Rhythm control versus rate control for atrial fibrillation and heart failure

Temporal trends in mortality, heart failure hospitalization, and stroke in heart failure patients with and without atrial fibrillation: a nationwide study from 1997 to 2018 on 152 059 patients

AIMS

We aimed to investigate temporal trends in all-cause mortality, heart failure (HF) hospitalization, and stroke from 1997 to 2018 in patients diagnosed with both HF and atrial fibrillation (AF).

METHODS AND RESULTS

From Danish nationwide registers, we identified 152 059 patients with new-onset HF between 1997 and 2018. Patients were grouped according to year of new-onset HF and AF-status: Prevalent AF (n = 34 734), New-onset AF (n = 12 691), and No AF (n = 104 634). Median age decreased from 76 to 73 years between 1997 and 2018. The proportion of patients with prevalent or new-onset AF increased from 24.7% (n = 9256) to 35.8% (n = 14 970). Five-year risk of all-cause mortality went from 69.1% [confidence interval (CI): 67.9-70.2%] to 51.3% (CI: 49.9-52.7%), 62.3% (CI: 60.5-64.4%) to 43.0% (CI: 40.5-45.5%), and 61.9% (CI: 61.3-62.4%) to 36.7% (CI: 35.9-37.6%) for the Prevalent AF, New-onset AF, and No AF-group, respectively. Minimal changes were observed in the risk of HF-hospitalization. Five-year stroke risk decreased from 8.5% (CI: 7.8-9.1%) to 5.0% (CI: 4.4-5.5%) for the prevalent AF group, 8.2% (CI: 7.2-9.2%) to 4.6% (CI: 3.7-5.5%) for new-onset AF, and 6.3% (CI: 6.1-6.6%) to 4.9% (CI: 4.6-5.3%) for the No AF group. Simultaneously, anticoagulant therapy increased for patients with prevalent (from 42.7 to 93.1%) and new-onset AF (from 41.9 to 92.5%).

CONCLUSION

From 1997 to 2018, we observed an increase in patients with HF and co-existing AF. Mortality decreased for all patients, regardless of AF-status. Anticoagulation therapy increased, and stroke risk for patients with AF was reduced to a similar level as patients without AF in 2013-2018.

Atrial Fibrillation in End-Stage Heart Failure

End-stage heart failure (HF) accounts for 1% to 10% of all HF cases. It is frequently associated with coexistent atrial fibrillation due in part to structural changes related to altered hemodynamics, increased wall stress, and neurohormonal activation. The treatment remains challenging because of frequent atrial remodeling, comorbidities, and high recurrence rates. Studies have found no benefit of medical rhythm control compared with rate control. However, recent data suggest that catheter ablation might be associated with a reduction in HF symptomatology and all-cause mortality. Alternative treatment options including AV nodal ablation are available for refractory cases, but should not delay urgent heart transplantation.

Rate Versus Rhythm Control for Atrial Fibrillation with Heart Failure

Atrial fibrillation with Heart Failure is a constellation of co-morbid conditions that now constitutes a major cardiovascular epidemic, with HF now the most common complication of AF. Mechanistically, both conditions promote substrate disease in the atrium and ventricle. AF is an independent rixk factor in HF progression and pump failure death. While early studies comparing rhythm control antiarrhythmic drugs and rate control drugs showed no significant benefit in cardiovascular outcomes, AF did promote HF emergence and hospitalizations. Newer rhythm control strategies with present day antiarrhythmic drugs and catheter ablation support benefits in cardiovascular outcomes in AF with HF. Catheter ablation improved HF outcomes in HF with reduced ejection fraction but further and larger studies are needed, especially for AF with HF with preserved ejection fraction.

Atrial Fibrillation Ablation in Heart Failure with Reduced Ejection Fraction

Multiple randomized clinical trials have demonstrated catheter ablation in heart failure with reduced ejection fraction reduces mortality and hospitalization as well as improves ventricular function, quality of life, and functional status. Catheter ablation has been shown to be superior to alternative rate and rhythm control strategies in these outcomes. Guidelines strongly support the use of catheter ablation to maintain sinus rhythm in patients with atrial fibrillation and heart failure.

Arrhythmia-Induced Cardiomyopathy: Predictors of Improvement in Left Ventricular Systolic Function After Catheter Ablation

Background: Arrhythmia-induced cardiomyopathy (AIC) is a relatively common yet poorly understood cardiac condition that occurs when arrhythmias cause left ventricular systolic dysfunction, which can be reversed with the resolution of the arrhythmia. Catheter ablation serves as a cornerstone treatment for eliminating the arrhythmic trigger. However, the variability in left ventricular recovery following ablation highlights the need to identify reliable predictors of reverse remodeling. Methods: This review explores key studies on AIC patients undergoing catheter ablation, primarily derived from observational cohorts, to identify significant predictors of left ventricular function recovery. Results: While echocardiography and cardiac magnetic resonance imaging remain the primary diagnostic modalities, additional insights have emerged from electrocardiograms and laboratory biomarkers. Despite these advancements, a comprehensive framework for identifying optimal candidates for ablation remains lacking. Conclusions: By synthesizing existing evidence, this review aims to pinpoint the most robust predictors of systolic recovery in AIC patients following ablation.

Relaxin-2 Exhibits a Beneficial Role in Energy Metabolism to Alleviate Atrial Fibrillation Susceptibility

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with energy metabolic disorder leading to severe clinical courses. Relaxin-2 (RLX), a peptide hormone, has been identified to activate crucial enzymes involved in cellular energy metabolism. However, whether relaxin-2 can improve the energy metabolism of atrial myocytes to inhibit AF pathogenesis remains unknown. Male New Zealand rabbits were randomly separated into sham, right atrial tachypacing (RAP), and RAP with a human recombinant relaxin-2 treatment (0.5 mg/kg) group for 2 weeks, and programmed intracardiac stimulation was performed to assess AF susceptibility. Ultrahigh-performance liquid chromatography (UHPLC) was performed to explore potential metabolic profiles in rabbit atria. Histology, transmission electron microscopy (TEM), Western blot, qRT-PCR, and Seahorse assays were used to explain the molecular mechanisms. The downregulated relaxin family peptide receptor 1 (RXFP1) protein was found in the atria of AF patients and rabbits, as well as in tachypacing HL-1 cells. RLX protected against RAP-induced AF with decreased atrial fibrosis and electrical remodeling in rabbits. UHPLC revealed that RLX improved fatty acid and glucose metabolism by activating the PPAR signaling pathway in rabbit atria. Mechanistically, RLX enhanced peroxisome proliferator-activated receptor-γ (PPARγ) expression via regulating RXFP1, which restored mitochondrial respiration and ATP production, along with reduced mitochondrial reactive oxygen species in both rabbit atria and HL-1 cells. Moreover, overexpression of PPARγ in tachypacing HL-1 cells prevented mitochondrial damage and alleviated energy metabolic disorder. Besides, we found that upregulated serum relaxin-2 levels with altered metabolites, including 13S-hydroxyoctadecadienoic acid, prostaglandin E2, glyceric acid, and deoxyribose 1-phosphate, were correlated with AF occurrence in patients. Our study reveals that relaxin-2 attenuates atrial energy metabolic remodeling to prevent AF pathogenesis, which could be considered a potential therapeutic approach in the clinic.

Atrial Fibrillation: A Review

Importance

In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.

Observations

Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

Conclusions and Relevance

AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

Design and rationale of a pragmatic randomized clinical trial of early dronedarone versus usual care to change and improve outcomes in persons with first-detected atrial fibrillation - the CHANGE AFIB study

BACKGROUND

While there are several completed clinical trials that address treatment strategies in patients with symptomatic and recurrent atrial fibrillation (AF), there are no randomized clinical trials that address first-line rhythm control of new-onset AF. Recent data suggest that early initiation of rhythm control within 1 year can improve outcomes.

METHODS

In this open-label pragmatic clinical trial nested within the Get with The Guidelines Atrial Fibrillation registry, approximately 3,000 patients with first-detected AF will be enrolled at approximately 200 sites. Participants will be randomized (1:1) to treatment with dronedarone in addition to usual care versus usual care alone. The primary endpoint will be time to first cardiovascular (CV) hospitalization or death from any cause through 12 months from randomization. Secondary endpoints will include a WIN ratio (all-cause death, ischemic stroke or systemic embolism, heart failure hospitalization, acute coronary hospitalization), CV hospitalization, and all-cause mortality. Patient reported outcomes will be analyzed based on change in Atrial Fibrillation Effect on Quality of Life (AFEQT) and change in Mayo AF-Specific Symptom Inventory (MAFSI) from baseline to 12 months.

CONCLUSION

CHANGE AFIB will determine if treatment with dronedarone in addition to usual care is superior to usual care alone for the prevention of CV hospitalization or death from any cause in patients with first-detected AF. The trial will also determine whether initiation of rhythm control at the time of first-detected AF affects CV events or improves patient reported outcomes.

TRIAL REGISTRATION

- NCT05130268.

Atrial Fibrillation Ablation During Hospitalization for Acute Heart Failure: Feasibility and Role of Pulsed Field Ablation

INTRODUCTION

Atrial fibrillation (AF) can cause or aggravate heart failure (HF). Catheter ablation (CA) is an effective treatment for AF. This study focused on the feasibility and outcomes of emergent AF ablation performed during hospitalization for acute HF.

METHODS AND RESULTS

We retrospectively investigated patients who underwent emergent CA for AF during hospitalization for acute HF in 2018-2024. Arrhythmia recurrence was the primary endpoint. The combination of arrhythmia recurrence, HF hospitalization, and all-cause death was the secondary endpoint. Patients were censored 1 year after the index procedure. We included 46 patients, 35% females, with median age of 67 [interquartile rage: 61, 72] years and left ventricular ejection fraction (LVEF) of 25 [23, 28]%. Thermal CA was performed in 14 patients, and pulsed field ablation (PFA) in 32 patients. Procedure time was significantly shorter with PFA compared to thermal CA (77 [57, 91] vs. 166 [142, 200] minutes, p < 0.001). Fluoroscopy time was longer with PFA (9.5 [7.6, 12.0] vs. 3.9 [2.9, 6.0] minutes, p < 0.001), with a borderline trend towards higher radiation dose (75 [53, 170] vs. 50 [30, 94] μGy.m2, p = 0.056). Extrapulmonary ablation was frequent (86% and 84% for thermal CA and PFA, p > 0.9). The estimated freedom from the primary endpoint was 79% after PFA and 64% after thermal CA (p = 0.44). The estimated freedom from the secondary endpoint was 76% after PFA and 57% after thermal CA (p = 0.43). LVEF improved by 24% ± 2% (p < 0.001) in patients with the first manifestation of HF and by 14% ± 4% (p = .004) in patients with decompensated HF diagnosed earlier.

CONCLUSIONS

Emergent CA of AF during acute HF hospitalization is safe and associated with improved LVEF and good clinical outcomes. In the PFA era, the rate of these procedures is progressively increasing as they are readily available and easy to perform compared to thermal ablation.

Transcatheter Approaches to Atrial Functional Mitral Regurgitation: How Far Have We Come?

Functional mitral regurgitation (MR) is associated with increased cardiovascular morbidity and mortality and over the past decade, the diagnosis of atrial functional mitral regurgitation (aFMR) has been increasingly observed in the elderly, especially in those with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF). Annular enlargement, perturbations of annular contraction, and atriogenic leaflet tethering distinguish the pathophysiology of aFMR from the one of ventricular origin. However, no consensus provides recommendations regarding the differential diagnosis and the subsequent management of aFMR. The advent of transcatheter mitral valve repair has paved the way for various treatments including edge-to-edge repair (TEER), mitral annuloplasty, and replacement, with optimistic results on short-medium-term outcome provided by preliminary studies. In parallel, rhythm control of AF for paroxysmal and persistent types, should be pursued to induce reverse remodeling and restoring the normal leaflet coaptation. In this setting, catheter ablation aiming for electrical isolation of the pulmonary veins is the most widely recognized and effective strategy for maintaining sinus rhythm. Nevertheless, arrhythmia-free survival is lower in patients with persistent and long-term persistent AF, leading to the adoption of hybrid strategies combining transcatheter endocardial ablation and thoracoscopic epicardial surgical ablation. This review provides an update on the diagnosis and treatment of aFMR, focusing on available transcatheter approaches that can be performed in the catheterization lab and electrophysiology lab.

Long-term impact of atrial fibrillation catheter ablation on heart failure with preserved ejection fraction

BACKGROUND

The efficacy of catheter ablation as a treatment approach for patients with concurrent atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) has been inadequately investigated.

OBJECTIVE

This study's objective was to assess the effectiveness of atrial fibrillation ablation (AFA) in patients with heart failure with preserved ejection fraction.

METHODS

Utilizing the TriNetX research network, we identified individuals aged 18 and older with atrial fibrillation (AF) and concurrent heart failure with preserved ejection fraction (HFpEF) from January 1, 2010, to June 1, 2021. Patients were further classified based on their catheter ablation procedure, using Current Procedural Terminology codes. Following propensity-score matching, each cohort consisted of 9440 patients. The primary endpoint was all-cause mortality at two years and secondary outcomes during the 2-year follow-up encompassing readmissions for heart failure, AF, and stroke.

RESULTS

In propensity-matched cohort, patients with AF and HFpEF who underwent AFA plus medical therapy had significantly lower all-cause mortality at two years than those who did not undergo AFA (hazard ratio (HR): 0.37, 95% CI: 0.34-0.40; P < 0.001) even after matching antiarrhythmic medications. At two years, secondary outcomes including HF readmissions (HR: 0.86 95% CI: 0.84-0.89; P < 0.001) and stroke readmissions (HR: 0.66 95% CI: 0.59-0.73; P < 0.001) were lower in the AFA group.

CONCLUSION

AFA amongst AF patients with concomitant HFpEF showed a significant reduction in all-cause mortality. It also leads to significant reductions in readmissions due to HF and ischemic stroke at two years.

Atrial Fibrillation in Heart Failure: Novel Insights, Challenges, and Treatment Opportunities

PURPOSE OF REVIEW

Atrial fibrillation and heart failure frequently co-exist. This review discusses the comorbidity of atrial fibrillation and heart failure, the bi-directional link between them, and the recent advances in the management of these co-existing diseases.

RECENT FINDINGS

Catheter ablation received a class 1 A recommendation for patients with AF and HF, after overwhelming evidence in heart failure with reduced ejection fraction and end-stage heart failure, while clinical trials are still lacking in patients with preserved ejection. Guideline-medical therapy of heart failure decreases the incidence of atrial fibrillation and the progression of atrial myopathy. Based on the current evidence, management of patients with both HF and AF should be include early optimization of comorbidity control, guideline-medical therapy for heart failure, and rhythm control preferentially through catheter ablation in properly selected patients.

Heart Failure and All-Cause Hospitalizations in Patients With Heart Failure: A Meta-Analysis

Importance

Heart failure (HF) hospitalization is a common end point in HF trials; however, how HF hospitalization is associated with all-cause hospitalization in terms of proportionality, correlation of treatment effects, and concomitant reporting has not been studied.

Objective

To determine the ratio of HF to all-cause hospitalizations, whether reported treatment effects on HF hospitalization are associated with treatment effects on all-cause hospitalization, and how often all-cause hospitalization is reported alongside HF hospitalization.

Data Sources

PubMed was searched from inception to September 2, 2024, for randomized clinical trials (RCTs) of HF treatments using MeSH (medical subject heading) terms and keywords associated with heart failure, ventricular failure, ventricular dysfunction, and cardiac failure, as well as the names of specific journals.

Study Selection

RCTs of HF treatments and reporting on HF hospitalization published in 1 of 3 leading medical journals (New England Journal of Medicine, The Lancet, or JAMA).

Data Extraction and Synthesis

The PRISMA guidelines were followed. Data extraction was performed by 2 reviewers, and disagreements were resolved by consensus. Trial baseline characteristics and outcome data on HF and all-cause hospitalizations were extracted. The ratio of HF to all-cause hospitalizations was calculated. The association of HF hospitalization effects with all-cause hospitalization effects was evaluated using hierarchical bayesian models with weak priors. The posterior distribution was used to calculate the HF hospitalization treatment effects that would need to be observed before a high probability (97.5%) of a reduction in all-cause hospitalization could be achieved. The proportion of trials reporting all-cause hospitalization was calculated.

Main Outcomes and Measures

HF and all-cause hospitalizations.

Results

Of 113 trials enrolling 261 068 patients (median proportion of female participants, 25.4% [IQR, 21.3%-34.2%]; median age, 66.2 [IQR, 62.8-70.0] years), 60 (53.1%) reported on all-cause hospitalization. The weighted median ratio of HF to all-cause hospitalizations was 45.9% (IQR, 30.7%-51.7%). This ratio was higher in trials with greater proportions of New York Heart Association class III or IV HF, with lower left ventricular ejection fractions, investigating nonpharmaceutical interventions, and that restricted recruitment to patients with HF and reduced ejection fraction. Reported effects on HF and all-cause hospitalizations were well-correlated (R2 = 90.1%; 95% credible interval, 62.3%-99.8%). In a large trial, the intervention would have to decrease the odds of HF hospitalization by 16% to ensure any reduction, 36% to ensure a 10% reduction, and 56% to ensure a 20% reduction in the odds of all-cause hospitalization with 97.5% probability.

Conclusions and Relevance

In this meta-analysis of HF trials, all-cause hospitalization was underreported despite a large burden of non-HF hospitalizations. Large reductions in HF hospitalization must be observed before clinically relevant reductions in all-cause hospitalization can be inferred.

Comparison of rhythm versus rate control of atrial fibrillation in heart failure subgroups: Systematic review and meta-analysis of randomized controlled trials

Patients with concurrent heart failure (HF) and atrial fibrillation (AF) have poor outcomes. Randomized clinical trials comparing rhythm control approaches to rate control of AF have yielded conflicting results and there is a paucity of updated and comprehensive evidence summaries to inform best practice in HF patients. We therefore conducted a systematic review and meta-analysis to compare outcomes with rhythm versus rate control of AF in various subgroups of HF patients. In HF patients overall, we found high certainty evidence that rhythm control decreased all-cause and cardiovascular mortality (hazard ratio [HR, 95 % confidence interval] 0.64 [0.43-0.94]) and HR 0.50 [0.34-0.74] respectively). Rhythm control was associated with decreased HF hospitalization (risk ratio [RR] 0.79 [0.63-0.99], moderate certainty), but did not significantly decrease thromboembolic events (RR 0.67 [0.32-1.39], low certainty). The mean difference in left ventricular ejection fraction [LVEF] from baseline to last follow-up was greater in rhythm control group by 6.01 % [2.73-9.28 %] compared with rate control. Subgroup analyses by age, HF etiology (ischemic or non-ischemic), LVEF, presence of diabetes and hypertension did not reveal any significant differences in treatment effect. The survival and hospitalization reduction benefit of rhythm control of AF in HF patients likely reflects the success of catheter ablation especially in HF with reduced ejection fraction. These data are important to guide shared decision-making when managing AF in HF patients.

Ventricular arrhythmias after atrial fibrillation electrical cardioversion: A multicenter study

Background

Ventricular arrhythmias (VAs) after atrial fibrillation (AF) electrical cardioversion (ECV) have been reported.

Objective

We sought to assess incidence, timing, and clinical characteristics of patients with post-AF ECV-related VAs.

Methods

Multicenter observational retrospective study including 13 centers, incorporating patients with VAs or sudden cardiac death within 10 days of ECV. The total number of ECVs performed during the collecting period was provided. Patients with pre-ECV VAs were excluded.

Results

Twenty-three patients with VAs were identified out of 11,897 AF ECVs performed in 13 centers during a median 2-year period, suggesting post-ECV VA incidence of 0.2%. The patients' mean age was 71 ± 11 years, and 13 (56.5%) were female. AF duration prior to ECV was 71 ± 54 days. Congestive heart failure and hypertension were both found in 17 (74%) patients. QT-prolonging drugs were used by 17 (74%). Index VA occurred 28.5 (interquartile range 5.5-72) hours post-ECV, including torsades de pointes, nonsustained polymorphic ventricular tachycardia, and sudden cardiac death in 17 (74%), 5 (22%), and 1 (4%) patient, respectively. Post-ECV heart rate was slower and QT duration longer compared with pre-ECV (57 ± 11 beats/min vs 113 ± 270 beats/min; P < .001; QT duration 482 ± 61 ms vs 390 ± 60 ms; P < .001). VAs reoccurred in 9 (39%) patients, 11 (interquartile range 3-13.5) hours post-index VA. Two patients had an arrhythmic death within 72 hours post-ECV.

Conclusion

VAs post-AF ECV are rare, occur within 3 to 72 hours post-ECV, and are potentially fatal. Our study gives a signal of caution favoring prolonged monitoring in small subset of patients as congestive heart failure patients treated with class III antiarrhythmic drugs, with post-ECV bradycardia, especially (but not exclusively) when QT prolongation noted.

Optogenetic modulation of cardiac autonomic nervous system

The following is a narrative review of the fundamentals of optogenetics. It focuses on the advantages and constraints of manipulating the autonomic nervous system by modifying the pathophysiological characteristics that arise in different diseases. Although the use of this technique is currently experimental, we will discuss improvements that have been implemented and identify the necessary measures for potential preclinical translation in the control of the cardiac autonomic nervous system.

Invasive strategies for rhythm control of atrial fibrillation: a narrative review

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its increasing prevalence has resulted in a growing healthcare burden. A recent landmark randomized trial, the EAST-AFNET 4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial), highlighted the importance of early rhythm control in AF, which was previously underemphasized. Rhythm control therapy includes antiarrhythmic drugs, direct-current cardioversion, and catheter ablation. Currently, catheter ablation is indicated for patients with AF who are either refractory or intolerant to antiarrhythmic drugs or who exhibit decreased left ventricular systolic function. Catheter ablation can be categorized according to the energy source used, including radiofrequency ablation (RFA), cryoablation, laser ablation, and the recently emerging pulsed field ablation (PFA). Catheter ablation techniques can also be divided into the point-by-point ablation method, which ablates the pulmonary vein (PV) antrum one point at a time, and the single-shot technique, which uses a spherical catheter to ablate the PV antrum in a single application. PFA is known to be applicable to both point-by-point and single-shot techniques and is expected to be promising owing to its tissue specificity, resulting in less collateral damage than catheter ablation involving thermal energy, such as RFA and cryoablation. In this review, we aimed to outline catheter ablation for rhythm control in AF by reviewing previous studies.

Pulsed Field Ablation of Atrial Fibrillation: A Novel Technology for Safer and Faster Ablation

Atrial fibrillation (AF), the most common arrhythmia, is associated with increased morbidity, mortality, and healthcare costs. Evidence indicates that rhythm control offers superior cardiovascular outcomes compared to rate control, especially when initiated early after the diagnosis of AF. Catheter ablation remains the single best therapy for AF; however, it is not free from severe complications and only a small percentage of AF patients in the Western world ultimately receive ablation. Ensuring that AF ablation is safe, effective, and efficient is essential to make it accessible to all patients. With the limitations of traditional thermal ablative energies, pulsed field ablation (PFA) has emerged as a novel non-thermal energy source. PFA targets irreversible electroporation of cardiomyocytes to achieve cell death without damaging adjacent structures. Through its capability to create rapid, selective lesions in myocytes, PFA presents a promising alternative, offering enhanced safety, reduced procedural times, and comparable, if not superior, efficacy to thermal energies. The surge of new evidence makes it challenging to stay updated and understand the possibilities and challenges of PFA. This review aims to summarize the most significant advantages of PFA and how this has translated to the clinical arena, where four different catheters have received CE-market approval for AF ablation. Further research is needed to explore whether adding new ablation targets, previously avoided due to risks associated with thermal energies, to pulmonary vein isolation can improve the efficacy of AF ablation. It also remains to see whether a class effect exists or if different PFA technologies can yield distinct clinical outcomes given that the optimization of PFA parameters has largely been empirical.

Influence of time to ablation on outcomes among patients with atrial fibrillation with pre-existing heart failure

Background

Atrial fibrillation (AF) and heart failure (HF) are cardiac disorders that often coexist.

Objective

This study aimed to investigate how time to ablation could influence the outcomes of AF patients with pre-existing HF.

Methods

Using the 2013 to 2022 Optum Clinformatics database, AF patients with pre-existing HF were classified into 2 groups: early ablation (ablation within 6 months of AF diagnosis) and late ablation (ablation in the 6- to 24-month period after AF diagnosis). Outcomes including AF-related hospitalization, electrical cardioversion, repeat ablation, antiarrhythmic drug (AAD) use, and AF recurrence (a composite outcome of the aforementioned events) were assessed in the postblanking 24-month period. Inverse probability of treatment weighted Poisson regression estimated risk ratio (RR) and 95% confidence interval (CI) for each outcome.

Results

Overall, 601 patients were identified (early ablation: 347; late ablation: 254). In 24 months, the weighted data suggested that patients in the early ablation cohort had significantly lower rate of composite outcome (49.32% vs 61.39%, P = .01), repeat ablation (8.56% vs 17.35%, P < .01), and AAD use (35.95% vs 47.92%, P = .01). Early ablation was associated with a 20%, 51%, and 25% lower risk of composite outcome (RR 0.80, 95% CI 0.69-0.94), repeat ablation (RR 0.49, 95% CI 0.31-0.79), and AAD use (RR 0.75, 95% CI 0.61-0.92), respectively. No significant difference in AF-related hospitalization and electrical cardioversion were observed.

Conclusion

AF patients with pre-existing HF undergoing ablation within 6 months of AF diagnosis have a lower risk of AF recurrence than those undergoing late ablation, which was evidenced by a lower rate of repeat ablation and AAD use.

Clinical decisions for appropriate management of patients with atrial fibrillation

The management of patients with atrial fibrillation (AF) requires intricate clinical decision-making to optimize outcomes. In everyday clinical practice, physicians undergo difficult choices to better manage patients with AF. They need to balance thromboembolic and bleeding risk to focus on patients' symptoms and to manage a variety of multiple comorbidities. In this review, we aimed to explore the multifaceted dimensions of clinical decision-making in AF patients, encompassing the definition and diagnosis of clinical AF, stroke risk stratification, oral anticoagulant therapy selection, consideration of bleeding risk, and the ongoing debate between rhythm and rate control strategies. We will also focus on possible grey zones for the management of AF patients. In navigating this intricate landscape, clinicians must reconcile the dynamic interplay of patient-specific factors, evolving guidelines, and emerging therapies. The review underscores the need for personalized, evidence-based clinical decision-making to tailor interventions for optimal outcomes according to specific AF patient profiles.

Effectiveness and safety of Liriope Tuber (Liriopis seu Ophiopogonis Tuber, Maidong) included traditional herbal medicine for patients with paroxysmal atrial fibrillation: A systematic review, meta-analysis, and network analysis

Background

Conventional medicine (CM) for paroxysmal atrial fibrillation (PAF) have limitations and side effects. Integrative approaches, including traditional herbal medicines like Liriope Tuber, are being explored for potential benefits, although evidence remains limited.

Methods

In April 2023, a literature search was conducted across nine databases, focusing on randomized controlled trials assessing the effects of Liriope Tuber in traditional herbal medicine (LTHM) on PAF. The risk of bias was evaluated using Version 2 of the Cochrane risk-of-bias tool for randomized trials. A random-effects model was employed for the meta-analysis.

Results

A total of 43 studies with 3,743 participants were included. The meta-analysis indicated that adding LTHM to CM reduced PAF frequency (SMD = -0.99, 95 % CI = -1.40 to -0.57, I² = 88 %, N = 16, n = 1266), left atrium diameter (LAD) (MD = -2.39 mm, 95 % CI = -3.09 to -1.68), P-wave dispersion (Pd) (MD = -6.41 ms, 95 % CI = -8.44 to -4.37), high sensitive C-Reactive Protein (hs-CRP) (MD = -1.10 mg/l, 95 % CI = -1.73 to -0.47), and improved left ventricular ejection fraction (LVEF) (MD = 4.71 %, 95 % CI = 3.17 to 6.25). Thirty-four studies raised concerns about bias, with eight showing high risk. Certainty of evidence was rated as "low" for PAF frequency, LAD, Pd, hs-CRP, and LVEF.

Conclusion

LTHM combined with CM may reduce PAF frequency. However, due to the complexity of interventions, with Liriope Tuber being only one component of the regimen, high risk of bias, substantial heterogeneity, and indirectness, interpretations should be cautious.

Study registration

PROSPERO (ID: CRD42023477926).

Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction: New Assessment of an Old Problem

Atrial fibrillation (AF) and heart failure (HF)-specifically, heart failure with reduced ejection fraction (HFrEF)-often coexist, and each contributes to the propagation of the other. This relationship extends from the mechanistic and physiological to clinical syndromes, quality of life, and long-term cardiovascular outcomes. The risk factors for AF and HF overlap and create a critical opportunity to prevent adverse outcomes among patients at greatest risk for either condition. Increasing recognition of the linkages between AF and HF have led to widespread interest in designing diagnostic, predictive, and interventional strategies targeting all aspects of disease, from identifying genetic predisposition to addressing social determinants of health. Advances across this spectrum culminated in updated multisociety guidelines for management of AF, which includes specific consideration of comorbid AF and HF. This review expands on these guidelines by further highlighting relevant clinical trial findings and providing additional context for the evolving recommendations for management in this important and growing population.

Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure: Focus on the Latest Clinical Evidence

Atrial fibrillation and heart failure are two common cardiovascular conditions that frequently coexist, and it has been widely demonstrated that in patients with chronic heart failure, atrial fibrillation is associated with a significant increase in the risk of all-cause death and all-cause hospitalization. Nevertheless, there is no unanimous consensus in the literature on how to approach this category of patients and which therapeutic strategy (rhythm control or frequency control) is the most favorable in terms of prognosis; moreover, there is still a lack of data comparing the different ablative techniques of atrial fibrillation in terms of efficacy, and many of the current trials do not consider current ablative techniques such as high-power short-duration ablation index protocol for radiofrequency pulmonary vein isolation. Eventually, while several RCTs have widely proved that in patients with heart failure with reduced ejection fraction, ablation of atrial fibrillation is superior to medical therapy alone, there is no consensus regarding those with preserved ejection fraction. For these reasons, in this review, we aim to summarize the main updated evidence guiding clinical decision in this complex scenario, with a special focus on the most recent trials and the latest meta-analyses that examined the role of catheter ablation (CA) in rhythm control in patients with AF and HF.

Prognosis and treatment strategies for atrial fibrillation in heart failure with mildly reduced ejection fraction

AIMS

The study investigates the prognosis of atrial fibrillation (AF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). Data concerning the prognostic impact of AF in patients with HFmrEF is scarce.

METHODS AND RESULTS

Consecutive patients with HFmrEF [i.e. left ventricular ejection fraction 41-49% and signs and/or symptoms of heart failure (HF)] were retrospectively included at one institution from 2016 to 2022. Patients with AF were compared with patients without with regard to the primary composite endpoint of all-cause mortality and HF-related rehospitalization at 30 months (median follow-up). Statistical analyses included Kaplan-Meier, multivariable Cox proportional regression analyses, and propensity score matching. A total of 2148 patients with HFmrEF were included with an overall prevalence of AF of 43%. The presence of AF was associated with a higher risk of the primary composite endpoint all-cause mortality and HF-related rehospitalization at 30 months [hazard ratio (HR) = 2.068; 95% confidence interval (CI) 1.802-2.375; P = 0.01], which was confirmed after propensity score matching (HR = 1.494; 95% CI 1.216-1.835; P = 0.01). AF was an independent predictor of both all-cause mortality (HR = 1.340; 95% CI 1.066-1.685; P = 0.01) and HF-related rehospitalization (HR = 2.061; 95% CI 1.538-2.696; P = 0.01). Finally, rhythm control may be associated with lower risk of all-cause mortality compared with rate control for AF (HR = 0.342; 95% CI 0.199-0.587; P = 0.01).

CONCLUSION

Atrial fibrillation affects 43% of patients with HFmrEF and represents an independent predictor of adverse long-term prognosis.

Atrial fibrillation burden: a new outcome predictor and therapeutic target

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is not a dichotomous disease trait. Technological innovations enable long-term rhythm monitoring in many patients and can estimate AF burden. These technologies are already used to detect and monitor AF. This review describes the relation between AF burden and outcomes and potential effects of AF burden reduction. A lower AF burden is associated with a lower risk of stroke and heart failure in patients with AF: stroke risk without anticoagulation is lower in patients with device-detected AF and a low AF burden (stroke rate 1%/year) than in patients with persistent and permanent AF (stroke rate 3%/year). Paroxysmal AF shows intermediate stroke rates (2%/year). Atrial fibrillation burden-reducing interventions can reduce cardiovascular outcomes in patients with AF: early rhythm control reduces cardiovascular events including stroke and heart failure in patients with recently diagnosed AF and cardiovascular conditions. In patients with heart failure and AF, early rhythm control and AF ablation, interventions that reduce AF burden, reduce mortality and heart failure events. Recent technological innovations allow to estimate AF burden in clinical care, creating opportunities and challenges. While evidence remains limited, the existing data already suggest that AF burden reduction could be a therapeutic goal. In addition to anticoagulation and treatment of cardiovascular conditions, AF burden reduction emerges as a therapeutic goal. Future research will define the AF burden that constitutes a relevant risk of stroke and heart failure. Technologies quantifying AF burden need careful validation to advance the field.

Multidisciplinary Approach in Atrial Fibrillation: As Good as Gold

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

Heart Failure Events After Long-term Continuous Screening for Atrial Fibrillation: Results From the Randomized LOOP Study

BACKGROUND

Mounting evidence indicates that even device-detected subclinical atrial fibrillation is associated with a higher risk of heart failure (HF). However, the potential impact of atrial fibrillation screening on HF remains unknown.

METHODS

The LOOP Study (Atrial Fibrillation detected by Continuous ECG Monitoring using Implantable Loop Recorder to prevent Stroke in High-risk Individuals) evaluated the effects of atrial fibrillation screening on stroke prevention using an implantable loop recorder (ILR) versus usual care in older individuals with additional stroke risk factors. In this secondary analysis, we explored the following HF end points: (1) HF event or cardiovascular death; (2) HF event; (3) event with HF with reduced ejection fraction (HFrEF); and (4) HFrEF event or cardiovascular death. Outcomes were assessed in a Cox model both as time-to-first events and as total (first and recurrent) events analyzed using the Andersen-and-Gill method.

RESULTS

Of 6004 participants (mean age 74.7 and 52.7% men), 1501 were randomized to ILR screening and 4503 to the control group. In total, 77 (5.1%) in the ILR group versus 295 (6.6%) in the control group experienced the primary outcome of an HF event or cardiovascular death. Compared with usual care, ILR screening was associated with a nonsignificant reduction in the primary outcome for the time-to-first event analysis (hazard ratio, 0.78 [95% CI, 0.61-1.01]) and the total event analysis (hazard ratio, 0.77 [95% CI, 0.59-1.01]). Similar results were obtained for the HF event. A significant risk reduction in total events was observed in the ILR group for the composite of HFrEF event or cardiovascular death and for HFrEF event (hazard ratio, 0.74 [95% CI, 0.56-0.98] and 0.65 [95% CI, 0.44-0.97], respectively).

CONCLUSIONS

In an older population with additional stroke risk factors, ILR screening for atrial fibrillation tended to be associated with a lower rate of total HF events and cardiovascular death, particularly those related to HFrEF. These findings should be considered hypothesis-generating and warrant further investigation.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02036450.

Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Rhythm control, either with antiarrhythmic drugs or catheter ablation, and rate control strategies are the cornerstones of atrial fibrillation (AF) management. Despite the increasing role of rhythm control over the past few years, it remains inconclusive which strategy is superior in improving clinical outcomes.

OBJECTIVES

This study summarizes the total and time-varying evidence regarding the efficacy of rhythm- vs rate-control strategies in the management of AF.

METHODS

We systematically perused the MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for randomized controlled trials from inception to November 2023. We included studies that compared the efficacy of rhythm control (ie, antiarrhythmic drugs classes Ia, Ic, or III, AF catheter ablation, and electrical cardioversion) and rate control (ie, beta-blocker, digitalis, or calcium antagonist) strategies among patients with nonvalvular AF. The primary outcome was cardiovascular (CV) death, whereas secondary outcomes included all-cause death, stroke, hospitalization for heart failure (HF), sinus rhythm at the end of the follow-up, and rhythm control-related adverse events. A cumulative meta-analysis to assess temporal trends and a meta-regression analysis using the percentage of ablation use was performed.

RESULTS

We identified 18 studies with a total of 17,536 patients (mean age: 68.6 ± 9.7 years, 37.9% females) and a mean follow-up of 28.5 months. Of those, 31.9% had paroxysmal AF. A rhythm control strategy reduced CV death (HR: 0.78; 95% CI: 0.62-0.96), stroke (HR: 0.801; 95% CI: 0.643-0.998), and hospitalization for HF (HR: 0.80; 95% CI: 0.69-0.94) but not all-cause death (HR: 0.86; 95% CI: 0.73-1.02) compared with a rate control strategy. This benefit was driven by contemporary studies, whereas more ablation use within the rhythm control arm was associated with improved outcomes, except stroke.

CONCLUSIONS

In patients with AF, a contemporary rhythm control strategy leads to reduced CV mortality, HF events, and stroke compared with a rate control strategy.

Benefits of early rhythm control of atrial fibrillation

In contrast to current guidelines and earlier trials, recent studies demonstrated superiority of rhythm- over rate-control and challenged the strategy of "rate versus rhythm" therapy in patients with atrial fibrillation. These newer studies have started to shift the use of rhythm-control therapy from the symptom-driven therapy of current guidelines to a risk-reducing strategy aimed at restoring and maintaining sinus rhythm. This review discusses recent data and presents an overview on the current discourse: The concept of early rhythm control seems attractive. Patients with rhythm control may undergo less atrial remodeling compared to those with rate control. In addition, in EAST-AFNET 4 an outcome-reducing effect of rhythm control was achieved by delivering therapy with relatively few complications early after the initial AF diagnosis. Successful rhythm control therapy and most likely reduced AF burden, estimated by the presence of sinus rhythm at 12 months after randomization, explained most of the reduction in cardiovascular outcomes achieved by rhythm control. However, it is too early to call for early rhythm control for all AF patients. Rhythm control may raise concerns regarding the generalizability of trial results in routine practice involving important questions on the definition of "early" and "successful", and the relevant issue of antiarrhythmic drugs versus catheter ablation. Further information is required to select patients who will benefit from an early ablative or non-ablative rhythm management.

Is it a thrombus or a tumor? An imaging dilemma for clinicians

Atrial fibrillation, the most common cardiac arrhythmia in the Western world, confers a 5-fold increase in stroke, mainly due to thrombus formation in the left atrial appendage. Early rhythm control is often beneficial in reducing adverse cardiovascular events in higher-risk populations. Here, we present a patient who was found to have a 1 cm stalk-like lesion in the left atrial appendage on transesophageal echocardiogram prior to electrical cardioversion. Using multiple cardiac imaging modalities, including cardiac magnetic resonance imaging and computed tomography, the mass was eventually determined to be a chronic resolving thrombus.

Arrhythmia-Induced Cardiomyopathy: JACC State-of-the-Art Review

Arrhythmias frequently accompany heart failure and left ventricular dysfunction. Tachycardias, atrial fibrillation, and premature ventricular contractions can induce a reversible form of dilated cardiomyopathy (CM) known as arrhythmia-induced CM (AiCM). The intriguing question is why certain individuals are more susceptible to AiCM, despite similar arrhythmia burdens. The primary challenge is determining the extent of arrhythmias' contribution to left ventricular systolic dysfunction. AiCM should be considered in patients with a mean heart rate of >100 beats/min, atrial fibrillation, or a PVC burden of >10%. Confirmation of AiCM occurs when CM reverses upon eliminating the responsible arrhythmia. Therapy choice depends on the specific arrhythmia, patient comorbidities, and preferences. After left ventricular function is restored, ongoing follow-up is essential if an abnormal myocardial substrate persists. Accurate diagnosis and treatment of AiCM have the potential to enhance patients' quality of life, improve clinical outcomes, and reduce hospital admissions and overall health care costs.

Real-World Outcomes of a Rhythm Control Strategy for Atrial Fibrillation Patients with Reduced Left Ventricular Ejection Fraction (<50%)

Background/Objectives: The effectiveness of a rhythm control strategy in patients with atrial fibrillation (AF) and reduced left ventricular ejection fraction (LVEF < 50%) in real-world practice remains uncertain. Our objective was to evaluate the real-world outcomes of a rhythm control strategy in patients with AF and reduced LVEF, focusing on changes in LV systolic function and brain natriuretic peptide (BNP) levels. Methods: The study retrospectively reviewed the medical records of 80 patients with concurrent AF and reduced LVEF who underwent rhythm control therapy between March 2015 and December 2021. Results: The patients had an average age of 63.6 years and an initial LVEF of 34.3%. Sinus rhythm was restored using anti-arrhythmic drugs (38, 47.5%) or electrical cardioversion (42, 52.5%). Over a follow-up period of 53.0 months, AF recurred in 65% of patients, with 57.7% undergoing catheter ablation. Significant improvements were noted in LVEF (from 34.3% to 55.1%, p < 0.001) and BNP levels (from 752 pg/mL to 72 pg/mL, p < 0.001) at the last follow-up. Nearly all patients (97.5%) continued with the rhythm control strategy during the follow-up period. Conclusions: In real-world settings, a rhythm control strategy proves to be feasible and effective for improving LVEF and reducing BNP levels in AF patients with reduced LVEF.

Chinese guidelines for the diagnosis and management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

A Q-transform-based deep learning model for the classification of atrial fibrillation types

According to the World Health Organization (WHO), Atrial Fibrillation (AF) is emerging as a global epidemic, which has resulted in a need for techniques to accurately diagnose AF and its various subtypes. While the classification of cardiac arrhythmias with AF is common, distinguishing between AF subtypes is not. Accurate classification of AF subtypes is important for making better clinical decisions and for timely management of the disease. AI techniques are increasingly being considered for image classification and detection in various ailments, as they have shown promising results in improving diagnosis and treatment outcomes. This paper reports the development of a custom 2D Convolutional Neural Network (CNN) model with six layers to automatically differentiate Non-Atrial Fibrillation (Non-AF) rhythm from Paroxysmal Atrial Fibrillation (PAF) and Persistent Atrial Fibrillation (PsAF) rhythms from ECG images. ECG signals were obtained from a publicly available database and segmented into 10-second segments. Applying Constant Q-Transform (CQT) to the segmented ECG signals created a time-frequency depiction, yielding 98,966 images for Non-AF, 16,497 images for PAF, and 52,861 images for PsAF. Due to class imbalance in the PAF and PsAF classes, data augmentation techniques were utilized to increase the number of PAF and PsAF images to match the count of Non-AF images. The training, validation, and testing ratios were 0.7, 0.15, and 0.15, respectively. The training set consisted of 207,828 images, whereas the testing and validation set consisted of 44,538 images and 44,532 images, respectively. The proposed model achieved accuracy, precision, sensitivity, specificity, and F1 score values of 0.98, 0.98, 0.98, 0.97, and 0.98, respectively. This model has the potential to assist physicians in selecting personalized AF treatment and reducing misdiagnosis.

Impact of an Organized Treatment Pathway on Management of Atrial Fibrillation: The ER2EP Study

Background

Atrial fibrillation (AF) is the most common arrhythmia reported worldwide. There is significant heterogeneity in AF care pathways for a patient seen in the emergency room, impacting access to guideline-driven therapies.

Objectives

The purpose of this study was to compare the difference in AF outcomes between those treated with an organized treatment pathway vs routine-care approach.

Methods

The emergency room to electrophysiology service study (ER2EP) is a multicenter, prospective observational registry (NCT04476524) enrolling patients with AF from sites where a pathway for management of AF was put in place compared to sites where a pathway was not in place within the same health system and the same physicians providing services at all sites. Multivariable regression modeling was performed to identify predictors of clinical outcomes. Beta coefficient or odds ratio was reported as appropriate.

Results

A total of 500 patients (ER2EP group, n = 250; control group, n = 250) were included in the study. The mean age was 73.4 ± 12.9 years, and 52.2% were males. There was a statistically significant difference in primary endpoint [time to ablation (56 ± 50.9 days vs 183.3 ± 109.5 days; P < 0.001), time to anticoagulation initiation (2.1 ± 1.6 days vs 19.7 ± 35 days, P < 0.001), antiarrhythmic drug initiation (4.8 ± 7.1 days vs 24.7 ± 44.4 days, P < 0.001) compared to the control group, respectively. As such, this resulted in reduced length of stay in the ER2EP group compared to the control group (2.4 ± 1.4 days vs 3.23 ± 2.5 days, P = 0.002).

Conclusions

This study provides evidence that having an organized pathway from the emergency department for AF patients involving electrophysiology services can improve early access to definitive therapies and clinical outcomes.

Atrial fibrillation: real-life experience of a rhythm control with electrical cardioversion in a community hospital

BACKGROUND

Atrial fibrillation is the most prevalent sustained cardiac arrhythmia. Electrical cardioversion, a well-established part of the rhythm control strategy, is probably underused in community settings. Here, we describe its use, safety, and effectiveness in a cohort of patients with atrial fibrillation treated in rural settings.

METHODS

It is a retrospective cohort study. Data on all procedures from January 1, 2016, till December 1, 2022, in Tarusa Hospital, serving mostly a rural population of 15,000 people, were extracted from electronic health records. Data on the procedure's success, age, gender, body mass index, comorbidities, previous procedures, echocardiographic parameters, type and duration of arrhythmia, anticoagulation, antiarrhythmic drugs, transesophageal echocardiography, and settings were available.

RESULTS

Altogether, 1,272 procedures in 435 patients were performed during the study period. The overall effectiveness of the procedure was 92%. Effectiveness was similar across all prespecified subgroups. Electrical cardioversion was less effective in patients undergoing the procedure for the first time (86%, 95% CI: 82-90) compared to repeated procedures (95%, 95% CI: 93-96), OR 0.39 (95% CI: 0.26-0.59). Complications were encountered in 13 (1.02%) procedures but were not serious.

CONCLUSIONS

Electrical cardioversion is an immediately effective procedure that can be safely performed in community hospitals, both in inpatient and outpatient settings. Further studies with longer follow-up are needed to investigate the rate of sinus rhythm maintenance in these patients.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Secondary stroke prevention in people with atrial fibrillation: treatments and trials

Atrial fibrillation is one of the most common cardiac arrhythmias and is a major cause of ischaemic stroke. Recent findings indicate the importance of atrial fibrillation burden (device-detected, subclinical, or paroxysmal and persistent or permanent) and whether atrial fibrillation was known before stroke onset or diagnosed after stroke for the risk of recurrence. Secondary prevention in patients with atrial fibrillation and stroke aims to reduce the risk of recurrent ischaemic stroke. Findings from randomised controlled trials assessing the optimal timing to introduce direct oral anticoagulant therapy after a stroke show that early start (ie, within 48 h for minor to moderate strokes and within 4-5 days for large strokes) seems safe and could reduce the risk of early recurrence. Other promising developments regarding early rhythm control, left atrial appendage occlusion, and novel factor XI inhibitor oral anticoagulants suggest that these therapies have the potential to further reduce the risk of stroke. Secondary prevention strategies in patients with atrial fibrillation who have a stroke despite oral anticoagulation therapy is an unmet medical need. Research advances suggest a heterogeneous spectrum of causes, and ongoing trials are investigating new approaches for secondary prevention in this vulnerable patient group. In patients with atrial fibrillation and a history of intracerebral haemorrhage, the latest data from randomised controlled trials on stroke prevention shows that oral anticoagulation reduces the risk of ischaemic stroke but more data are needed to define the safety profile.

Aggressive Rhythm Control Strategy in Atrial Fibrillation Patients Presenting at the Emergency Department: The HEROMEDICUS Study Design and Initial Results

Atrial fibrillation has progressively become a more common reason for emergency department visits, representing 0.5% of presenting reasons. Registry data have indicated that about 60% of atrial fibrillation patients who present to the emergency department are admitted, emphasizing the need for more efficient management of atrial fibrillation in the acute phase. Management of atrial fibrillation in the setting of the emergency department varies between countries and healthcare systems. The most plausible reason to justify a conservative rather than an aggressive strategy in the management of atrial fibrillation is the absence of specific guidelines from diverse societies. Several trials of atrial fibrillation treatment strategies, including cardioversion, have demonstrated that atrial fibrillation in the emergency department can be treated safely and effectively, avoiding admission. In the present study, we present the epidemiology and characteristics of atrial fibrillation patients presenting to the emergency department, as well as the impact of diverse management strategies on atrial-fibrillation-related hospital admissions. Lastly, the design and initial data of the HEROMEDICUS protocol will be presented, which constitutes an electrophysiology-based aggressive rhythm control strategy in patients with atrial fibrillation in the emergency department setting.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Mortality benefit with AF ablation: Impact of normal sinus rhythm seen in CABANA and EAST AFnet

Atrial fibrillation (AF) is significantly associated with morbidity and mortality and erodes the quality and quantity of life. It is standard of care to treat patients with AF and an increased risk of stroke with oral anticoagulation therapy, but the more daunting question many clinicians face is whether to pursue a "rate-only" or "rhythm" control strategy. Historical studies over the years have sought to answer this question but have found no significant difference in major clinical outcomes between the two strategies. There are opportunities based on new data to improve the natural history of the disease. The EAST AFnet trial for the first time revealed a significant morbidity and mortality advantage to rhythm control therapy when performed early in the disease process of AF and in the setting of comprehensive medical management that was maintained. The CABANA trial clearly demonstrated that catheter ablation was a more effective long-term treatment of AF in general and significantly lowers risk of AF progression compared to medical therapy. Like multiple prior trials of rhythm management strategies, when rhythm control was effective in these trials, independent of therapy assignment, there was a significantly lower risk of adverse outcomes and death. These contemporary data provide optimism that the pervasive mortality risk in patients with AF observed over the past 50 years may be improved by the timing, use, and efficacy of use of therapeutic interventions.

Adverse Events and Clinical Correlates in Asian Patients with Atrial Fibrillation and Diabetes Mellitus: A Report from Asia Pacific Heart Rhythm Society Atrial Fibrillation Registry

Aims. To evaluate the adverse events (and its clinical correlates) in a large prospective cohort of Asian patients with atrial fibrillation (AF) and diabetes mellitus (DM). Material and Methods. We recruited patients with atrial fibrillation (AF) from the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry and included those for whom the diabetic mellitus (DM) status was known. We used Cox-regression analysis to assess the 1-year risk of all-cause death, thromboembolic events, acute coronary syndrome, heart failure and major bleeding. Results. Of 4058 patients (mean age 68.5 ± 11.8 years; 34.4% females) considered for this analysis, 999 (24.6%) had DM (age 71 ± 11 years, 36.4% females). Patients with DM had higher mean CHA2DS2-VASc (2.3 ± 1.6 vs. 4.0 ± 1.5, p < 0.001) and HAS-BLED (1.3 ± 1.0 vs. 1.7 ± 1.1, p < 0.001) risk scores and were less treated with rhythm control strategies compared to patients without DM (18.7% vs. 22.0%). After 1-year of follow-up, patients with DM had higher incidence of all-cause death (4.9% vs. 2.3%, p < 0.001), cardiovascular death (1.3% vs. 0.4%, p = 0.003), and major bleeding (1.8% vs. 0.9%, p = 0.002) compared to those without DM. On Cox regression analysis, adjusted for age, sex, heart failure, coronary and peripheral artery diseases and previous thromboembolic event, DM was independently associated with a higher risk of all-cause death (HR 1.48, 95% CI 1.00-2.19), cardiovascular death (HR 2.33, 95% CI 1.01-5.40), and major bleeding (HR 1.91, 95% 1.01-3.60). On interaction analysis, the impact of DM in determining the risk of all-cause death was greater in young than in older patients (p int = 0.010). Conclusions. Given the high rates of adverse outcomes in these Asian AF patients with DM, efforts to optimize the management approach of these high-risk patients in a holistic or integrated care approach are needed.

Atrial fibrillation: better symptom control with rate and rhythm management

Atrial fibrillation (AF) is often associated with limiting symptoms, and with significant impairment in quality of life. As such, treatment strategies aimed at symptom control form an important pillar of AF management. Such treatments include a wide variety of drugs and interventions, including, increasingly, catheter ablation. These strategies can be utilised either singly or in combination, to improve and restore quality of life for patients, and this review covers the current evidence base underpinning their use. In this Review, we discuss the pros and cons of rate vs. rhythm control, while offering practical tips to non-specialists on how to utilise various treatments and counsel patients about all relevant treatment options. These include antiarrhythmic and rate control medications, as well as interventions such as cardioversion, catheter ablation, and pace-and-ablate.

Antiarrhythmic Treatment in Heart Failure

PURPOSE OF REVIEW

Arrhythmias are common in patients with heart failure (HF) and are associated with a significant risk of mortality and morbidity. Optimal antiarrhythmic treatment is therefore essential. Here, we review current approaches to antiarrhythmic treatment in patients with HF.

RECENT FINDINGS

In atrial fibrillation, rhythm control and ventricular rate control are accepted therapeutic strategies. In recent years, clinical trials have demonstrated a prognostic benefit of early rhythm control strategies and AF catheter ablation, especially in patients with HF with reduced ejection fraction. Prevention of sudden cardiac death with ICD therapy is essential, but optimal risk stratification is challenging. For ventricular tachycardias, recent data support early consideration of catheter ablation. Antiarrhythmic drug therapy is an adjunctive therapy in symptomatic patients but has no prognostic benefit and well-recognized (proarrhythmic) adverse effects. Antiarrhythmic therapy in HF requires a systematic, multimodal approach, starting with guideline-directed medical therapy for HF and integrating pharmacological, device, and interventional therapy.

Atrial fibrillation: comorbidities, lifestyle, and patient factors

Modern anticoagulation therapy has dramatically reduced the risk of stroke and systemic thromboembolism in people with atrial fibrillation (AF). However, AF still impairs quality of life, increases the risk of stroke and heart failure, and is linked to cognitive impairment. There is also a recognition of the residual risk of thromboembolic complications despite anticoagulation. Hence, AF management is evolving towards a more comprehensive understanding of risk factors predisposing to the development of this arrhythmia, its' complications and interventions to mitigate the risk. This review summarises the recent advances in understanding of risk factors for incident AF and managing these risk factors. It includes a discussion of lifestyle, somatic, psychological, and socioeconomic risk factors. The available data call for a practice shift towards a more individualised approach considering an increasingly broader range of health and patient factors contributing to AF-related health burden. The review highlights the needs of people living with co-morbidities (especially with multimorbidity), polypharmacy and the role of the changing population demographics affecting the European region and globally.

Computational Studies Show How the H463R Mutation Turns hKv1.5 into an Inactivation State

The KCNA5 gene provides the code for the α-subunit of the potassium channel Kv1.5. The genetic variant H463R in the Kv1.5 channel has been reported to cause a functional loss in atrial fibrillation (AF) patients. Understanding the mutations at a molecular level is key to developing improved therapeutics concerning cardiac hKv1.5 and hKv1.4 channels. Molecular dynamics and umbrella sampling free energy simulations are an effective tool to understand the mutation's effect on ion conduction, which we have employed and found that the hKv1.5[H463R] mutation imposes an energy barrier on the ion conduction pathway compared to the wild-type channel's ion free energy and pore structure. These results imply that the arginine mutation associated with the AF disease in particular modulates the inactivation process of hKv1.5. Kv1.4, encoded by the KCNA4 gene, is also present in the heart. Therefore, we considered simulation studies of the equivalent H507R mutation in the hKv1.4 channel and found that the mutation slightly reduces the ion conduction barrier in the ion conduction pathway, making it insignificant.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.