AFFIRM Investigators. Atrial Fibrillation Follow-up Investigation of Rhythm Management. Baseline characteristics of patients with atrial fibrillation: the AFFIRM Study

Rate control or rhythm control in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention

Background

Restoring and maintaining sinus rhythm in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) has been studied in clinical trials to reduce symptoms and improve quality of life. Limited data exist on the effectiveness of rate or rhythm control therapy in these patients.

Methods

Consecutive patients with AF and ACS or referred for PCI were prospectively recruited in Fuwai Hospital during 2017-2020. The primary endpoints were all-cause death and major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular mortality, myocardial infarction, ischemic stroke, non-central nervous system embolism and ischemia-driven revascularization. Kaplan-Meier curves and Cox regressions were performed to evaluate the association between rhythm/rate control and subsequent outcomes. For the primary endpoints, we used the Benjamini-Hochberg correction for multiple comparisons.

Results

A total of 1499 patients with AF and ACS or undergoing PCI were included, with a median follow-up of 34.7 months. Compared to non-rate control, rate control strategy reduced the risk of subsequent MACCEs (adjusted HR, 0.320; 95 % CI 0.220-0.466; p <0.001; *p <0.002) and all-cause death (adjusted HR, 0.148; 95 % CI 0.093-0.236; p <0.001; *p <0.002). Similar trends were observed across all predefined subgroups (p <0.001). In the final multivariate model, rhythm control was not associated with a lower subsequent MACCEs but significantly improved all-cause mortality compared to non-rhythm control (adjusted HR, 0.546; 95 % CI 0.313-0.951; p =0.033; *p =0.044).

Conclusions

In this real-world study, rate control strategy was associated with lower risk of MACCEs and all-cause death in AF and ACS or undergoing PCI. Besides, management with rhythm control strategy may improve all-cause mortality.

Correlation between thromboembolic risk and prevalence of coronary artery disease in patients with atrial fibrillation and impaired renal function

Background

Atrial fibrillation (AF) and coronary artery disease (CAD) often co-occur. The prevalence of coincident AF and CAD, the characteristics of such patients, and the correlation with thromboembolic risk in association with renal function are unclear.

Methods and Results

We studied 435 consecutive patients who underwent contrast-enhanced computed tomography (CT) before catheter ablation for AF. Nineteen patients with inconclusive CT underwent coronary angiography for a calcified coronary artery. Overall, 87 of the 435 patients had CAD (20.0 %: paroxysmal AF, 63.9 %; persistent AF, 35.2 %; and longstanding AF, 0.9 %). Of these, 17.9 % were newly diagnosed with CAD. There was a stepwise increase in CAD prevalence according to the CHADS2 score (10.1 % at 0, 20.1 % at 1, 24.7 % at 2, 35.1 % at 3, and 41.7 % at ≥ 4 points). Of note, in patients with low estimated glomerular filtration rate < 50 mL/min/1.73 m2, the CAD prevalence increased for all CHADS2 scores (15.4 % at 0, 40.0 % at 1, 32.4 % at 2, 38.5 % at 3, and 50.0 % at ≥ 4 points).

Conclusions

The prevalence of coexisting CAD increases with the CHADS2 score. This underscores the importance of screening for coexisting CAD in patients who are at high risk for thromboembolic events, particularly in patients with impaired renal function.

The relationship between atrial fibrillation and coronary artery disease: Understanding common denominators

Atrial fibrillation (AF) and coronary artery disease (CAD) are highly prevalent cardiovascular conditions. The coexistence of both diseases is common as they share similar risk factors and common pathophysiological characteristics. Systemic inflammatory conditions are associated with an increased incidence of both AF and CAD. The presence of both entities increases the incidence of complications and adverse outcomes. Furthermore, their coexistence poses challenges for the management of patients, particularly with respect to anticoagulation and rhythm management. In this review, we aim to better understand the relationship between AF and CAD by detailing basic molecular pathophysiology, assessing therapeutic guidelines, and describing interactions between the two conditions.

New Insights into Rate Control: Time in Target Range of Resting Heart Rate and Major Adverse Outcomes in Atrial Fibrillation

Background

Few studies have examined the relationship between the fluctuation of heart rate control over time and cardiovascular outcomes in patients with atrial fibrillation. Our study sought to evaluate the independent association between time in target range (TIR) of resting heart rate and cardiovascular outcomes in the AFFIRM (Atrial Fibrillation Follow-Up Investigation of Rhythm Management) study.

Methods

Target range of resting heart was defined as less than 80 beats per minute (bpm) for both rate and rhythm control groups. Time in target range was estimated over the first 8 months of follow-up using Rosendaal interpolation method. The association between TIR of resting heart rate and cardiovascular outcomes was estimated using adjusted Cox proportional hazards regression models.

Results

Time in target range of resting heart rate (months 0 through 8) was 71 ± 34% in the rate control group and 83 ± 27% in the rhythm control group. Each 1-SD increase in TIR of resting heart rate was significantly associated with lower risk of major adverse cardiovascular events after full adjustment for demographics, medical history and history of prior heart surgery, as well as all-cause mortality.

Conclusions

Time in target range of resting heart rate independently predicts the risk of cardiovascular outcomes in patients with atrial fibrillation. Long-term maintenance of heart rate on target is of great importance for patients with atrial fibrillation.

Combined use of anticoagulant and antiplatelet on outcome after stroke in patients with nonvalvular atrial fibrillation and systemic atherosclerosis

This study aimed to investigate whether there was a difference in one-year outcome after stroke between patients treated with antiplatelet and anticoagulation (OAC + antiplatelet) and those with anticoagulation only (OAC), when comorbid atherosclerotic disease was present with non-valvular atrial fibrillation (NVAF). This was a retrospective study using a prospective cohort of consecutive patients with ischemic stroke. Patients with NVAF and comorbid atherosclerotic disease were assigned to the OAC + antiplatelet or OAC group based on discharge medication. All-cause mortality, recurrent ischemic stroke, hemorrhagic stroke, myocardial infarction, and bleeding events within 1 year after the index stroke were compared. Of the 445 patients included in this study, 149 (33.5%) were treated with OAC + antiplatelet. There were no significant differences in all outcomes between groups. After inverse probability of treatment weighting, OAC + antiplatelet was associated with a lower risk of all-cause mortality (hazard ratio 0.48; 95% confidence interval 0.23-0.98; P = 0.045) and myocardial infarction (0% vs. 3.0%, P < 0.001). The risk of hemorrhagic stroke was not significantly different (P = 0.123). OAC + antiplatelet was associated with a decreased risk of all-cause mortality and myocardial infarction but an increased risk of ischemic stroke among patients with NVAF and systemic atherosclerotic diseases.

Antithrombotic and prohemorrhagic actions of different concentrations of apixaban in patients exposed to single and dual antiplatelet regimens

We evaluated modifications in the hemostatic balance of different concentrations of apixaban (APIX) in 25 healthy donors and 53 patients treated with aspirin (ASA, n = 21), ASA and clopidogrel (ASA + CLOPI, n = 11), or ASA and ticagrelor (ASA + TICA, n = 21). Blood samples from participants were spiked ex vivo with apixaban 0 (APIX0), 40 (APIX40), and 160 ng/mL (APIX160). We assessed the effects of APIX on (1) clot formation, by ROTEM thromboelastometry; (2) thrombin generation primed by platelets; and (3) platelet and fibrin interactions with a thrombogenic surface, in a microfluidic model with circulating blood. APIX caused dose-related prolongations of clotting time with minimal impact on other ROTEM parameters. Thrombin generation was significantly inhibited by APIX160, with ASA + TICA actions showing the strongest inhibition (p < 0.01 vs APIX0). Microfluidic studies showed that APIX160 was more potent at suppressing platelet and fibrin interactions (p < 0.001 vs. APIX0). APIX40 demonstrated a consistent antithrombotic action but with a favorable protective effect on the structural quality of fibrin. APIX potentiated the antithrombotic effects of current antiplatelet regimens. APIX at 40 ng/mL, enhanced the antithrombotic action of single or dual antiplatelet regimens but was more conservative for hemostasis than the 160 ng/mL concentration.

Disease-Related Knowledge and Need for Revision of Care for Patients with Atrial Fibrillation: A Cross Sectional Study

Purpose

To evaluate the disease-related knowledge of outpatients with atrial fibrillation (AF), and the relationship with health literacy and other background variables.

Patients and Methods

In this cross-sectional survey study, conducted in Iceland, patients with AF scheduled for an electrical cardioversion or AF catheter ablation were recruited from a hospital outpatient clinic. They completed the validated Atrial Fibrillation Knowledge Scale (AFKS), a 11-item instrument (with possible score 0-10, 10 being the best knowledge) which evaluates knowledge pertaining to AF in general, AF symptom detection and AF treatment. Health literacy was assessed with the 16 item European Health Literacy Survey Questionnaire (HLS-EU-Q) and patients answered questions about their background. Data was analysed with parametric tests.

Results

In total, 185 participants completed the questionnaire (mean age 63 ±10), 77% were male, 74% with previous electrical cardioversion and 76% were on non-vitamin K antagonist oral anticoagulants (NOAC) medication. The mean score on the AFKS was 6.5 (±1.8). The best knowledge was concerning oral anticoagulation therapy (96% answered correctly) and the least knowledge was regarding responses to AF episodes (17% answered correctly). Patients with sufficient health literacy (52%) had better knowledge of AF (M 6.8 ±1.7 vs M 6.3 ±1.9, p = 0.05). Age, educational level, health literacy and AF pattern explained 22% of the variance in AF knowledge.

Conclusion

Patients with AF have inadequate knowledge of their condition, potentially as a result of insufficient health literacy. AF knowledge may be improved using integrated management where patients are actively involved in the care and health literacy is considered in the provided patient education.

Evaluation of coronary artery disease in patients undergoing atrial fibrillation ablation: a non-invasive FFR computed tomography study

To evaluate coronary artery disease (CAD) with computed tomography coronary angiography (CTCA)-derived fractional flow reserve (FFR) in patients with atrial fibrillation (AF) requiring ablation. The study population consisted of 151 patients who underwent CTCA before AF ablation (AF group), and a control group of 151 patients from the outpatient clinic who underwent CTCA without any history of AF (non-AF group), matched for age, sex, BMI, and angina symptomatology. All study patients underwent CTCA with subdivision of coronary lesion type into severe (≥ 70% luminal narrowing), moderate (50% ≤ luminal narrowing < 70%), and mild stenosis (< 50% luminal narrowing). In patients with ≥ 1 moderate or severe stenosis, non-invasive FFR was calculated from CTCA (FFR_CT). Baseline characteristics and CAD risk factors were similar between the 2 groups. During CTCA, 38% of the patients in the AF group were in ongoing atrial arrhythmia (either AF or regular atrial tachycardia). The number of patients with severe (10 (6.6%) vs 10 (6.6%), P = 1.00), moderate (14 (9.5%) vs 10 (6.7%), P = 0.4), and mild stenosis (43 (28.5%) vs 56 (37.1%), P = 0.11) was not significantly different between the 2 groups. Performance of FFR_CT was feasible in 32/44 patients (73%), and failed in 27% of the patients (7 and 5 patients in the AF and non-AF group, respectively, P = 0.74). No difference was observed in the prevalence of hemodynamically significant stenosis (FFR_CT ≤ 0.80) (15 (9.9%) vs 12 (7.9%), P = 0.85). Our study showed technical feasibility of CTCA in all patients of both groups, including the patients with AF as presenting rhythm. The FFR_CT add-on analysis failed equally frequent in patients of the AF versus non-AF group. An equal rate of CAD was observed in the AF group and non-AF group, favoring the concept of shared associated risk factors for CAD and AF.

Use of SAMe-TT2R2 in a racially diverse anticoagulation clinic: prediction of optimal anticoagulation

The SAMe-TT₂R₂ score predicts optimal long-term oral Vitamin K Antagonist (VKA) anticoagulation for homogenous Caucasian and homogenous Asian populations for non-valvular atrial fibrillation but at different score thresholds. The score that predicts optimal VKA anticoagulation in significantly diverse populations for multiple indications for systemic anticoagulation has not been reported. We determined whether optimal VKA anticoagulation is predicted by SAMe-TT₂R₂ score in a diverse inner-city population for non-valvular atrial fibrillation (NVAF), unprovoked venous and pulmonary thromboembolic disease (VTE), mechanical prosthetic heart valves and all other indications. All patients on long term VKA's that attended an inner-city anticoagulation clinic between February 2016 and October 2017 were included in this study. Eligible patients were grouped according to oral anticoagulation indication: (1) NVAF, (2) VTE, (3) prosthetic valves and (4) other indications. Each patient's SAMe-TT₂R₂ score and percent time of INR in the therapeutic range (TTR) was calculated with optimal international normalized ratio (INR) control defined as TTR ≥ 65%. The correlation between SAMe-TT₂R₂ score and TTR was determined by logistic regression for each oral anticoagulant indication. Receiver operating characteristic curves were then used to identify the best cutoff for prediction of ≥ 65% TTR. Of 316 patients meeting study criteria, 54% were non-Caucasian and there was a significant negative correlation between the SAMe-TT₂R₂ score and TTR (coefficient - 0.35, P < 0.0001) for all patients. A SAMe-TT₂R₂ score < 4 was identified as the best threshold for predicting optimal TTR (Youden's J-statistics = 0.238) with accuracy and positive likelihood ratio of 63.4% and 1.73, respectively. The SAMe-TT₂R₂ score predicts optimal VKA anticoagulation for systemic anticoagulation for multiple indications in a diverse urban population at a higher score than the original report for non-valvular atrial fibrillation of a cohort where < 10% non-Caucasians.

Machine learning for atrial fibrillation risk prediction in patients with sleep apnea and coronary artery disease

Background

Patients with sleep apnea (SA) and coronary artery disease (CAD) are at higher risk of atrial fibrillation (AF) than the general population. Our objectives were: to evaluate the role of CAD and SA in determining AF risk through cluster and survival analysis, and to develop a risk model for predicting AF.

Methods

Electronic medical record (EMR) database from 22,302 individuals including 10,202 individuals with AF, CAD, and SA, and 12,100 individuals without these diseases were analyzed using K-means clustering technique; k-nearest neighbor (kNN) algorithm and survival analysis. Age, sex, and diseases developed for each individual during 9 years were used for cluster and survival analysis.

Results

The risk models for AF, CAD, and SA were identified with high accuracy and sensitivity (0.98). Cluster analysis showed that CAD and high blood pressure (HBP) are the most prevalent diseases in the AF group, HBP is the most prevalent disease in CAD; and HBP and CAD are the most prevalent diseases in the SA group. Survival analysis demonstrated that individuals with HBP, CAD, and SA had a 1.5-fold increased risk of developing AF [hazard ratio (HR): 1.49, 95% CI: 1.18-1.87, p = 0.0041; HR: 1.46, 95% CI: 1.09-1.96, p = 0.01; HR: 1.54, 95% CI: 1.22-1.94, p = 0.0039, respectively] and individuals with chronic kidney disease (CKD) developed AF approximately 50% earlier than patients without these comorbidities in a period of 7 years (HR: 3.36, 95% CI: 1.46-7.73, p = 0.0023). Comorbidities that contributed to develop AF earlier in females compared to males in the group of 50-64 years were HBP (HR: 3.75 95% CI: 1.08-13, p = 0.04) CAD and SA in the group of 60-75 years were (HR: 2.4 95% CI: 1.18-4.86, p = 0.02; HR: 2.51, 95% CI: 1.14-5.52, p = 0.02, respectively).

Conclusion

Machine learning based algorithms demonstrated that CAD, SA, HBP, and CKD are significant risk factors for developing AF in a Latin-American population.

Pharmacologic Rate versus Rhythm Control for Atrial Fibrillation in Heart Failure Patients

Atrial fibrillation (AF) and Heart failure (HF) constitute two frequently coexisting cardiovascular diseases, with a great volume of the scientific research referring to strategies and guidelines associated with the best management of patients suffering from either of the two or both of these entities. The common pathophysiological paths, the adverse outcomes, the hospitalization rates, and the mortality rates that occur from various reports and trials indicate that a targeted therapy to the common background of these cardiovascular conditions may reverse the progression of their interrelating development. Among other optimal treatments concerning the prevalence of both AF and HF, the introduction of rhythm and rate control strategies in the guidelines has underlined the importance of sinus rhythm and heart rate control in the prevention of deleterious complications. The use of these strategies in the clinical practice has led to a debate about the superiority of rhythm versus rate control. The current guidelines as well as the published randomized trials and studies have not proved that rhythm control is more beneficial than the rate control treatments in the terms of survival, all-cause mortality, hospitalization rates, and quality of life. Therefore, the current therapeutic strategy is based on the therapy guidelines and the clinical judgment and experience. The aim of this review was to elucidate the endpoints of pharmacologic randomized clinical trials and the clinical data of each antiarrhythmic or rate-limiting medication, so as to promote their effective, individualized, evidence-based clinical use.

Long-Term Outcomes for Patients With Acute Coronary Syndrome and Nonvalvular Atrial Fibrillation

Short-term outcomes are worse for patients with acute coronary syndrome (ACS) with a history of nonvalvular atrial fibrillation (NVAF). However, long-term prognosis remains unclear. We linked administrative health databases to identify patients hospitalized with ACS (ST-elevation myocardial infarction [STEMI], non-STEMI [NSTEMI], and unstable angina) between 2008 and 2019 in Alberta, Canada. Patients were stratified according to history of NVAF before hospitalization. The primary outcome was a composite of all-cause mortality, hospitalization for myocardial infarction, or stroke at 3 years. Cox models were constructed to estimate the association between ACS, NVAF, and outcomes. Of 54,309 ACS hospitalizations, 6,351 patients (11.7%) had a history of NVAF. Compared with patients without NVAF, patients with previous NVAF were older (75.6 ± 11.6 vs 64.9 ± 13.4 years), women (35.1% vs 30.0%), had higher comorbid burden (Charlson co-morbidity index 3.0 vs 1.0), and more often presented with NSTEMI (57.5% vs 49.0%). The primary outcome occurred in 37.0% of patients with previous NVAF and 17.4% without (p <0.001). In the multivariable analysis, there was a 1.14-fold (95% confidence interval [CI] 1.09 to 1.20) higher risk of the primary outcome in patients with previous NVAF. There was a significant association with STEMI (adjusted harazard ratio [aHR] 1.24, 95% CI 1.12 to 1.36) and NSTEMI (aHR 1.12, 95% CI 1.06 to 1.19) but not with unstable angina (aHR 1.04, 95% CI 0.90 to 1.22). In conclusion, in this population-based study, we identified that a history of NVAF at ACS presentation is associated with worse long-term prognosis, particularly for STEMI and NSTEMI.

Rate versus rhythm control for atrial fibrillation: from AFFIRM to EAST-AFNET 4 - a paradigm shift

The clinical choice between rate or rhythm control therapies has been debated over the years. In 2002, the AFFIRM trial demonstrated that the rhythm-control strategy had no survival advantage over the rate-control strategy. Eighteen years later, EAST-AFNET 4 showed that the rhythm-control approach is better than rate control in reducing adverse cardiovascular outcomes in patients with a recent diagnosis of atrial fibrillation (AF). During the time between AFFIRM and EAST-AFNET 4, rhythm control understanding, specifically ablation, improved, while rate-control strategies remained the same possibly leading to the change in results seen in EAST-AFNET 4. This review seeks to evaluate the rate- and rhythm-control strategies, focusing on the important clinical trials in the past two decades. These trials have shown great advancement in AF management; however, the search for the best approach to controlling AF and minimizing the burden of symptoms is still a work in progress and needs further research.

Atherosclerosis and Atrial Fibrillation: Double Trouble

PURPOSE OF REVIEW

This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis.

RECENT FINDINGS

MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.

Atrial fibrillation is a predictor of nonobstructive coronary artery disease in elective angiography in old age: a cross-sectional study in Poland and Russia

BACKGROUND

Significant changes in the coronary vessels are not confirmed in a large proportion of patients undergoing cardiac catheterization.

AIMS

The present study aimed to determine correlates and independent predictors of nonobstructive coronary artery disease (CAD) in older adults referred for elective coronary angiography.

METHODS

A cross-sectional study was conducted involving 2,214 patients referred to two medical centers (in Poland and Russia) between 2014 and 2016 for elective coronary angiography due to exacerbated angina, despite undergoing optimal therapy for CAD. The median age was 72 years (IQR: 68-76), and 49.5% patients were women.

RESULTS

Significant stenosis (defined as stenosis of 50% or more of the diameter of the left main coronary artery stem or stenosis of 70% or more of the diameter of the remaining major epicardial vessels) was diagnosed only in 1135 (51.3%) patients. Female sex (odds ratio [OR], 3.01; 95% confidence interval [CI], 2.44-3.72; p < 0.001) and atrial fibrillation (OR, 1.87; 95% CI 1.45-2.40; p < 0.001) were the main independent predictors of nonobstructive CAD. Significantly lower ORs were observed for diabetes (OR, 0.75; 95% CI 0.59-0.95; p = 0.02), chronic kidney disease (OR, 0.76; 95% CI 0.61-0.96; p = 0.02), and anemia (OR, 0.69; 95% CI 0.50-0.95; p = 0.02) after controlling for age, chronic heart failure, BMI, and study center.

DISCUSSION AND CONCLUSIONS

The results confirmed that nonobstructive CAD occurs in a high percentage of older patients referred for elective coronary angiography. This suggests the need to improve patient stratification for invasive diagnosis of CAD, especially for older women and patients with atrial fibrillation. Trial registration number and date of registration: NCT04537507, September 3, 2020.

Angiographic profile and outcomes in persistent non-valvular atrial fibrillation: A study from tertiary care center in North India

Background

The relationship of atrial fibrillation (AF) with coronary artery disease (CAD) is well established, yet it is often missed. There is evidence of myocardial ischemia on stress imaging in AF patients in the absence of obstructive CAD. In this prospective cohort, we studied the angiographic profiles of non-valvular AF patients.

Methods

The study was a nonrandomized, prospective, single-center observational study of consecutive patients of persistent non-valvular AF. Patients symptomatic for AF despite optimal medical therapy for 3 months were recruited and all underwent coronary angiograms (CAG). Patients with prior history of CAD were excluded.

Results

A total of 70 patients were followed for a mean duration of 12 ± 1.4 months. The mean age of the study group was 66.07 (±11.49) years. Hypertension was the commonest comorbidity seen in 74% patients. Obstructive CAD was present in 32 (46%) patients, non-obstructive (<50% stenosis) CAD in 17 (24%) patients and normal coronaries in 21 (30%) patients. Overall 49 (70%) patients had evidence of CAD. Amongst patients without obstructive CAD, slow flow was seen in 16 (42%) patients. Lower baseline ejection fraction, lower haemoglobin & albumin levels and higher creatinine levels was associated with increased mortality. In patients without obstructive CAD, hospitalizations for fast ventricular rate were significantly increased in those having slow flow on CAG (p = 0.005).

Conclusions

Majority (70%) of our patients had evidence of atherosclerotic CAD on CAG. A large proportion of patients without obstructive CAD had slow flow on CAG.

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Coexistent coronary artery disease is common in symptomatic non-valvular atrial fibrillation (AF).

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Revascularization was needed in 35.7% of patients.

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Lower ejection fraction, haemoglobin and serum albumin levels correlated with worse outcomes.

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Coronary slow-flow is highly prevalent in AF patients (42%) and has a bearing of future events.

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Hospitalizations for fast ventricular rate were significantly increased in those having slow flow.

The Association Between Recurrence of Atrial Fibrillation and Revascularization in Patients With Coronary Artery Disease After Catheter Ablation

Aim: The connection between revascularization for coronary artery disease (CAD) and the incidence of recurrent events of atrial fibrillation (AF) after ablation is unclear. This study aimed to explore the relationship between coronary revascularization and AF recurrence in patients who underwent radiofrequency catheter ablation (RFCA). Methods: Four hundred and nineteen patients who underwent performed coronary angiography at the same time as RFCA were enrolled in this study. Obstructive CAD was defined as at least one coronary artery vessel stenosis of ≥75% and percutaneous coronary intervention (PCI) was recommended. Non-obstructive CAD was defined as coronary artery vessel stenosis of <75%. The endpoint was freedom from recurrence from AF after RFCA during the 24-month follow-up. Results: In total, 102, 95, and 212 patients were undergone coronary angiography and diagnosed as having obstructive CAD, Non-obstructive CAD, and Non-CAD, respectively. During the 24-month follow-up period, patients without obstructive CAD were significantly more likely to achieve freedom from AF than patients with obstructive CAD (hazard ratio [HR]: 1.72; 95% confidence interval [CI]: 1.23-2.41; P = 0.001). The recurrence rate of AF was significantly lower in patients who underwent PCI than in those who did not (HR: 0.45; 95% CI: 0.25-0.80; P = 0.007). The multivariate regression analysis showed that the other predictors of AF recurrence for obstructive CAD were multivessel stenosis (HR: 1.92; 95% CI: 1.04-3.54; P = 0.036) and left atrial diameter (HR: 2.56; 95% CI: 1.31-5.00; P = 0.006). Conclusions: This study suggests that obstructive CAD is associated with a higher rate of AF recurrence. Additionally, For patients with CAD, coronary revascularization is related to a lower recurrence rate of AF after RFCA.

Atrial Fibrillation and Chronic Kidney Disease-A Risky Combination for Post-Contrast Acute Kidney Injury

Atrial fibrillation (AF) symptoms may mimic coronary artery disease (CAD) which reflects the difficulties in qualifying AF patients for invasive diagnostics. A substantial number of coronary angiographies may be unnecessary or even put patients at risk of post-contrast acute kidney injury (PC-AKI), especially patients with chronic kidney disease (CKD). We aimed to investigate the hypothesis indicating higher prevalence of PC-AKI in patients with AF scheduled for coronary angiography. The study population comprised of 8026 patients referred for elective coronarography including 1621 with AF. In the comparison of prevalence of PC-AKI in distinguished groups we can see that kidney impairment was twice more frequent in patients with AF in both groups with CKD (CKD (+)/AF (+) 6.24% vs. CKD (+)/AF (−) 3.04%) and without CKD (CKD (−)/AF (+) 2.32% vs. CKD (−)/AF (−) 1.22%). In our study, post-contrast acute kidney disease is twice more frequent in patients with AF, especially in subgroup with chronic kidney disease scheduled for coronary angiography. Additionally, having in mind results of previous studies stating that AF is associated with non-obstructive coronary lesions on angiography, patients with AF and CKD may be unnecessarily exposed to contrast agent and possible complications.

Clinical and Economic Outcomes Among Nonvalvular Atrial Fibrillation Patients With Coronary Artery Disease and/or Peripheral Artery Disease

To address literature gaps on treatment with real-world evidence, this study compared effectiveness, safety, and cost outcomes in NVAF patients with coronary or peripheral artery disease (CAD, PAD) prescribed apixaban versus other oral anticoagulants. NVAF patients aged ≥65 years co-diagnosed with CAD/PAD initiating warfarin, apixaban, dabigatran, or rivaroxaban were selected from the US Medicare population (January 1, 2013 to September 30, 2015). Propensity score matching was used to match apixaban versus warfarin, dabigatran, and rivaroxaban cohorts. Cox models were used to evaluate the risk of stroke/systemic embolism (SE), major bleeding (MB), all-cause mortality, and a composite of stroke/myocardial infarction/all-cause mortality. Generalized linear and two-part models were used to compare stroke/SE, MB, and all-cause costs between cohorts. A total of 33,269 warfarin-apixaban, 9,335 dabigatran-apixaban, and 33,633 rivaroxaban-apixaban pairs were identified after matching. Compared with apixaban, stroke/SE risk was higher in warfarin (hazard ratio [HR]: 1.93; 95% confidence interval [CI]: 1.61 to 2.31), dabigatran (HR: 1.69; 95% CI: 1.18 to 2.43), and rivaroxaban (HR: 1.24; 95% CI: 1.01 to 1.51) patients. MB risk was higher in warfarin (HR: 1.67; 95% CI: 1.52 to 1.83), dabigatran (HR: 1.37; 95% CI: 1.13 to 1.68), and rivaroxaban (HR: 1.87; 95% CI: 1.71 to 2.05) patients vs apixaban. Stroke/SE- and MB-related medical costs per-patient per-month were higher in warfarin, dabigatran, and rivaroxaban patients versus apixaban. Total all-cause health care costs were higher in warfarin and rivaroxaban patients compared with apixaban patients. In conclusion, compared with apixaban, patients on dabigatran, rivaroxaban, or warfarin had a higher risk of stroke/SE, MB, and event-related costs.

Impact of frailty and atrial fibrillation in elderly patients with acute coronary syndromes

BACKGROUND

There is scarce information on the prognostic role of frailty and atrial fibrillation (AF) in elderly patients with acute coronary syndrome (ACS).

METHODS

The aim was to analyse the management of elderly patients with frailty and AF who suffered an ACS using data of the prospective multicentre LONGEVO-SCA registry. We evaluated the predictive performance of FRAIL, Charlson scores and AF status for adverse events at 6-month follow-up.

RESULTS

A total of 531 unselected patients with ACS and above 80 years old [mean age 84.4 (SD = 3.6) years; 322 (60.6%) male] were enrolled, of whom 128 (24.1%) with AF and 145 (27.3%) with frailty. Mutually exclusive number of patients were as follows: non-frail and sinus rhythm (SR) 304 (57.2%); frail and SR 99 (18.6%); non-frail and AF 82 (15.4%); and frail and AF 46 (8.7%). Frail and AF patients compared with non-frail and SR patients had higher risk of all-cause mortality [HR 2.61, (95% CI 1.28-5.31; P = .008)], readmissions [HR 2.28, (95%CI 1.37-3.80); P = .002)] and its composite [HR 2.28, (95% CI 1.44-3.60); P < .001)]. After multivariate adjustment, FRAIL score [HR 1.41, (95% CI 1.02-1.97); P = .040] and Charlson index [HR 1.32, (95% CI 1.09-1.59); P = .003] were significantly associated with mortality. AF status was not independently related with adverse events.

CONCLUSIONS

Frailty but not AF status was independently associated with follow-up adverse events. Frailty status and high Charlson index were independent conditions associated with adverse events during the follow-up. The impact of functional status has a bigger prognostic role over AF status in elderly patients with ACS.

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry

Background: We aimed to assess characteristics and treatment of AF patients with and without heart failure (HF). Methods: The prospective, observational Polish Atrial Fibrillation (POL-AF) Registry included consecutive patients with AF hospitalized in 10 Polish cardiology centers in 2019–2020. Results: Among 3999 AF patients, 2822 (71%) had HF (AF/HF group). Half of AF/HF patients had preserved ejection fraction (HFpEF). Compared to patients without HF (AF/non–HF), AF/HF patients were older, more often male, more often had permanent AF, and had more comorbidities. Of AF/HF patients, 98% had class I indications to oral anticoagulation (OAC). Still, 16% of patients were not treated with OAC at hospital admission, and 9%—at discharge (regardless of the presence of HF and its subtypes). Of patients not receiving OAC upon admission, 61% were prescribed OAC (most often apixaban) at discharge. AF/non–HF patients more often converted from AF at admission to sinus rhythm at discharge compared to AF/HF patients (55% vs. 30%), despite cardioversion performed as often in both groups. Class I antiarrhythmics were more often prescribed in AF/non–HF than in AF/HF group (13% vs. 8%), but still as many as 15% of HFpEF patients received them. Conclusions: Over 70% of hospitalized AF patients have coexisting HF. A significant number of AF patients does not receive the recommended OAC.

Big Data and Atrial Fibrillation: Current Understanding and New Opportunities

Atrial fibrillation (AF) is the most common arrhythmia with diverse etiology that remarkably relates to high morbidity and mortality. With the advancements in intensive clinical and basic research, the understanding of electrophysiological and pathophysiological mechanism, as well as treatment of AF have made huge progress. However, many unresolved issues remain, including the core mechanisms and key intervention targets. Big data approach has produced new insights into the improvement of the situation. A large amount of data have been accumulated in the field of AF research, thus using the big data to achieve prevention and precise treatment of AF may be the direction of future development. In this review, we will discuss the current understanding of big data and explore the potential applications of big data in AF research, including predictive models of disease processes, disease heterogeneity, drug safety and development, precision medicine, and the potential source for big data acquisition. Grapical abstract.

Platelets Promote Ang II (Angiotensin II)-Induced Atrial Fibrillation by Releasing TGF-β1 (Transforming Growth Factor-β1) and Interacting With Fibroblasts

Hypertension is a risk factor of atrial fibrillation (AF), and a certain number of patients with hypertension were found with an enlarged left atrium. Platelet activation is found in patients with hypertension or pressure overload/Ang II (angiotensin II)-induced hypertensive animal models and contribute to ventricular fibrosis. Whether hypertension-induced atrial fibrosis is mediated by platelets remains unknown. Our previous experimental data showed that platelet-derived TGF-β1 (transforming growth factor-β1) was reduced in patients with hypertensive AF. The present study is to investigate whether platelet-derived TGF-β1 promotes Ang II-induced atrial fibrosis and AF. Platelet activation and atrial platelet accumulation were measured in sinus rhythm controls, normotensive AF, and patients with hypertensive AF. Ang II (1500 ng/kg per minute, 3 weeks) infused mice with pharmacological (clopidogrel) and genetic platelet inhibition (TGF-β1 deletion in platelets) were used. Platelet activation, atrial structural remodeling, atrial electrical transmission, AF inducibility, inflammation, and fibrosis were measured in mice. We found that circulating platelets were activated in patients with hypertensive AF. A large amount of platelet was accumulated in the atriums of patients with hypertensive AF. Both clopidogrel treatment and platelet-specific deletion of TGF-β1 attenuated Ang II-induced structural remodeling, atrial electrical transmission, AF inducibility, as well as atrial inflammation and fibrosis than mice without interventions. Furthermore, clopidogrel blocked atrial platelet accumulation and platelet-fibroblast conjugation. Platelets promoted atrial fibroblast differentiation in cell culture. Profibrotic actions of platelets are largely via activation of atrial fibroblasts by releasing TGF-β1 and inducing platelet-fibroblast conjugation, and platelet inhibition is sufficient to inhibit atrial fibrosis and AF inducibility.

Rhythm Control in Heart Failure Patients with Atrial Fibrillation

AF and heart failure (HF) commonly coexist. Left atrial ablation is an effective treatment to maintain sinus rhythm (SR) in patients with AF. Recent evidence suggests that the use of ablation for AF in patients with HF is associated with an improved left ventricular ejection fraction and lower death and HF hospitalisation rates. We performed a systematic search of world literature to analyse the association in more detail and to assess the utility of AF ablation as a non-pharmacological tool in the treatment of patients with concomitant HF.

Feasibility and Prognostic Value of Vasodilator Stress Perfusion CMR in Patients With Atrial Fibrillation

OBJECTIVES

The aim of this study was to assess the feasibility and prognostic value of vasodilator stress perfusion cardiovascular magnetic resonance (CMR) in patients with atrial fibrillation (AF).

BACKGROUND

Because most studies have excluded arrhythmic patients, the prognostic value of stress perfusion CMR in patients with AF is unknown.

METHODS

Between 2008 and 2018, consecutive patients with suspected or stable chronic coronary artery disease and AF referred for vasodilator stress perfusion CMR were included and followed for the occurrence of major adverse cardiovascular event(s) (MACE), defined as cardiovascular death or nonfatal myocardial infarction. The diagnosis of AF was defined by 12-lead electrocardiography before and after CMR. Univariate and multivariate Cox regressions were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR.

RESULTS

Of 639 patients (mean age 72 ± 9 years, 77% men), 602 (94%) completed the CMR protocol, and 538 (89%) completed follow-up (median 5.1 years); 80 had MACE. Using Kaplan-Meier analysis, the presence of ischemia (hazard ratio [HR]: 7.56; 95% confidence interval [CI]: 4.86 to 11.80) or LGE (HR: 2.41; 95% CI: 1.55 to 3.74) was associated with the occurrence of MACE (p < 0.001 for both). In a multivariate Cox regression including clinical and CMR indexes, the presence of ischemia (HR: 5.98; 95% CI: 3.68 to 9.73) or LGE (HR: 2.61; 95% CI: 1.89 to 3.60) was an independent predictor of MACE (p < 0.001 for both).

CONCLUSIONS

In patients with AF, stress perfusion CMR is feasible and has good discriminative prognostic value to predict the occurrence of MACE.

[Progression of precerebral atherosclerosis and predictors of ischemic complications in cardiac patients]

OBJECTIVE

To identify predictors of progression of precerebral atherosclerosis in long-term period after coronary artery bypass surgery.

MATERIAL AND METHODS

There were 97 procedures of carotid endarterectomy in patients after previous coronary artery bypass grafting for the period from 2006 to 2017. Inclusion criteria were previous CABG, no significant (over 60%) stenosis of internal carotid arteries at discharge after CABG. The control group included 447 patients without progression of precerebral atherosclerosis in long-term period after CABG.

RESULTS

Careful monitoring of progression of precerebral atherosclerosis and therapeutic prevention of ischemic stroke are required in patients with mild-to-moderate ICA stenosis after CABG. The most significant predictors of progression of precerebral atherosclerosis after CABG were AF (OR=1.97, 95% CI 1.04-3.73), previous occlusion of stent (OR=7.89, 95% CI=2.3-27.0), chronic brain ischemia grade II or III (OR=22.45, 95% CI=11.9-42.3), chronic kidney disease (OR=15.8, 95% CI=5.04-49.5).

CONCLUSION

It was revealed that the majority of predictors of adverse ischemic cerebral and myocardial events are indirectly associated with atrial fibrillation.

Evaluation of Mortality in Atrial Fibrillation: Clinical Outcomes in Digital Electrocardiography (CODE) Study

Aims

Atrial fibrillation (AF) is a public health problem and its prevalence is increasing worldwide. Electronic cohorts, with large electrocardiogram (ECG) databases linked to mortality data, can be useful in determining prognostic value of ECG abnormalities. Our aim is to evaluate the risk of mortality in patients with AF from Brazil.

Methods

This observational retrospective study of primary care patients was developed with the digital ECG database from the Telehealth Network of Minas Gerais, Brazil. ECGs performed from 2010 to 2017 were interpreted by cardiologists and the University of Glasgow automated analysis software. An electronic cohort was obtained linking data from ECG exams and those from a national mortality information system, using standard probabilistic linkage methods. We considered only the first ECG of each patient. Patients under 16 years were excluded. Hazard ratios (HR) for mortality were adjusted for demographic and self-reported clinical factors and estimated with Cox regression.

Results

From a dataset of 1,773,689 patients, 1,558,421 were included, mean age 51.6 years; 40.2% male. There were 3.34% deaths from all causes in 3.68 years of median follow up. The prevalence of AF was 1.33%. AF was an independent risk factor for all-cause mortality (HR 2.10, 95%CI 2.03-2.17) and cardiovascular mortality (HR 2.06, 95%CI 1.86-2.29). Females with AF had a higher risk of overall and cardiovascular mortality compared with males (p < 0.001).

Conclusions

AF was a strong predictor of cardiovascular and all-cause mortality in a primary care population, with increased risk in women.

Condensed abstract

To assess risk of mortality in AF patients, an electronic cohort was obtained linking data from ECG exams of Brazilian primary care patients and a national mortality information system. From 1,558,421 patients, AF (prevalence 1.33%) carried a higher risk of overall and cardiovascular mortality, with increased risk in women.

What’s New

This is the first study with a large Brazilian electronic cohort to evaluate the risk of mortality linked to AF in primary care patients.AF patients from a Brazilian primary care population had a higher risk of death for all causes (HR 2.10, 95%CI 2.03-2.17) and cardiovascular mortality (HR 2.06, 95%CI 1.86-2.29).Female patients with AF had an increased risk of overall and cardiovascular mortality compared with male patients (p < 0.001).

Prevalence of Coronary Artery Calcium in Patients With Atrial Fibrillation With and Without Cardiovascular Risk Factors

The burden of coronary artery atherosclerosis in patients with atrial fibrillation (AF) is unknown. We aimed to assess the coronary artery calcium (CAC) in AF patients. We retrospectively analyzed 324 consecutive patients with AF who had CT angiogram before AF ablation and their cardiovascular risk were prospectively collected. Mean age of the cohort was 66 years and 71% were male. The previous history of coronary artery disease (CAD) was present in 19% (n = 63) and CAC was positive in all. In patients without known CAD (n = 261), CAC was present in 70% (n = 182) with a comparable prevalence between men and women, which raised the prevalence of coronary atherosclerosis to 76% (n = 245) for the entire cohort. The median CAC score was 170 (range 1 to 6,157) and largely in multivessel distribution in patients without known CAD. Presence of CAC increased with an increasing number of cardiovascular risk factors. Nevertheless, CAC was present in 58% (n = 40) of patients without conventional cardiovascular risk factors. If CAC score >100 was considered as CAD equivalent as 10-year risk of incident atherosclerotic cardiovascular diseases is >7.5% it would have resulted in higher CAD prevalence of 52% and significant reclassification of CHA₂DS₂-VASc score in 41% of patients without known CAD. In conclusion, coronary calcium is highly prevalent in AF patients, including those without cardiovascular risk factors. Advanced CAC can potentially shift CHA₂DS₂-VASc score in many AF patients. Our findings suggest that characterizing CAC in AF may be clinically valuable in thromboembolic risk stratification and management of preventive cardiac therapies.

Prevalence of Coronary Artery Calcification on Pre-Atrial Fibrillation Ablation CT Pulmonary Venograms and its Impact on Selection for Statin Therapy

Atherosclerotic cardiovascular disease (ASCVD) shares many risk factors with atrial fibrillation (AF). Obtaining computed tomography images of the pulmonary veins (CTPV) before AF ablation procedures is common and can incidentally detect coronary artery calcification (CAC). The purpose of this study was to investigate the prevalence of CAC on pre-ablation CTPV, the frequency of CAC reporting on CTPV reports, and its impact on statin therapy among patients hospitalized for AF procedures. We retrospectively evaluated consecutive patients undergoing CTPV and AF procedures from October 2016 to December 2017 in a single-center tertiary hospital. The patients’ demographic and clinical characteristics were analyzed. The CAC presence on CTPV was visually assessed. The severity was classified qualitatively. The statin therapy status was evaluated using the patient’s admission and discharge medication lists. A total of 638 subjects were included in our study, with 34.5% female. The mean age was 63.3 ± 10.8 years. CAC was detected in 70.1% of all patients, and in 58.1% of patients without a history of ASCVD. When present, CAC was documented in 92.6% of the clinical CTPV reports. While coronary artery atherosclerosis was present in a majority of AF patients, and its presence was widely reported, it was not associated with increased statin therapy at discharge.

Effect of concomitant antiplatelet therapy in patients with nonvalvular atrial fibrillation initiating non-vitamin K antagonists

BACKGROUND

Antiplatelet therapy (APT) use in combination with oral anticoagulation is common among patients with atrial fibrillation, but there is scarce information regarding its effect on outcomes in patients on non-vitamin K antagonist oral anticoagulants (NOAC). We aimed to evaluate the safety and efficacy of APT use in a 'real-world' cohort of nonvalvular atrial fibrillation (NVAF) patients initiating NOAC.

DESIGN

We conducted a retrospective multicentre study including 2361 consecutive NVAF patients initiating NOAC between January 2013 and December 2016. Patients with an acute ischaemic event within the last 12 months (acute coronary syndrome, stroke or revascularization) were excluded. Patients were followed up, and all clinical events were recorded at 3 months. The primary outcome of the study was major bleeding, and the secondary outcomes were stroke, nonfatal myocardial infarction, intracranial bleeding and death.

RESULTS

One hundred forty-five (6.1%) patients received concomitant APT, and aspirin was the more common (79%). At 3 months, 25 (1.1%) patients had major bleeding, 8 (0.3%) had nonfatal myocardial infarction, 7 (0.3%) had ischaemic stroke, and 40 (1.7%) died. After multivariate adjustment, concomitant APT was associated with higher risk for major bleeding (HR = 3.62, 95% CI 1.32-9.89; P = .012), but was not associated with a higher risk of other clinical outcomes.

CONCLUSIONS

Concomitant APT use is uncommon among these patients and does not seem to be associated with lower rates of ischaemic events or death. However, there are signals for an increased risk of bleeding, which reinforces current guideline recommendations.

Thermodynamic properties of atrial fibrillation cryoablation: a model-based approach to improve knowledge on energy delivery

The objective of this study is to describe a suitable model of atrial fibrillation cryoablation thermodynamic properties. Three different thermal loads were applied to a cylindrical copper element simulating the cryoprobe, thermally coupled with a Peltier stack producing the freezing effect, and in contact with a bovine liver sample. Thermal events occurring inside the samples were measured using mirror image technique. Heat subtracted flux during ice formation and minimum temperature measured at probe-tissue interface were, respectively, 1.33 W cm^-2 and -27.8°C for Sample#0, 1.88 W cm^-2 and -35.6°C for Sample#1 and 1.82 W cm^-2 and 1.44 W cm^-2 before and after the ice trigger, respectively, and -29.3°C for Sample#2. Ice trigger temperature was around -8.5°C for Sample#0 and Sample#2, and -10.4°C for Sample#1. In all the investigated samples, ice front penetration was proportional to the square root of time and its velocity depended on the heat flux subtracted. The fraction of the useful energy spent for ice formation was less than 60% for Sample#0, and about 80% for Sample#1 and for Sample#2, before the reduction of the removed heat flux. Freezing time exceeding a cut-off, according to the heat subtracted flux, does not improve the procedure effectiveness and is detrimental to the surrounding tissues.

Subclinical and Asymptomatic Atrial Fibrillation: Current Evidence and Unsolved Questions in Clinical Practice

Atrial Fibrillation (AF) may be diagnosed due to symptoms, or it may be found as an incidental electrocardiogram (ECG) finding, or by implanted devices recordings in asymptomatic patients. While anticoagulation, according to individual risk profile, has proven definitely beneficial in terms of prognosis, rhythm control strategies only demonstrated consistent benefits in terms of quality of life. In fact, evidence collected by observational data showed significant benefits in terms of mortality, stroke incidence, and prevention of cognitive impairment for patients referred to AF catheter ablation compared to those medically treated, however randomized trials failed to confirm such results. The aims of this review are to summarize current evidence regarding the treatment specifically of subclinical and asymptomatic AF, to discuss potential benefits of rhythm control therapy, and to highlight unclear areas.

Diagnostic accuracy of an algorithm for detecting atrial fibrillation in a wrist-type pulse wave monitor

We evaluated the diagnostic value of atrial fibrillation (AF) measured by a wrist-type pulse wave monitor in this case-control study. Six serial pulse wave values (three in the left and three in the right wrist) were measured using a wrist-type monitor in 29 AF patients and 30 subjects with sinus rhythm. We defined "monitor AF in irregular pulse peak (IPP) 15/20/25" as follows: (a) IPP: |interval of pulse peak - the average of the interval of the pulse peak| ≥ the average of the interval of the pulse peak × 15/20/25%; (b) irregular heartbeat (IHB): beats of IPP ≥ total pulse × 20%; and (c) monitor AF: ≥4 IHBs of the six pulse wave measurements. In IPP 15, the sensitivity and specificity were 0.97 and 1.00, respectively. Pulse wave analysis by a wrist-type monitor was shown to have high sensitivity and specificity for the diagnosis of AF.

Safety and Efficacy of Triple Antithrombotic Therapy with Dabigatran versus Vitamin K Antagonist in Atrial Fibrillation Patients: A Pilot Study

Background

Combination of dual antiplatelet (DAPT) and oral anticoagulation therapy is required to decrease cardioembolic stroke and stent thrombosis risk in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS). We compared the safety and efficacy of dabigatran etexilate with vitamin K antagonist (VKA), in combination with DAPT (aspirin plus clopidogrel) treatment in AF patients who underwent percutaneous coronary intervention (PCI) with stenting for ACS.

Methods

Consecutive nonvalvular AF patients who received twice-daily dabigatran 110 mg (n = 389) or VKA (n = 510) and DAPT were included. Primary endpoints were major bleeding (safety) and the composite of ischemic stroke, systemic embolism, and myocardial infarction (efficacy). The secondary efficacy endpoint was hospitalization for cardiovascular disease.

Results

After propensity score matching, comparative treatment groups comprised 175 dabigatran recipients and 175 VKA recipients. The cumulative incidence of major bleeding was lower in the dabigatran group (2.3%) compared with the VKA group (10.3%) with a hazard ratio (HR) of 4.81 [95% confidence interval (CI) 1.6-14.2, p < 0.005]. The cumulative incidence of thromboembolic events with dabigatran was slightly higher (8.0%) than with VKA (6.85%), but not statistically significantly so (0.8, 0.39-1.8; p = 0.6). Cumulative incidence of hospitalization for cardiovascular disease was lower with dabigatran (10.3%) compared with VKA (20.6%) treatment (2.2, 1.25-3.8; p < 0.006).

Conclusion

Dabigatran at the dose used for stroke prevention appears safer than VKA and maintains a similar efficacy profile, when used with DAPT, in AF patients who have undergone PCI with stenting for ACS.

Patients with Atrial Fibrillation and Chronic Kidney Disease More Often Undergo Angioplasty of Left Main Coronary Artery - a 867 Patient Study

BACKGROUND/AIMS

Several studies have implicated atrial fibrillation (AF) as a contributing factor in chronic kidney disease (CKD) and cardiovascular events. The prevalence of coronary artery disease (CAD) in patients with AF varies substantially from 17% to 46.5%. There are only few studies concerning renal function in population with AF undergoing coronary angiography. The aim of the present study was to assess which type of AF is dominant in CKD population scheduled for coronary angiography and if it can influence patients' outcome, the association between renal impairment and the type of coronary procedures in AF patients and the influence of renal function on in-hospital mortality.

METHODS

We retrospectively studied 867 patients with AF hospitalized due to coronary angiography in two year time. The cut off value of CKD was eGFR ≤ 60 ml/min./1.73m2 evaluated by CKD-EPI formula.

RESULTS

A total of 867 patients with AF (44% women; mean age 72±10 years) were included in the analysis. The mean eGFR was 44±11ml/min./1.73m2 in patients with CKD and 89±18 ml/min./1.73m2 in patients with preserved renal function. Patients with CKD and AF were older (p< 0.001), had more often diabetes (p=0.009), heart failure (p< 0.001) and anaemia (p< 0.001). Patients with CKD and AF had more often permanent type of AF (p< 0.001). In CKD patients CHA2DS2VASc score was 4.3±1.5 and HAS-BLED score was 2.0±1.2 and it was significantly higher as compared to population with preserved renal function (p< 0.001, p=0.02, respectively). The use of oral anticoagulation was less frequent in CKD group (p< 0.001) although these patients had higher CHA2DS2VASc score. Patients with AF and CKD were more often admitted due to myocardial infarction (STEMI or NSTEMI) (p=0.02, p< 0.001, respectively) and more often underwent percutaneous coronary intervention (PCI) (p=0.01). Among coronary arteries the percutaneous coronary intervention (PCI) of left main artery was done more frequently in CKD patients (p=0.01). Among CKD population in-hospital mortality was significantly higher in patients with eGFR < 30 ml/min (p< 0.001).

CONCLUSION

Patients with CKD had more often permanent type of AF. Percutaneous interventions of the left main coronary artery, the only elective procedures influencing patients' prognosis, were done more frequently in CKD patients with AF. In-hospital mortality was significantly higher in patients with severe renal impairment. Despite the higher risk of ischaemic stroke in CKD group the use of oral anticoagulation therapy was significantly less frequent and the patients were deprived of the confirmed benefits of such treatment.

Effectiveness and Safety of Anticoagulants in Adults with Non-valvular Atrial Fibrillation and Concomitant Coronary/Peripheral Artery Disease

BACKGROUND

Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among patients with nonvalvular atrial fibrillation. Limited evidence is available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral artery disease.

METHODS

Non-valvular atrial fibrillation patients aged ≥65 years diagnosed with coronary/peripheral artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected from January 1, 2013 to September 30, 2015. Propensity score matching was used to compare DOACs vs warfarin. Cox proportional hazards models were used to estimate the risk of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality.

RESULTS

There were 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin-matched pairs, with a mean follow-up of 5-6 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.37-0.62), major bleeding (HR 0.66; 95% CI, 0.58-0.75), and stroke/myocardial infarction/all-cause mortality (HR 0.63; 95% CI, 0.58-0.69); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.79; 95% CI, 0.70-0.90 and HR 0.87; 95% CI, 0.81-0.92, respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (HR 0.72; 95% CI, 0.60-0.89) and a higher rate of major bleeding (HR 1.14; 95% CI, 1.05-1.23) vs warfarin.

CONCLUSIONS

All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality rates compared with warfarin; differences were observed in rates of stroke/systemic embolism and major bleeding. Findings from this observational analysis provide important insights about oral anticoagulation therapy among non-valvular atrial fibrillation patients with coronary/peripheral artery disease and may help physicians in the decision-making process when treating this high-risk group of patients.

An open-Label, 2 × 2 factorial, randomized controlled trial to evaluate the safety of apixaban vs. vitamin K antagonist and aspirin vs. placebo in patients with atrial fibrillation and acute coronary syndrome and/or percutaneous coronary intervention: Rationale and design of the AUGUSTUS trial

BACKGROUND

The optimal antithrombotic strategy for patients with atrial fibrillation (AF) who develop acute coronary syndrome (ACS) and/or the need for percutaneous coronary intervention (PCI) is uncertain. The risk of bleeding is a major concern when oral anticoagulation is required to prevent stroke, and concomitant therapy with antiplatelet agents is required to minimize recurrent ischemic events.

DESIGN

AUGUSTUS is an international, multicenter randomized trial with a 2 × 2 factorial design to compare apixaban with vitamin K antagonists and aspirin with placebo in patients with AF who develop ACS and/or undergo PCI and are receiving a P2Y12 inhibitor. Patients will be evaluated for eligibility during their ACS and/or PCI hospitalization. The primary outcome is the composite of major and clinically relevant nonmajor bleeding defined by the International Society on Thrombosis and Haemostasis. A key secondary outcome is the composite of all-cause death and all-cause hospitalization. Other secondary objectives are to evaluate ischemic outcomes including the composite of death, myocardial infarction, stroke, stent thrombosis, urgent revascularization, and all-cause hospitalization and each individual component. The aim is to enroll approximately 4,600 patients from around 500 sites in 33 countries.

SUMMARY

AUGUSTUS will provide insight into the optimal oral antithrombotic therapy strategy for patients with AF and concomitant coronary artery disease. The unique 2 × 2 factorial design will delineate the bleeding effects of various anticoagulant and antiplatelet therapies and generate evidence to guide the selection of the optimal antithrombotic regimen for this challenging group of patients. It is the largest and only prospective randomized trial to investigate in a blinded fashion the risk and benefits of aspirin on top of a non-vitamin K antagonist oral anticoagulant and P2Y12 receptor inhibition.

Comparison of Anticoagulant Therapy for Atrial Fibrillation - Novel Oral Anticoagulants Versus Vitamin K Antagonists

In patients with non-valvular atrial fibrillation (NVAF), oral anticoagulation is important for prevention of stroke and systemic embolism (SE). While Vitamin K antagonists (VKAs) have historically been the standard of care, these medications are limited by numerous food and drug interactions with onerous requirements for frequent monitoring and dose adjustments. Over the past decade, several novel oral anticoagulants (NOACs) have been developed to directly inhibit factor IIa/thrombin (dabigatran) or activated factor X (apixaban, rivaroxaban, edoxaban). These medications have been shown to be at least as effective as warfarin for stroke prevention in NVAF with more favorable safety profiles. However, their advantages are underscored by a lack of specific antidotes and assays quantifying their anticoagulant effects. This paper addresses the use of NOACs compared to VKAs in patients with NVAF, with a special focus on high-risk populations, including the elderly, those with renal disease, diabetes mellitus, coronary artery disease, and previous stroke. The current literature surrounding special clinical scenarios including the treatment of bleeding, perioperative management, and the use of NOACs in cardioversion and catheter ablation will be also discussed.

The effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter: A systematic review with meta-analysis and Trial Sequential Analysis

Background

Atrial fibrillation and atrial flutter may be managed by either a rhythm control strategy or a rate control strategy but the evidence on the clinical effects of these two intervention strategies is unclear. Our objective was to assess the beneficial and harmful effects of rhythm control strategies versus rate control strategies for atrial fibrillation and atrial flutter.

Methods

We searched CENTRAL, MEDLINE, Embase, LILACS, Web of Science, BIOSIS, Google Scholar, clinicaltrials.gov, TRIP, EU-CTR, Chi-CTR, and ICTRP for eligible trials comparing any rhythm control strategy with any rate control strategy in patients with atrial fibrillation or atrial flutter published before November 2016. Our primary outcomes were all-cause mortality, serious adverse events, and quality of life. Our secondary outcomes were stroke and ejection fraction. We performed both random-effects and fixed-effect meta-analysis and chose the most conservative result as our primary result. We used Trial Sequential Analysis (TSA) to control for random errors. Statistical heterogeneity was assessed by visual inspection of forest plots and by calculating inconsistency (I²) for traditional meta-analyses and diversity (D²) for TSA. Sensitivity analyses and subgroup analyses were conducted to explore the reasons for substantial statistical heterogeneity. We assessed the risk of publication bias in meta-analyses consisting of 10 trials or more with tests for funnel plot asymmetry. We used GRADE to assess the quality of the body of evidence.

Results

25 randomized clinical trials (n = 9354 participants) were included, all of which were at high risk of bias. Meta-analysis showed that rhythm control strategies versus rate control strategies significantly increased the risk of a serious adverse event (risk ratio (RR), 1.10; 95% confidence interval (CI), 1.02 to 1.18; P = 0.02; I² = 12% (95% CI 0.00 to 0.32); 21 trials), but TSA did not confirm this result (TSA-adjusted CI 0.99 to 1.22). The increased risk of a serious adverse event did not seem to be caused by any single component of the composite outcome. Meta-analysis showed that rhythm control strategies versus rate control strategies were associated with better SF-36 physical component score (mean difference (MD), 6.93 points; 95% CI, 2.25 to 11.61; P = 0.004; I² = 95% (95% CI 0.94 to 0.96); 8 trials) and ejection fraction (MD, 4.20%; 95% CI, 0.54 to 7.87; P = 0.02; I² = 79% (95% CI 0.69 to 0.85); 7 trials), but TSA did not confirm these results. Both meta-analysis and TSA showed no significant differences on all-cause mortality, SF-36 mental component score, Minnesota Living with Heart Failure Questionnaire, and stroke.

Conclusions

Rhythm control strategies compared with rate control strategies seem to significantly increase the risk of a serious adverse event in patients with atrial fibrillation. Based on current evidence, it seems that most patients with atrial fibrillation should be treated with a rate control strategy unless there are specific reasons (e.g., patients with unbearable symptoms due to atrial fibrillation or patients who are hemodynamically unstable due to atrial fibrillation) justifying a rhythm control strategy. More randomized trials at low risk of bias and low risk of random errors are needed.

Trial registration

PROSPERO CRD42016051433

Is SYNTAX Score Predictive of Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery?

Background and Objectives

The relationship of synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score and development of atrial fibrillation (AF) after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between the SYNTAX score and development of AF after CABG (POAF).

Subjects and Methods

The medical records of consecutive patients, who underwent CABG surgery from January 2013 to September 2015, were retrospectively reviewed for the development of AF in the postoperative period. SYNTAX score, clinical and echocardiographic parameters were evaluated. The independent variables for the development of POAF were defined and their predictive values were measured.

Results

The study group consisted of 106 patients, of which 36 (34%) developed POAF. Age, hypertension, stroke, chronic obstructive pulmonary disease (COPD), heart failure (HF), diabetes mellitus (DM), left atrial diameter, neutrophil/lymphocyte ratio, platelet large cell ratio, creatinine, blood urea nitrogen and SYNTAX score were identified as important variables for the development of POAF. However, in logistic regression analysis COPD (OR=19.313, 95% CI=2.416-154.407, p=0.005), HF (OR=28.362, 95% CI=2.034-395.515, p=0.013), SYNTAX score (OR=0.863, 95% CI=0.757-0.983, p=0.026), and DM (OR=20.770, 95% CI=3.791-113.799, p<0.001) appeared as independent variables predicting the development of POAF. In receiver operation characteristic analysis, SYNTAX score (≥22.25) (AUC=0.777, 95% CI=0.676-0.877, p<0.001) was one of the strongest predictors for the development of POAF.

Conclusion

The SYNTAX score level was independently associated with the development of AF after CABG.

Predictors of significant coronary artery disease in atrial fibrillation: Are cardiac troponins a useful measure

BACKGROUND

Cardiac Troponin I (cTnI) is frequently measured in patients presenting with symptomatic atrial fibrillation (AF). The significance of elevated cTnI levels in this patient cohort is unclear. We investigated the value of cTnI elevation in this setting and whether it is predictive for significant coronary artery disease (sCAD).

METHODS

We conducted a retrospective, single-center, case-control study of 231 patients who presented with symptomatic AF to The Prince Charles Hospital emergency department, Brisbane, Australia between 2006 and 2014. Patients who underwent serial cTnI testing and assessment for CAD were included. Clinical variables that are known to predict CAD and could potentially predict cTnI elevation were collected. Binary logistic regression was performed to identify predictors of sCAD and cTnI elevation.

RESULTS

Cardiac Troponin I elevation above standard cut off was not predictive for sCAD after adjustment for other predictors (OR 1.62, 95% CI 0.79-3.32. p=0.19). However, the highest cTnI concentration value (cTnI peak) was predictive for sCAD (OR 2.02, 95% CI 1.02-3.97, p=0.04). Dyspnea on presentation (OR 4.52, 95% CI 1.87-10.91, p=0.001), known coronary artery disease (OR 3.44, 95% CI 1.42-8.32, p=0.006), and ST depression on the initial electrocardiogram (OR 2.57, 95% CI 1.11-5.97, p=0.028) predicted sCAD in our cohort, while heart rate on initial presentation was inversely correlated with sCAD (OR 0.99, 95% CI 0.971-1.00, p=0.034).

CONCLUSION

Troponin elevation is common in patients presenting to hospital with acute symptomatic AF and it is not a reliable indicator for underlying sCAD in this patient cohort. However, cTnI peak was a predictor of significant coronary artery disease.

Prevalence of left atrial abnormalities in atrial fibrillation versus normal sinus patients

Background

Atrial fibrillation (AF) may be the cause or sequela of left atrial abnormalities and variants.

Purpose

To determine the prevalence of left atrial (LA) abnormalities in AF patients compared to normal sinus rhythm (NSR) patients.

Material and Methods

We retrospectively reviewed 281 cardiac CT examinations from 2010 to 2012, excluding patients with prior pulmonary vein ablation, known coronary artery disease, prior coronary stent placement, or coronary artery bypass grafts. The first group consisted of 159 AF patients undergoing cardiac CT prior to pulmonary vein ablation and the second group consisted of 122 NSR patients evaluated with coronary CT angiography. Demographic data were collected. LA abnormalities were analyzed. Left atrial diameter was measured on an axial view.

Results

A total of 281 patients were included. The male gender has significantly higher prevalence of AF than female gender, P value <0.001. Patients with AF were significantly older (mean age, 57.4 years; standard deviation [SD], 11.8 years) than NSR patients (mean age, 53.4 years; SD, 13.6 years), P value, 0.01. The left atrial diameter was greater in the AF patients (mean diameter, 4.3 cm; SD, 0.82 cm) versus the NSR patients (3.4 cm; SD, 0.58 cm), P value, <0.0001. LA diverticulum was the most prevalent variant, occurring in 28.4% of the entire patient population followed by LA pouch, occurring in 24%. There was no significant between group differences in the prevalence of these or the remainder of the LA variants.

Conclusion

AF patients differed significantly from NSR patients in LA size, gender, and mean age. There was no statistical significance between the two groups with regard to the LA morphologic abnormalities other than size.

Impact of arrhythmia on diagnostic performance of adenosine stress CMR in patients with suspected or known coronary artery disease

BACKGROUND

The diagnostic performance of adenosine stress cardiovascular magnetic resonance (CMR) in patients with arrhythmias presenting for work-up of suspected or known CAD is largely unknown, since most CMR studies currently available exclude arrhythmic patients from analysis fearing gating problems, or other artifacts will impair image quality. The primary aim of our study was to evaluate the diagnostic performance of adenosine stress CMR for detection of significant coronary stenosis in patients with arrhythmia presenting for 1) work-up of suspected coronary artery disease (CAD), or 2) work-up of ischemia in known CAD.

METHODS

Patients with arrhythmia referred for work-up of suspected CAD or work-up of ischemia in known CAD undergoing adenosine stress CMR were included if they had coronary angiography within four weeks of CMR.

RESULTS

One hundred fifty-nine patients were included (n = 64 atrial fibrillation, n = 87 frequent ventricular extrasystoles, n = 8 frequent supraventricular extrasystoles). Of these, n = 72 had suspected CAD, and n = 87 had known CAD. Diagnostic accuracy of the adenosine stress CMR for detection of significant CAD was 73 % for the entire population (sensitivity 72 %, specificity 76 %). Diagnostic accuracy was 75 % (sensitivity 80 %, specificity 74 %) in patients with suspected CAD, and 74 % (sensitivity 71 %, specificity 79 %) in the group with known CAD. For different types of arrhythmia, diagnostic accuracy of CMR was 70 % in the atrial fibrillation group, and 79 % in patients with ventricular extrasystoles. On a per coronary territory analysis, diagnostic accuracy of CMR was 77 % for stenosis of the left and 82 % for stenosis of the right coronary artery.

CONCLUSION

The present data demonstrates good diagnostic performance of adenosine stress CMR for detection of significant coronary stenosis in patients with arrhythmia presenting for work-up of suspected CAD, or work-up of ischemia in known CAD. This holds true for a per patient, as well as for a per coronary territory analysis.

Prevalence and Implications of Subclinical Coronary Artery Disease in Patients With Atrial Fibrillation

The objective of this study was to examine prevalence and clinical implications of subclinical coronary artery disease (CAD) detected by coronary artery calcium score (CACS) testing in patients with atrial fibrillation (AF). CACS was assessed in patients without history of CAD undergoing catheter ablation of AF. Age- and gender-matched patients with normal sinus rhythm (NSR) presenting with chest pain served as controls. Predicted arterial age using the Multi-Ethnic Study of Atherosclerosis registry was also compared to the chronologic age. A total of 860 patients (430 AF and 430 NSR, age 63 ± 10 years, 65% men) were included. Subclinical CAD prevalence (CACS >0) was 74% (319 of 430) in the AF group. Compared to the patients with NSR, patients with AF had higher prevalence of Subclinical CAD (74% vs 63%; p <0.001). In multivariate analysis, AF was independently associated with Subclinical CAD (hazard ratio 1.60; p = 0.002) but only with persistent AF (hazard ratio 2.28; p <0.001). Predicted arterial age was greater than chronologic age in patients with AF (69 ± 12 vs 64 ± 9 years). CACS-diagnosed subclinical CAD identified new potential candidates for statin therapy (12%; 33 of 267) and for oral anticoagulation (19%; 40 of 206) by addition of subclinical CAD to the CHA2DS2-VASc scores. In conclusion, in patients without known history of CAD, prevalence of subclinical CAD was significantly higher in those with persistent AF than those with NSR. AF was associated with subclinical CAD independently and complimentarily to clinical risk factors. Identifying subclinical CAD has potential clinical indications for prevention of CAD progression and stroke.

Stroke prevention in the elderly atrial fibrillation patient with comorbid conditions: focus on non-vitamin K antagonist oral anticoagulants

Stroke prevention in elderly atrial fibrillation patients remains a challenge. There is a high risk of stroke and systemic thromboembolism but also a high risk of bleeding if anticoagulants are prescribed. The elderly have increased chronic kidney disease, coronary artery disease, polypharmacy, and overall frailty. For all these reasons, anticoagulant use is underutilized in the elderly. In this manuscript, the benefits of non-vitamin K antagonist oral anticoagulants compared with warfarin in the elderly patient population with multiple comorbid conditions are reviewed.