incorporated into the government-endorsed health care system is rarely reported in Asian countries.

OBJECTIVES

 We aimed to test the feasibility of adding AF screening into the preexistent adult health check program and report the AF detection rate and percentages of OAC prescriptions before and after AF screening with the involvement of public health care systems.

METHODS

 We performed this program in three counties (Chiayi county, Keelung City, and Yilan county) in Taiwan which have their own official preexistent adult health check programs conducted by public health bureaus for years. However, electrocardiography (ECG) was not included in these programs before. We cooperated with the public health bureaus of the three counties and performed single-lead 30-second ECG recording for every participant.

RESULTS

 From January to December 2020, AF screening was performed in 199 sessions with 23,572 participants. AF was detected in 278 subjects with a detection rate of 1.19% (age ≥65 years: 2.39%; ≥75 years: 3.73%). The mean CHA2DS2-VASc score of these 278 subjects was 2.36, with 91% of them had a score ≥1 (males) or ≥2 (females). The number needed to screen was 42 and 27 for subjects aged ≥65 and ≥75 years, respectively. The prescription rate of OACs significantly increased from 11.4 to 60.6% in Chiayi county and from 15.8 to 50.0% in Keelung City after screening (both p-values <0.001).

CONCLUSION

 This community-based and government-endorsed AF screening project in Taiwan demonstrated that incorporation of AF screening into the preexistent adult health check programs through co-operations with the government was feasible. Actions to detect AF, good education, and well-organized transferring plan after AF being detected with the involvement of public health care systems could result in a substantial increase in the prescription rate of OACs.

Asymptomatic vs. symptomatic atrial fibrillation: Clinical outcomes in heart failure patients

BACKGROUND

The outcome implications of asymptomatic vs. symptomatic atrial fibrillation (AF) in specific groups of patients according to clinical heart failure (HF) and left ventricular ejection fraction (LVEF) need to be clarified.

METHODS

In a prospective observational study, patients were categorized according to overt HF with LVEF≤40 %, or with LVEF>40 %, or without overt HF with LVEF40 %≤ or > 40 %, as well as according to the presence of asymptomatic or symptomatic AF.

RESULTS

A total of 8096 patients, divided into 8 groups according to HF and LVEF, were included with similar proportions of asymptomatic AF (ranging from 43 to 48 %). After a median follow-up of 730 [699 -748] days, the composite outcome (all-cause death and MACE) was significantly worse for patients with asymptomatic AF associated with HF and reduced LVEF vs. symptomatic AF patients of the same group (p = 0.004). On adjusted Cox regression analysis, asymptomatic AF patients with HF and reduced LVEF were independently associated with a higher risk for the composite outcome (aHR 1.32, 95 % CI 1.04-1.69) and all-cause death (aHR 1.33, 95 % CI 1.02-1.73) compared to symptomatic AF patients with HF and reduced LVEF. Kaplan-Meier curves showed that HF-LVEF≤40 % asymptomatic patients had the highest cumulative incidence of all-cause death and MACE (p < 0.001 for both).

CONCLUSIONS

In a large European cohort of AF patients, the risk of the composite outcome at 2 years was not different between asymptomatic and symptomatic AF in the whole cohort but adverse implications for poor outcomes were found for asymptomatic AF in HF with LVEF≤40 %.

Asymptomatic atrial fibrillation among hospitalized patients: clinical correlates and in-hospital outcomes in Improving Care for Cardiovascular Disease in China-Atrial Fibrillation

AIMS

The clinical correlates and outcomes of asymptomatic atrial fibrillation (AF) in hospitalized patients are largely unknown. We aimed to investigate the clinical correlates and in-hospital outcomes of asymptomatic AF in hospitalized Chinese patients.

METHODS AND RESULTS

We conducted a cross-sectional registry study of inpatients with AF enrolled in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation Project between February 2015 and December 2019. We investigated the clinical characteristics of asymptomatic AF and the association between the clinical correlates and the in-hospital outcomes of asymptomatic AF. Asymptomatic and symptomatic AF were defined according to the European Heart Rhythm Association score. Asymptomatic patients were more commonly males (56.3%) and had more comorbidities such as hypertension (57.4%), diabetes mellitus (18.6%), peripheral artery disease (PAD; 2.3%), coronary artery disease (55.5%), previous history of stroke/transient ischaemic attack (TIA; 17.9%), and myocardial infarction (MI; 5.4%); however, they had less prevalent heart failure (9.6%) or left ventricular ejection fractions ≤40% (7.3%). Asymptomatic patients were more often hospitalized with a non-AF diagnosis as the main diagnosis and were more commonly first diagnosed with AF (23.9%) and long-standing persistent/permanent AF (17.0%). The independent determinants of asymptomatic presentation were male sex, long-standing persistent AF/permanent AF, previous history of stroke/TIA, MI, PAD, and previous treatment with anti-platelet drugs. The incidence of in-hospital clinical events such as all-cause death, ischaemic stroke/TIA, and acute coronary syndrome (ACS) was higher in asymptomatic patients than in symptomatic patients, and asymptomatic clinical status was an independent risk factor for in-hospital all-cause death, ischaemic stroke/TIA, and ACS.

CONCLUSION

Asymptomatic AF is common among hospitalized patients with AF. Asymptomatic clinical status is associated with male sex, comorbidities, and a higher risk of in-hospital outcomes. The adoption of effective management strategies for patients with AF should not be solely based on clinical symptoms.

Incidence of clinical atrial fibrillation and related complications using a screening algorithm at a nationwide level

AIMS

In a recent position paper, the European Heart Rhythm Association (EHRA) proposed an algorithm for the screening and management of arrhythmias using digital devices. In patients with prior stroke, a systematic screening approach for atrial fibrillation (AF) should always be implemented, preferably immediately after the event. Patients with increasing age and with specific cardiovascular or non-cardiovascular comorbidities are also deemed to be at higher risk. From a large nationwide database, the aim was to analyse AF incidence rates derived from this new EHRA algorithm.

METHODS AND RESULTS

Using the French administrative hospital discharge database, all patients hospitalized in 2012 without a history of AF, and with at least a 5-year follow-up (FU) (or if they died earlier), were included. The yearly incidence of AF was calculated in each subgroup defined by the algorithm proposed by EHRA based on a history of previous stroke, increasing age, and eight comorbidities identified via International Classification of Diseases 10th Revision codes. Out of the 4526 104 patients included (mean age 58.9 ± 18.9 years, 64.5% women), 1% had a history of stroke. Among those with no history of stroke, 18% were aged 65-74 years and 21% were ≥75 years. During FU, 327 012 patients had an incidence of AF (yearly incidence 1.86% in the overall population). Implementation of the EHRA algorithm divided the population into six risk groups: patients with a history of stroke (group 1); patients > 75 years (group 2); patients aged 65-74 years with or without comorbidity (groups 3a and 3b); and patients < 65 years with or without comorbidity (groups 4a and 4b). The yearly incidences of AF were 4.58% per year (group 2), 6.21% per year (group 2), 3.50% per year (group 3a), 2.01% per year (group 3b), 1.23% per year (group 4a), and 0.35% per year (group 4b). In patients aged < 65 years, the annual incidence of AF increased progressively according to the number of comorbidities from 0.35% (no comorbidities) to 9.08% (eight comorbidities). For those aged 65-75 years, the same trend was observed, i.e. increasing from 2.01% (no comorbidities) to 11.47% (eight comorbidities).

CONCLUSION

These findings at a nationwide scale confirm the relevance of the subgroups in the EHRA algorithm for identifying a higher risk of AF incidence, showing that older patients (>75 years, regardless of comorbidities) have a higher incidence of AF than those with prior ischaemic stroke. Further studies are needed to evaluate the usefulness of algorithm-based risk stratification strategies for AF screening and the impact of screening on major cardiovascular event rates.

Stroke and Myocardial Infarction in Patients with Abdominal Aortic Aneurysm and New-Onset Atrial Fibrillation

OBJECTIVE

 We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease.

METHODS

 Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy.

RESULTS

 A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA₂DS₂-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%.

CONCLUSION

 Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI.

Managing high-risk atrial fibrillation patients with multiple comorbidities

Atrial fibrillation (AF) patients are often high risk being elderly and having multiple comorbidities. Many risk factors are established to be associated with new onset incident AF, as well as AF-related complications such as stroke and hospitalisations. Multimorbidity AF patients are high risk and require a holistic approach to care, which should be proactively managing with an integrated care or holistic approach as per the ABC (atrial fibrillation better care) pathway.

Stroke Prevention in Atrial Fibrillation

PURPOSE OF REVIEW

Atrial fibrillation is associated with a significant increase in stroke and systemic embolism. This review explores the areas of stroke prevention.

RECENT FINDINGS

In the last decade, NOAC has overtaken warfarin as the anticoagulant of choice for stroke prevention in AF. For patients unable to take anticoagulation, LAA closure has proven to be a valid option. The use of digital devices has led to widespread consumer-directed AF screening. It remains to be determined if all device detect AF pose the same amount of risk as recent studies have shown that short and infrequent episodes of AF may not benefit from anticoagulation. Stroke prevention is paramount in the management of AF. In this review we describe the risk factors contributing to stroke, recent advances in antithrombotic therapies, and the increasing role of digital health in guiding AF detection and stroke prevention.

Clinical Outcomes of Rhythm Control Strategies for Asymptomatic Atrial Fibrillation According to the Quality-of-Life Score: The CODE-AF (Comparison Study of Drugs for Symptom Control and Complication Prevention of Atrial Fibrillation) Registry

Background Atrial fibrillation (AF) is associated with an increased risk of poor cardiovascular outcomes; appropriate rhythm control can reduce the incidence of these adverse events. Therefore, catheter ablation is recommended in symptomatic patients with AF. The aims of this study were to compare AF-related outcomes according to a baseline symptom scale score and to determine the best treatment strategy for asymptomatic patients with AF. Methods and Results This study enrolled all patients who completed a baseline Atrial Fibrillation Effect on Quality-of-Life (AFEQT) survey in a prospective observational registry. The patients were divided into 2 groups according to AFEQT score at baseline; scores ≤80 were defined as symptomatic, whereas scores >80 represented asymptomatic patients. The primary outcome was defined as a composite of hospitalization for heart failure, ischemic stroke, or cardiac death. This study included 1515 patients (mean age: 65.7±10.5 years; 998 [65.9%] men). The survival curve showed a poorer outcome in the symptomatic group compared with the asymptomatic group (log-rank P=0.04). Rhythm control led to a significantly lower risk of a composite outcome in asymptomatic patients (hazard ratio [HR], 0.47 [95% CI, 0.27-0.84], P=0.01). Rhythm control was associated with more favorable composite outcomes in the asymptomatic group with paroxysmal AF, left atrium diameter ≤50 mm, and CHA₂DS₂-VASc score ≥3. Conclusions Symptomatic patients with AF experienced more adverse outcomes compared with asymptomatic patients. In asymptomatic patients with AF, a strategy of rhythm control improved the outcomes, especially with paroxysmal AF, smaller left atrium size, or higher stroke risk. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02786095.

Impact of diabetes on the management and outcomes in atrial fibrillation: an analysis from the ESC-EHRA EORP-AF Long-Term General Registry

BACKGROUND

The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF.

METHODS

The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events.

RESULTS

Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]).

CONCLUSION

In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 1)

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement.

Development and Validation of 3-Year Atrial Fibrillation Prediction Models Using Electronic Health Record With or Without Standardized Electrocardiogram Diagnosis and a Performance Comparison Among Models

Background Improved prediction of atrial fibrillation (AF) may allow for earlier interventions for stroke prevention, as well as mortality and morbidity from other AF-related complications. We developed a clinically feasible and accurate AF prediction model using electronic health records and computerized ECG interpretation. Methods and Results A total of 671 318 patients were screened from 3 tertiary hospitals. After careful exclusion of cases with missing values and a prior AF diagnosis, AF prediction models were developed from the derivation cohort of 25 584 patients without AF at baseline. In the internal/external validation cohort of 117 523 patients, the model using 6 clinical features and 5 ECG diagnoses showed the highest performance for 3-year new-onset AF prediction (C-statistic, 0.796 [95% CI, 0.785-0.806]). A more simplified model using age, sex, and 5 ECG diagnoses (atrioventricular block, fusion beats, marked sinus arrhythmia, supraventricular premature complex, and wide QRS complex) had comparable predictive power (C-statistic, 0.777 [95% CI, 0.766-0.788]). The simplified model showed a similar or better predictive performance than the previous models. In the subgroup analysis, the models performed relatively better in patients without risk factors. Specifically, the predictive power was lower in patients with heart failure or decreased renal function. Conclusions Although the 3-year AF prediction model using both clinical and ECG variables showed the highest performance, the simplified model using age, sex, and 5 ECG diagnoses also had a comparable prediction power with broad applicability for incident AF.

The Patient Pathway Review for Atrial Fibrillation

The care pathway for patients with atrial fibrillation (AF) is variable and this variability is explored in a patient pathway review. This review describes events that may take place for a patient with AF considering the "ideal" and the "real-world" pathway and attempts to rationalize them by considering the patient, clinician, health service, and societal perspective. In the "ideal" pathway, AF in a patient is either identify before or after stroke. The "real-world" pathway introduces the concepts that symptoms may influence patient decision-making to seek help, AF may be identified incidentally, and healthcare professionals may fail to identify AF. The management of AF includes no treatment or treatment such as stroke prevention, rate or rhythm control, and comorbidity management. The overall outcomes for patient depend on the presence of symptoms and response to therapies. The two major priorities for patients are symptomatic relief and avoidance of stroke. While most clinicians will find that initial AF management is not challenging but there may be incidental opportunities for earlier identification. From the healthcare service perspective, noncardiologists and cardiologists care for patients with AF, which results in much heterogeneity management. From the societal perspective, the burden of AF is significant resulting in substantial cost from hospitalizations and treatments. People with AF can take on different paths, which depend on factors related to the patient's decision-making, clinical decision-making, and patient's response to the treatment. A streamlined approach to a holistic and integrated care pathway approach to AF management is needed.

Early rhythm control and the risks of ischaemic stroke, heart failure, mortality and adverse events when performed early (<3 months)

BACKGROUND

In EAST-AFNET 4 trial, early rhythm control was associated with better clinical outcomes for patients with atrial fibrillation (AF). However, whether the better outcomes of patients assigned to rhythm control were solely due to "early" intervention or because of more regular and structured follow up was unclear.

OBJECTIVE

To investigate whether the findings of EAST trial are applicable to the 'real world' clinical setting, where a less structured management protocol is operated.

METHODS

From 2001 to 2016, 301,064 newly-diagnosed AF patients were identified from Taiwan National Health Insurance Research Database. Among these patients, 62,649 AF patients receiving antiarrhythmic drugs or catheter ablation within 1 year after AF being diagnosed were categorized as the early rhythm control group, and the remaining 238,415 patients were defined as usual care group. Risk of clinical events were compared.

RESULTS

Compared to usual care, early rhythm control was associated with a lower adjusted risk of ischemic stroke(aHR 0.771; p<0.001), heart failure(aHR 0.851; p<0.001), acute myocardial infarction(aHR 0.915; p<0.001), mortality(aHR 0.794; p<0.001) and composite adverse events(aHR 0.823; p<0.001). Compared to usual care, the lower risks of ischemic stroke(aHR 0.746), heart failure(aHR 0.819), mortality(aHR 0.777) and composite adverse events(aHR 0.802) associated with early rhythm control were even more evident when performed early (<3months)(pint<0.001). Principal results were generally consistent for majority of subgroups studied and among the cohort after propensity matching.

CONCLUSIONS

Early rhythm control, especially when performed earlier (<3months), was associated with a lower risk of adverse events than usual care among patients with early AF.

Non-alcoholic Fatty Liver Disease and the Risk of Incident Atrial Fibrillation in Young Adults: A Nationwide Population-Based Cohort Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease including cardiovascular. However, the association between NAFLD and the risk of incident atrial fibrillation (AF), especially in young adults, remains unclear. We aimed to evaluate the association between NAFLD as assessed by the fatty liver index (FLI) and the risk of AF in young adults.

METHODS

We identified individuals aged 20-39 years who underwent health examinations conducted by the Korean National Health Insurance Corporation between January 2009 and December 2012. Individuals with significant liver disease, heavy alcohol consumption, or prevalent AF were excluded. We categorized based on FLI: <30, 30 to <60, and ≥60. Incident AF was evaluated as the primary outcome.

RESULTS

We included 5,333,907 subjects (mean age, 31 ± 5 years; men, 57%). During a mean follow-up of 7.4 ± 1.1 years, 12,096 patients had newly diagnosed AF (incidence rate 0.31 per 1,000 person-years). After adjustment, subjects with FLI 30 to <60 and FLI ≥60 showed a higher risk of AF compared to those with FLI <30 (hazard ratio [HR] 1.21, 95% confidence interval [CI, 1.15-1.27] and HR 1.47, 95% CI [1.39-1.55], p < 0.001, respectively). In women, the increased AF risk was accentuated in the higher FLI group than in the individuals with FLI <30, compared with men (p-for-interaction = 0.023). A higher incident AF risk in the higher FLI groups was consistently observed in various subgroups.

CONCLUSION

Among young adults, NAFLD assessed using FLI was positively correlated with the AF risk. These findings support the evidence of AF screening in young adults with high FLI scores.

Comparing Outcomes in Asymptomatic and Symptomatic Atrial Fibrillation: A Systematic Review and Meta-Analysis of 81,462 Patients

BACKGROUND

In atrial fibrillation (AF) patients, the presence of symptoms can guide the decision between rate or rhythm control therapy, but it is still unclear if AF-related outcomes are determined by symptomatic status of their clinical presentation.

METHODS

We performed a systematic review and metanalysis following the PRISMA recommendations on available studies that compared asymptomatic to symptomatic AF reporting data on all-cause mortality, cardiovascular death, and thromboembolic events (TEs). We included studies with a total number of patients enrolled equal to or greater than 200, with a minimum follow-up period of six months.

RESULTS

From the initial 5476 results retrieved after duplicates' removal, a total of 10 studies were selected. Overall, 81,462 patients were included, of which 21,007 (26%) were asymptomatic, while 60,455 (74%) were symptomatic. No differences were found between symptomatic and asymptomatic patients regarding the risks of all-cause death (odds ratio (OR) 1.03, 95% confidence interval (CI) 0.81-1.32), and cardiovascular death (OR 0.87, 95% CI 0.54-1.39). No differences between symptomatic and asymptomatic groups were evident for stroke (OR 1.22, 95% CI 0.77-1.93) and stroke/TE (OR 1.06, 95% CI 0.86-1.31) risks.

CONCLUSIONS

Mortality and stroke/TE events in AF patients were unrelated to symptomatic status of their clinical presentation. Adoption of management strategies in AF patients should not be based on symptomatic clinical status.