Prognosis and treatment of atrial fibrillation patients by European cardiologists: one year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry)

Atrial fibrillation management in older hospitalized patients: Evidence of a poor oral anticoagulants prescriptive attitude from the Italian REPOSI registry

Atrial fibrillation (AF) prevalence increases in older patients which also show a high thromboembolic risk. Oral anticoagulants (OACs) are recommended to prevent cardioembolic events and direct oral anticoagulants (DOACs) improved anti-thrombotic treatment. However, the benefits/risks of anticoagulant in older patients still need to be completely defined. This retrospective observational study aimed to describe the treatment with OACs in older AF hospitalized patients, and to identify factors influencing OAC therapy or discontinuation using the REgistro Politerapie SIMI. Univariate and multivariate logistic regression models were applied to identify predictors of OACs treatment and discontinuation. Cox proportional hazards models were performed to evaluate one-year mortality by treatment groups. AF patients were 1,128(26.5 %) at discharge and 1,098(97.3 %) required OAC treatment; about half of them (N = 528;48.1 %) were no-OACs users; 236(21.5 %) and 334(30.4 %) used DOACs and VKA, respectively. Increasing DOACs use was observed during the study period. Predictors of OACs treatment were: BMI (OR:1.04; 95 %CI:1.01-1.07), Barthel index (OR:1.01; 95 %CI:1.01-1.02), medications number (OR:1.07; 95 %CI:1.01-1.13). Conversely, a lower probability was found in patients with a high CIR.S (OR:0.59; 95 %CI:0.36-0.97) and neoplasm (OR:0.57; 95 %CI:0.37-0.88). Hospital stay (OR:1.02; 95 %CI:1.01-1.05), neoplasm (OR:2.25; 95 %CI:1.07-4.70) and INR (OR:1.21; 95 %CI:1.05-1.40) increased OACs discontinuation. A lower discontinuation was observed in dyslipidemic patients (OR:0.18; 95 %CI:0.04-0.82) and heart failure (OR:0.38; 95 %CI:0.21-0.70). Among AF patients, 157(14.3 %) died during the follow-up year. Age (HR = 1.05; 95 %CI = 1.03-1.08) and CIR.S (HR = 2.54; 95 %CI = 1.53-4.21) were associated with a greater mortality risk. In conclusion, critical issues related to the underuse and discontinuation of OACs therapy in hospitalized older patients were highlighted.

Clinical and economic impact of first-line or drug-naïve catheter ablation and delayed second-line catheter ablation for atrial fibrillation using a patient-level simulation model

AIMS

To determine the clinical and economic implications of first-line or drug-naïve catheter ablation compared to antiarrhythmic drugs (AADs), or shorter AADs-to-Ablation time (AAT) in atrial fibrillation (AF) patients in France and Italy, using a patient level-simulation model.

MATERIALS AND METHODS

A patient-level simulation model was used to simulate clinical pathways for AF patients using published data and expert opinion. The probabilities of adverse events (AEs) were dependent on treatment and/or disease status. Analysis 1 compared scenarios of treating 0%, 25%, 50%, 75% or 100% of patients with first-line ablation and the remainder with AADs. In Analysis 2, scenarios compared the impact of delaying transition to second-line ablation by 1 or 2 years.

RESULTS

Over 10 years, increasing first-line ablation from 0% to 100% (versus AAD treatment) decreased stroke by 12%, HF hospitalization by 29%, and cardioversions by 45% in both countries. As the rate of first-line ablation increased from 0% to 100%, the overall 10-year per-patient costs increased from €13,034 to €14,450 in Italy and from €11,944 to €16,942 in France. For both countries, the scenario with no delay in second-line ablation had fewer AEs compared to the scenarios where ablation was delayed after AAD failure. Increasing rates of first-line or drug-naïve catheter ablation, and shorter AAT, resulted in higher cumulative controlled patient years on rhythm control therapy.

LIMITATIONS

The model includes assumptions based on the best available clinical data, which may differ from real-world results, however, sensitivity analyses were included to combat parameter ambiguity. Additionally, the model represents a payer perspective and does not include societal costs, providing a conservative approach.

CONCLUSION

Increased first-line or drug-naïve catheter ablation, and shorter AAT, could increase the proportion of patients with controlled AF and reduce AEs, offsetting the small investment required in total AF costs over 10 years in Italy and France.

Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives

Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.

Sex-specific association of cardiovascular drug doses with adverse outcomes in atrial fibrillation

OBJECTIVES

Sex differences occur in atrial fibrillation (AF), including age at first manifestation, pathophysiology, treatment allocation, complication rates and quality of life. However, optimal doses of cardiovascular pharmacotherapy used in women with AF with or without heart failure (HF) are unclear. We investigated sex-specific associations of beta-blocker and renin-angiotensin system (RAS) inhibitor doses with cardiovascular outcomes in patients with AF or AF with concomitant HF.

METHODS

We used data from the prospective Basel Atrial Fibrillation and Swiss Atrial Fibrillation cohorts on patients with AF. The outcome was major adverse cardiovascular events (MACEs), including death, myocardial infarction, stroke, systemic embolisation and HF-related hospitalisation. Predictors of interest were spline (primary analysis) or quartiles (secondary analysis) of beta-blocker or RAS inhibitor dose in per cent of the maximum dose (reference), in interaction with sex. Cox models were adjusted for demographics, comorbidities and comedication.

RESULTS

Among 3961 patients (28% women), MACEs occurred in 1113 (28%) patients over a 5-year median follow-up. Distributions of RAS inhibitor and beta-blocker doses were similar in women and men. Cox models revealed no association between beta-blocker dose or RAS inhibitor dose and MACE. In a subgroup of patients with AF and HF, the lowest hazard of MACE was observed in women prescribed 100% of the RAS inhibitor dose. However, there was no association between RAS dose quartiles and MACE.

CONCLUSIONS

In this study of patients with AF, doses of beta-blockers and RAS inhibitors did not differ by sex and were not associated with MACE overall.

Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association

AIMS

The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial.

METHODS AND RESULTS

STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022-23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers.

CONCLUSION

The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT04396418.

Streamlining atrial fibrillation ablation management using a digitization solution

Aims

Catheter ablation is a widely accepted intervention for atrial fibrillation (AF) management. Prior to undertaking this procedure, thorough patient education on its efficacy and potential complications is crucial. Additionally, educating patients about stroke risk management and anticoagulant therapy is imperative. At Mater Private Hospital in Dublin, we implemented a solution, integrating a customized treatment pathway and a mobile application. This patient-centred approach aims to optimize the clinical management of AF catheter ablation candidates, focusing on knowledge gaps and adherence to guideline-based care to enhance overall outcomes.

Methods and results

The application automates pre-operative assessments and post-operative support, facilitating seamless patient-clinician communication. During the observation period (September 2022-April 2023), 63 patients installed the app. Patient adherence to the pathway was strong, with 98% of patients actively engaging in the treatment pathway and with 81% completing all pre-operative tasks. The average enrolment-to-admission duration was 14 days, and post-ablation tasks were fulfilled by 62% of patients within an average of 36 days. Operators perceived the solution as user-friendly and effective in enhancing patient connectivity. Patient satisfaction was high, and knowledge about AF improved notably through the solution, particularly concerning the recognition of symptoms and anticoagulation therapy-related complications.

Conclusion

Our findings demonstrate the successful implementation of the app-based Ablation Solution, showcasing widespread patient use, improved adherence, and enhanced understanding of AF and its treatments. The system effectively connects healthcare providers with patients, offering a promising approach to streamline AF catheter ablation management and improve patient outcomes.

Design, Rationale and Initial Findings From HERA-FIB on 10 222 Patients With Atrial Fibrillation Presenting to an Emergency Department Over An 11-Year Period

BACKGROUND

For the majority of patients with atrial fibrillation (AF), disease management has improved in recent years. However, there are still populations underrepresented or excluded in current registries and randomized controlled trials. HERA-FIB (Heidelberg Registry of Atrial Fibrillation) was planned to assess real-world evidence for the prevalence, demographic characteristics and management of patients with the diagnosis of AF presenting consecutively to a chest pain unit.

METHODS AND RESULTS

HERA-FIB is a retrospective, observational, single-center study on patients with a diagnosis of AF presenting to a chest pain unit from June 2009 until March 2020. This article describes the structure, governance, outcome assessment, quality and data collection processes of the registry. Additionally, characteristics of populations of special interest are described. The study consecutively enrolled 10 222 patients presenting with AF to the chest pain unit of the University Hospital of Heidelberg. Clinical parameters and patient characteristics were assessed retrospectively. Outcome parameters included rates for all-cause death, stroke, myocardial infarction and major bleedings. We were able to investigate patient cohorts of special interest such as advanced chronic kidney disease, octogenarians, and those with acute coronary syndrome who are often underrepresented in current studies and randomized controlled trials.

CONCLUSIONS

HERA-FIB is one of the largest real-world single-center retrospective registries on patients with AF, which captures the era of transition from vitamin K antagonists to non-vitamin K oral anticoagulation regimens in clinical practice and offers the possibility to investigate patient populations usually underrepresented or excluded in current available randomized controlled trials and registries.

REGISTRATION

URL: https://www.clinicaltrials.gov; unique identifier: NCT05995561.

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.

Statin Therapy Is Associated With a Lower Risk of Heart Failure in Patients With Atrial Fibrillation: A Population-Based Study

BACKGROUND

Whether statin use can reduce the risk of heart failure (HF) remains controversial. The present study evaluates the association between statin use and HF in patients with atrial fibrillation.

METHODS AND RESULTS

Patients with newly diagnosed atrial fibrillation from 2010 to 2018 were included. An inverse probability of treatment weighting was used to balance baseline covariates between statin users (n=23 239) and statin nonusers (n=29 251). The primary outcome was incident HF. Cox proportional hazard models with competing risk regression were used to evaluate the risk of HF between statin users and nonusers. The median age of the cohort was 74.7 years, and 47.3% were women. Over a median follow-up of 5.1 years, incident HF occurred in 3673 (15.8%) statin users and 5595 (19.1%) statin nonusers. Statin use was associated with a 19% lower risk of HF (adjusted subdistribution hazard ratio, 0.81 [95% CI, 0.78-0.85]). Restricted to the statin users, duration of statin use was measured during follow-up; compared with short-term use (3 months to <2 years), there was a stepwise reduction in the risk of incident HF among those with 2 to <4 years of statin use (subdistribution hazard ratio, 0.86 [95% CI, 0.84-0.88]), 4 to <6 years of statin use (subdistribution hazard ratio, 0.74 [95% CI, 0.72-0.76]), and ≥6 years of statin use (subdistribution hazard ratio, 0.71 [95% CI, 0.69-0.74]). Subgroup analysis showed consistent reductions in the risk of HF with statin use.

CONCLUSIONS

Statin use was associated with a decreased risk of incident HF in a duration-dependent manner among patients with atrial fibrillation.

Future Perspectives to Improve CHA2DS2VASc Score: The Role of Left Atrium Remodelling, Inflammation and Genetics in Anticoagulation of Atrial Fibrillation

In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients.

[Antithrombotiques oraux et pronostic après un an des patients atteints de fibrillation auriculaire dans un milieu à ressources limitées]

BACKGROUND

Atrial fibrillation is associated with increased risk of morbidity and mortality. There's limited data on the outcomes of atrial fibrillation patients in Africa. We aimed at evaluating the clinical outcomes and their associated factors in patients with atrial fibrillation on antithrombotic therapy in Douala.

METHODS

The Douala atrial fibrillation registry is a prospective, observational cohort study of patients with atrial fibrillation followed by cardiovascular specialists in 3 specialized care centres. From January to April 2018, all patients with electrocardiographic diagnosis of atrial fibrillation, aged 21 years or older, were included in the registry provided their consent. The composite endpoint of heart failure, stroke, major bleeding, hospitalisation and mortality as well as their individual occurrence were assessed at 12 months.

RESULTS

Of 113 participants that were included, 6(5.3%) were lost to follow-up. The mean age was 70 ± 12 years, with a female predominance (68%). After a mean follow-up time of 12.2 ± 0.7 months, 51 patients (47.7%) had at least one outcome. Hospitalisation, all-cause mortality, heart failure, stroke and major bleeding rates were 33.3%, 16.8%, 15.2%, 4.8% and 2.9% respectively. There was no significant difference in the composite outcome and mortality according to the antithrombotic treatment. Previous heart failure [aHR = 3.07, 95% CI (1.48-6.36) p = 0.003], new onset atrial fibrillation [aHR= 4.00, 95% CI (0.96-8.19) p < 0.001] and paroxystic atrial fibrillation [aHR= 3.74, 95% CI (1.33-10.53) p = 0.013] were significant predictors of outcome.

CONCLUSION

Half of patients with atrial fibrillation in this registry developed an outcome after one year of follow-up, with heart failure, new onset and paroxystic atrial fibrillation being the main predicting factors. Diagnosing and managing atrial fibrillation in patients with heart disease should therefore be considered as a key priority.

Global and regional burden of ischemic stroke associated with atrial fibrillation, 2009-2019

The extent of the preventable burden of ischaemic stroke associated with atrial fibrillation (AF) remains uncertain to date. To address this knowledge gap, we utilised the comparative risk assessment methodology to estimate the burden of ischaemic stroke associated with AF at both global and regional levels. The population attributable fraction for ischaemic stroke and AF was obtained from published literature, while data on the prevalence, incidence, deaths, and disability-adjusted life years (DALY) associated with ischaemic stroke were sourced from the Global Burden of Disease study database. Our analysis revealed that in 2019, globally, there were an estimated 0.7 (95% uncertainty interval [UI] of 0.55 to 0.83) million incident cases, 6.9 (5.81 to 8.12) million prevalence cases, 0.3 0.25 to 0.34) million deaths and 5.7 (4.91 to 6.57) million DALY resulting from ischaemic stroke associated with AF. The age-standardised death and DALY rates declined between 2009 and 2019 in all regions to varying degrees. Conversely, the age-standardised incidence and prevalence rates reduced only in high-income countries, Central Europe, Eastern Europe and Central Asia and Latin America and Caribbean regions. It is likely that our findings under-estimated the true burden of ischaemic stroke associated with AF due to limitations such as the use of a fixed population attributable fraction and poor quality of data. Nevertheless, we believe that our estimates provide valuable insights and highlight the urgent need for optimised management of AF through the implementation of efficacious interventions. Such efforts can help reduce the occurrence of preventable ischaemic strokes.

Atrial fibrillation: primary prevention, secondary prevention, and prevention of thromboembolic complications: part 1

Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia. It was once thought to be benign as long as the ventricular rate was controlled, however, AF is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a MEDLINE search to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched via the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare noninvasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.

Anti-arrhythmic drugs in atrial fibrillation: tailor-made treatments

During the last decades, many improvements have been made regarding the treatment of atrial fibrillation in terms of risk prevention, anti-coagulation strategies, and gain in quality of life. Among those, anti-arrhythmic drugs (AADs) have progressively fallen behind and overtaken by technological aspects as devices as procedures are now the standards of care for many patients. But is this it? Are AADs doomed to be relegated to an obscure and rarely read paragraph of the European recommendations? Or could they be still employed safely and effectively? In the present paper, we will discuss contemporary evidence in order to define where AADs still play a pivotal role, how should AADs be used, and whether a tailored approach can be the way to propose the right treatment to the right patient.

Prevalence and treatment of atrial fibrillation in older adults

BACKGROUND

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia with an impact on morbidity and mortality found in the geriatric population.

OBJECTIVE

This retrospective study is the first to investigate the prevalence, treatment and comorbidities of AF in a large cohort of older adults.

MATERIAL AND METHODS

Older adults with AF hospitalized between 2010 and 2018. The mean age of the 10,700 AF patients in 2018 was 83.2 ± 6.4 years. The frequency of anticoagulation in older adults with AF between 2010 and 2018 was analyzed. The relationship between comorbidities and anticoagulation in 2018 was examined. Logistic regression analysis was used to identify possible predictive factors for anticoagulation.

RESULTS

The prevalence of AF in 35,887 hospitalized older adults was 29.8% in 2018. The mean CHA₂DS₂VASc score was 4.4 ± 1.3 (male 3.8 ± 1.3, female 4.7 ± 1.2). From 2010 to 2018, the frequency of anticoagulation for patients with AF rose from 32.1% to 64.2%. Statistically significant differences in the examined characteristics between anticoagulated and not anticoagulated patients were found. Furthermore, there were no predictive factors for anticoagulation in multivariate logistic analysis.

CONCLUSION

Hospitalized older adults have an increased prevalence of AF compared to the general population. Despite the higher risk of bleeding, older adults were more frequently anticoagulated in the observation period, preferably with direct oral anticoagulants (DOACs). Patients without anticoagulation had more diagnoses and were worse in functional tests. This study suggests that the decision to give anticoagulants to older adults should be personalized.

Patient selection, peri-procedural management, and ablation techniques for catheter ablation of atrial fibrillation: an EHRA survey

Catheter ablation (CA) of atrial fibrillation (AF) is the therapy of choice for the maintenance of sinus rhythm in patients with symptomatic AF. Time towards interventional treatment and peri-procedural management of patients undergoing AF ablation may vary in daily practice. The scope of this European Heart Rhythm Association (EHRA) survey was to report the current clinical practice regarding the management of patients undergoing AF ablation and physician's adherence to the European Society of Cardiology Guidelines and the EHRA/HRS/ECAS expert consensus statement on the CA for AF. This physician-based survey was conducted among EHRA members, using an internet-based questionnaire developed by the EHRA Scientific Initiatives Committee. A total of 258 physicians participated in the survey. In patients with paroxysmal or persistent AF, 42 and 9% of the physicians would routinely perform AF ablation as first-line therapy respectively, whereas 71% of physicians would consider ablation as first-line therapy in patients with symptomatic AF and left ventricular ejection fraction <35%. Only 14% of the respondents manage cardiovascular risk factors in patients referred for CA using a dedicated AF risk factor management programme. Radiofrequency CA is the preferred technology for first-time AF (56%), followed by cryo-balloon CA (40%). This EHRA survey demonstrated a considerable variation in the management of patients undergoing AF ablation in routine practice and deviations between guideline recommendations and clinical practice.

Prognosis and treatment of atrial fibrillation in Asian cities: 1-year review of the Asia-Pacific Heart Rhythm Society Atrial Fibrillation Registry

AIMS

The aim of this study is to describe the implementation of the current guidance for stroke prevention and treatment option in atrial fibrillation (AF) and to evaluate mortality and morbidity in relation to therapeutic decisions, including persistence with treatment at 1 year in Asia-Pacific regions.

METHODS AND RESULTS

We recruited 4664 patients consecutive in- and outpatients with AF who presented to cardiologists in five countries under the Asia-Pacific Heart Rhythm Society (APHRS) in whom 1-year follow-up was completed for 4003 (65.5% male; mean age 68.5 years). Oral anticoagulant (OAC) use remained high, 77% at follow-up, including 17% prescribed a vitamin K antagonist (VKA) and 60% a non-VKA oral anticoagulant (NOAC). At 1-year follow-up, 93% and 88% remained on a VKA or NOAC, respectively. With good adherence to OAC therapy, 1-year mortality was only 2.7%. Most deaths were non-cardiovascular (72.3%) and the 1-year incidence of stroke/transient ischaemic events (TIA) was low (<1%). Hospital readmissions were common for non-cardiovascular cases and atrial tachyarrhythmias. On multivariate analysis, independent baseline predictors of mortality and/or stroke/TIA/peripheral embolism were age, previous heart failure for >12 months, and malignancy. Independent predictors of mortality were age, chronic obstructive pulmonary disease, malignancy, and diuretic use. AF as a primary presentation was predictive of lower mortality and/or stroke/TIA/peripheral embolism as well as mortality.

CONCLUSION

In this 1-year analysis of the APHRS-AF registry, overall OAC use and persistence were high and were associated with low 1-year cardiovascular mortality and morbidity, but mortality and morbidity related to non-cardiovascular causes were high in AF patients, particularly from malignancy and pneumonia.

Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation

BACKGROUND

Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs.

AIM

To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department.

METHODS

A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once.

RESULTS

From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001).

CONCLUSION

Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.

Impact of anthropometric factors on outcomes in atrial fibrillation patients: analysis on 10 220 patients from the European Society of Cardiology (ESC)-European Heart Rhythm Association (EHRA) EurObservational Research Programme on Atrial Fibrillation (EORP-AF) general long-term registry

AIM

To investigate the association of anthropometric parameters [height, weight, body mass index (BMI), body surface area (BSA), and lean body mass (LBM)] with outcomes in atrial fibrillation (AF).

METHODS AND RESULTS

Ten-thousand two-hundred twenty patients were enrolled [40.3% females, median age 70 (62-77) years, followed for 728 (interquartile range 653-745) days]. Sex-specific tertiles were considered for the five anthropometric variables. At the end of follow-up, survival free from all-cause death was worse in the lowest tertiles for all the anthropometric variables analyzed. On multivariable Cox regression analysis, an independent association with all-cause death was found for the lowest vs. middle tertile when body weight (hazard ratio [HR] 1.66, 95%CI 1.23-2.23), BMI (HR 1.65, 95%CI 1.23-2.21), and BSA (HR 1.49, 95%CI 1.11-2.01) were analysed in female sex, as well as for body weight in male patients (HR 1.61, 95%CI 1.25-2.07). Conversely, the risk of MACE was lower for the highest tertile (vs. middle tertile) of BSA and LBM in males and for the highest tertile of weight and BSA in female patients. A higher occurrence of haemorrhagic events was found for female patients in the lowest tertile of height [odds ratio (OR) 1.90, 95%CI 1.23-2.94] and LBM (OR 2.13, 95%CI 1.40-3.26).

CONCLUSIONS

In AF patients height, weight, BMI, BSA, and LBM were associated with clinical outcomes, with all-cause death being higher for patients presenting lower values of these variables, i.e. in the lowest tertiles of distribution. The anthropometric variables independently associated with other outcomes were also different between male and female subjects.

Is there an association between left atrial outpouching structures and recurrence of atrial fibrillation after catheter ablation?

Objective

The aim of this study was to investigate the impact of left atrial diverticula (LADs), left sided septal pouches (LSSPs) and middle right pulmonary veins (MRPVs) on recurrent atrial fibrillation (rAF) in patients undergoing laser pulmonary vein isolation procedure (PVI).

Material and methods

This retrospective study enrolled 139 patients with pre-procedural multiple detector computed tomography (MDCT) imaging and 12 months follow-up examination. LADs, LSSPs and MRPV were identified by two radiologists on a dedicated workstation using multiplanar reconstructions and volume rendering technique. Univariate and bivariate regression analyses with patient demographics and cardiovascular risk factors as covariates were performed to reveal independent factors associated with rAF.

Results

LADs were recorded in 41 patients (29%), LSSPs in 20 (14%) and MRPVs in 15 (11%). The right anterosuperior wall of the left atrium was the most prevalent location of LADs (68%). rAF occured in 20 patients, thereof, 15 exhibited an outpouching structure of the left atrium (LAD: 9, LSSP: 2 and MRPV: 3). Presence of an LAD (HR: 2.7, 95%CI: 1.0–8.4, p = 0.04) and permanent AF (HR: 4.8, 95%CI: 1.5–16.3, p = 0.01) were independently associated with rAF.

Conclusions

LAD, LSSP and MRPV were common findings on pre-procedural cardiac computed tomography. LADs were revealed as potential independent risk factor of rAF, which might be considered for treatment planning and post-treatment observation.

Clinical utility and prognostic implications of the 4S-AF scheme: Report from Asia Pacific Heart Rhythm Society Atrial Fibrillation Registry

BACKGROUND

The 4S-AF classification scheme comprises of four domains (stroke risk [St], symptoms [Sy], severity of atrial fibrillation (AF) burden [Sb] and substrate [Su]), which has been recommended in the 2020 ESC guidelines to characterize and evaluate patients with AF.

OBJECTIVES

We aimed to determine whether the 4S-AF scheme would be useful for AF characterization and provides prognostic information in a large contemporary prospective Asian registry conducted by the Asia Pacific Heart Rhythm Society (APHRS).

METHODS

Among 4666 patients enrolled in APHRS registry, 3586 of them whose data about left atrial (LA) dimension and European Heart Rhythm Association (EHRA) symptom score were available have constituted as the study population. The 4S-AF score was calculated as the sum of each domain with a maximum score of 9. The clinical endpoint was defined as the 1-year composite risk of any thromboembolic event, ischaemic stroke, heart failure, acute coronary syndrome, significant coronary artery disease requiring coronary intervention and all-cause mortality.

RESULTS

Based on the 4S-AF domains, 86.7% were 'non-low risk' for stroke; 94.3% had EHRA Class I-II, 48.5% were newly diagnosed or paroxysmal AF; and only 8.4% had no cardiovascular risk factors or LA enlargement. The risk of clinical events was higher in patients who were 'non-low risk' for stroke (aOR 2.175, 95% CI 1.060-4.461), with permanent AF (aOR 1.579, 95% CI 1.106-2.225) and increasing points for substrate (aORs 2.376-4.968 from score 2 to 4). When compared to the first tertile of 4S-AF score (0-3 points), patients in the second tertile (4-5 points) had approximately 2.5-fold increase in adverse events (OR 2.478, 95% CI 1.678-3.661, p < .001), while those in the third tertile (6-9 points), had a 3.5-fold increase (OR 3.484, 95% CI 2.322-5.226, p < .001), both without significant differences between the 5 participating countries (p for interaction > .05). If all 4S-AF domains were appropriately treated, this was associated with a lower risk of composite clinical outcomes (aOR 0.384, p < .001; p for interaction for different countries = .234).

CONCLUSIONS

Categorization according to the 4S-AF scheme can be related to the risk of the composite adverse event rate in Asian AF patients, and appropriate treatments based on the 4S-AF scheme resulted in better clinical outcomes. These observations support the characterization and management according to the 4S-AF scheme in Asian patients.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

Antithrombotic therapy and clinical outcomes at 1 year in the Spanish cohort of the EORP-AF Long-term General Registry

BACKGROUND

Atrial fibrillation (AF) increases the risk of thromboembolism. We investigate the efficacy and safety of oral anticoagulation (OAC) therapy and explored the number needed to treat for net effect (NNTnet) of OAC in the Spanish cohort of the EURObservational Research Programme-AF (EORP-AF) Long-term General Registry.

METHODS

The EORP-AF General Registry is a prospective, multicentre registry conducted in ESC countries, including consecutive AF patients. For the present analysis, we used the Spanish cohort, and the primary outcome was any thromboembolism (TE)/acute coronary syndrome (ACS)/cardiovascular death during the first year of follow-up.

RESULTS

729 AF patients were included (57.1% male, median age 75 [IQR 67-81] years, median CHA₂ DS₂ -VASc and HAS-BLED of 3 [IQR 2-5] and 2 [IQR 1-2], respectively). 548 (75.2%) patients received OAC alone (318 [43.6%] on VKAs and 230 [31.6%] on DOACs). After 1 year, the use of OAC alone showed lower rates of any TE/ACS/cardiovascular death (3.0%/year; p < 0.001) compared to other regimens, and non-use of OAC alone (HR 4.18, 95% CI 2.12-8.27) was independently associated with any TE/ACS/cardiovascular death. Balancing the effects of treatment, the NNTnet to provide an overall benefit of OAC therapy was 24. The proportion of patients on OAC increased at 1 year (87% to 88.1%), particularly on DOACs (33.6% to 39.9%) (p = 0.015), with low discontinuation rates.

CONCLUSIONS

In this contemporary cohort of AF patients, OAC therapy was associated with better clinical outcomes at 1 year and positive NNTnet. OAC use slightly increased during the follow-up, with low discontinuation rates and higher prescription of DOACs.

Temporary Trends Concerning the Extent and Efficacy of Atrial Fibrillation Ablation Using Radiofrequency Energy in a Polish Single-Center Experience

Background and Objectives: Atrial fibrillation (AF) is the most common supraventricular arrhythmia. Currently, catheter ablation is a preferred treatment strategy. The main objective of our study was a temporary trends analysis of patients’ data undergoing a single AF ablation procedure using radiofrequency energy (RF). The efficacy of the procedure underwent assessment during a 12-month follow-up. Materials and Methods: We analyzed 585 consecutive patients with symptomatic, recurrent, and drug-refractory AF hospitalized in our department between 2013 and 2018 who underwent RF ablation supported by a 3D electroanatomical system. The baseline characteristics, periprocedural parameters, and efficacy of the procedure at 6-, 9- and 12-month follow-ups were analyzed over the years. Results: The number of patients undergoing ablation increased. Patients with paroxysmal AF predominated (71.5%). However, the number of patients with the persistent type of arrhythmia increased over the years. The percentage of patients with chronic heart failure (CHF) increased to 27.5% in 2018, and patients presented with increasingly larger left atria (LA). In all patients, circumferential pulmonary vein isolation was performed. The percentage of patients who underwent arrhythmogenic substrate modification and cavotricuspid isthmus ablation increased. Over the years, the efficacy of a single procedure at the 12-month follow-up remained without significant differences between the years (72.0%, 69.6%, 75.5%, 74.8%, 71.7%, 71.7%). Conclusions: The rate of patients with CHF and advanced LA disease undergoing more extensive ablation increased over the years. The efficacy of a single procedure remained without significant differences between the years.

Chronic kidney disease and risks of adverse clinical events in patients with atrial fibrillation

BACKGROUND

Chronic kidney disease (CKD) is highly prevalent in patients with atrial fibrillation (AF). However, the association between CKD and clinical consequences in AF patients is still under debate.

METHODS

We included 19,079 nonvalvular AF patients with available estimated glomerular filtration rate (eGFR) values in the Chinese Atrial Fibrillation Registry from 2011 to 2018. Patients were classified into no CKD (eGFR ≥ 90 mL/min per 1.73 m²), mild CKD (60 ≤ eGFR < 90 mL/min per 1.73 m ²), moderate CKD (30 ≤ eGFR < 60 mL/min per 1.73 m ²), and severe CKD (eGFR < 30 mL/min per 1.73 m ²) groups. The risks of thromboembolism, major bleeding, and cardiovascular mortality were estimated with Fine-Gray regression analysis according to CKD status. Cox regression was performed to assess the risk of all-cause mortality associated with CKD.

RESULTS

Over a mean follow-up of 4.1 ± 1.9 years, there were 985 thromboembolic events, 414 major bleeding events, 956 cardiovascular deaths, and 1,786 all-cause deaths. After multivariate adjustment, CKD was not an independent risk factor of thromboembolic events. As compared to patients with no CKD, those with mild CKD, moderate CKD, and severe CKD had a 45%, 47%, and 133% higher risk of major bleeding, respectively. There was a graded increased risk of cardiovascular mortality associated with CKD status compared with no CKD group: adjusted hazard ratio [HR] was 1.34 (95% CI: 1.07-1.68,P = 0.011) for mild CKD group, 2.17 (95% CI: 1.67-2.81,P < 0.0001) for moderate CKD group, and 2.95 (95% CI: 1.97-4.41, P < 0.0001) for severe CKD group, respectively. Risk of all-cause mortality also increased among patients with moderate or severe CKD.

CONCLUSIONS

CKD status was independently associated with progressively higher risks of major bleeding and mortality, but didn't seem to be an independent predictor of thromboembolism in AF patients.

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

BACKGROUND

Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients' clinical phenotypes and analyse the differential clinical course.

METHODS

We performed a hierarchical cluster analysis based on Ward's Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry.

RESULTS

A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients' prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P < .001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27-3.62; HR 3.42, 95%CI 2.72-4.31; HR 2.79, 95%CI 2.32-3.35), and Cluster 1 (HR 1.88, 95%CI 1.48-2.38; HR 2.50, 95%CI 1.98-3.15; HR 2.09, 95%CI 1.74-2.51) reported a higher risk for the three outcomes respectively.

CONCLUSIONS

In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes.

Comparison of HAS-BLED and ORBIT Bleeding Risk Scores in AF Patients treated with NOACs: A Report from the ESC-EHRA EORP-AF General Long-Term Registry

INTRODUCTION

Bleeding risk assessment is recommended in guidelines for the management of atrial fibrillation (AF). HAS-BLED score was proposed prior to non-vitamin K antagonist oral anticoagulants (NOACs) and has been suggested that the ORBIT score may be superior in predicting bleeds in NOAC users. We aimed to compare the HAS-BLED and ORBIT scores in contemporary AF patients treated with NOACs.

METHODS AND RESULTS

We analyzed patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. HAS-BLED and ORBIT scores were computed based on original schemes. The primary outcome was the occurrence of Major Bleeding (MB). A total of 3018 patients (median age 70; 39.6% females) were included: median [IQR] HAS-BLED and ORBIT scores were 1 [1-2] and 1 [0-2], respectively; 356 (11.8%) patients were at high risk for MB using HAS-BLED (≥3) and 123 (4.1%) using ORBIT (≥4). Overall, 60 (2.0%) MB events were recorded, with an incidence of 1.1 per 100 patient-years.Both HAS-BLED and ORBIT were associated with outcome, modestly predicting MB (AUC 0.653, 95% CI 0.593-0.714 and AUC 0.601, 95% CI 0.526-0.677, respectively). Calibration plots showed that both scores were poorly calibrated, particularly the ORBIT score, which showed consistent poorer calibration. Time-dependent reclassification analysis showed a trend towards incorrect lower risk reclassification using ORBIT compared to HAS-BLED.

CONCLUSION

In this real-life contemporary cohort of AF patients treated with NOACs, the ORBIT score did not provide reclassification improvement, showing even poorer calibration compared to HAS-BLED. Our findings do not support the preferential use of ORBIT in NOAC-treated AF patients.

Direct Oral Anticoagulants and Non-valvular Atrial Fibrillation: Compliance with Dose Level Guidelines in Patients Aged 80 Years and Over

BACKGROUND

Direct oral anticoagulants (DOACs) are currently recommended as first-line or (after vitamin K antagonists) second-line therapy for preventing stroke and systemic embolism in patients with non-valvular atrial fibrillation. In patients aged 80 years and over, however, the fear of DOAC-associated bleeding and the complexity of DOAC dosing regimes may prompt physicians to prescribe inappropriate dose levels.

OBJECTIVE

The objective of this study was to determine compliance with French and European guidelines of doses of three DOACs (apixaban, dabigatran and rivaroxaban) prescribed to patients aged over 80 years in an indication of non-valvular atrial fibrillation, and to identify factors associated with poor compliance.

METHODS

We performed a retrospective single-centre study of patients aged over 80 years routinely treated with a DOAC (apixaban, dabigatran or rivaroxaban) for non-valvular atrial fibrillation at Valenciennes General Hospital (Valenciennes, France) between 1 January, 2016 and 31 December, 2017. We determined compliance with French and European guidelines of DOAC doses as a function of each patient's clinical and laboratory parameters, and thus classified the regime as being appropriately dosed, overdosed or underdosed.

RESULTS

A total of 703 patients (371 taking apixaban, 92 taking dabigatran and 240 taking rivaroxaban) were included in the study. We found that 274 patients (39%) had been prescribed an inappropriate DOAC regime, with underdosing in 241 cases (34%) and overdosing in 33 cases (5%). Underdosing mainly concerned the two most widely prescribed DOACs, i.e. apixaban (39% of all apixaban prescriptions were underdosed) and rivaroxaban (40%). Concomitant treatment with an antidepressant was associated with underdosing of rivaroxaban or apixaban (p = 0.0339). In contrast, initial management in a neurology department was associated with appropriate dosing (p = 0.000146) for both these DOACs.

CONCLUSIONS

Among patients with non-valvular atrial fibrillation aged 80 years and over, about 40% of DOAC prescriptions feature inappropriate dose levels. It might be possible to reduce inappropriate dosing by raising awareness among hospital-based and private-practice prescribers, providing prescription support tools for DOACs, and performing medication reconciliations and reviews at hospital and in private practice.

Real-world applicability and impact of early rhythm control for European patients with atrial fibrillation: a report from the ESC-EHRA EORP-AF Long-Term General Registry

Background

Use of rate/rhythm control is essential to control symptoms in patients with atrial fibrillation (AF). Recently, the EAST-AFNET 4 trial described how early rhythm control strategy was associated with a lower risk of adverse clinical outcomes.

Objectives

The aim was to evaluate the real-world applicability and impact of an early rhythm control strategy in patients with AF.

Methods

Use of an early rhythm control strategy was assessed in a European cohort of AF patients derived from the EHRA-ESC EORP-AF General Long-Term Registry. Early rhythm control was defined as use of antiarrhythmic drugs or cardioversion/catheter ablation. The primary outcome included cardiovascular death, stroke, acute coronary syndrome, and worsening of heart failure. Quality of life and health-care resource usage were also assessed as outcomes.

Results

Among the 10,707 patients evaluated for eligibility to EAST-AFNET 4, a total of 3774 (34.0%) were included. Early rhythm control was associated with better quality of life, but with greater use of health-care resources. During follow-up, the primary outcome occurred less often in early rhythm control patients than in those with no rhythm control (13.6% vs. 18.5%, p < 0.001). In the multivariate adjusted Cox regression model, no significant difference was found between no rhythm control and early rhythm control, for the primary outcome. No difference in the primary outcome between early rhythm control and ‘no rhythm control patients’ adherent to Atrial fibrillation Better Care (ABC) pathway’ was evident (p = 0.753)

Conclusions

Use of an early rhythm control strategy was associated with a lower rate of major adverse events, but this difference was non-significant on multivariate analysis, being mediated by differences in baseline characteristics and clinical risk profile. Early rhythm control was associated with a higher use of health-care resources and risk of hospital admission, despite showing better quality of life.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01914-y.

SETAP: epidemiology and prevention of stroke and transient ischaemic attack in Czech patients with atrial fibrillation

AIMS

The aim of this study is to analyse the prevalence, epidemiology, and anticoagulation prevention of stroke or transient ischaemic attack (TIA) in Czech patients with atrial fibrillation (AF).

METHODS AND RESULTS

Retrospective observational analysis of diagnoses, procedures, and treatment reported to the Czech National Registry of Reimbursed Healthcare Services between 2015 and 2018. Prevalence of AF in 2018 was 4.3% of Czech population and the prevalence of stroke/TIA in AF patients was 22.3% with annual incidence of 181.62 cases per 100 000 inhabitants. In 2018, CHA2DS2-ASc score ≥4 was present in 98% AF patients in secondary and 59% in primary prevention, respectively, while the anticoagulation treatment was used by 71-81% of them. Between 2015 and 2018, the percentage of AF patients treated with warfarin monotherapy in primary prevention decreased from 35% to 31%, with acetylsalicylic acid (ASA) monotherapy from 18% to 16% and non-vitamin K antagonist oral anticoagulants (NOACs) monotherapy increased from 7% to 11%. In secondary prevention, the percentage of warfarin monotherapy treatment decreased from 35% to 32%, with ASA monotherapy from 20% to 18% and with NOACs monotherapy increased from 9% to 15%.

CONCLUSION

This study followed all Czech patients with AF. The unadjusted prevalence and incidence of AF was higher compared with other countries and 2019 European Society of Cardiology Statistics. The study identified several gaps in standard of reimbursed care. 20-30% of AF patients with other risk factors were without any prevention medication and the share of ASA monotherapy in treated patients was 16-18%.

Impact of centre volume on atrial fibrillation ablation outcomes in Europe: a report from the ESC EHRA EORP Atrial Fibrillation Ablation Long-Term (AFA LT) Registry

AIMS

The aim of the study was to investigate differences in clinical outcomes and complication rates among European atrial fibrillation (AF) ablation centres related to the volume of AF ablations performed.

METHODS AND RESULTS

Data for this analysis were extracted from the ESC EHRA EORP European AF Ablation Long-Term Study Registry. Based on 33rd and 67th percentiles of number of AF ablations performed, the participating centres were classified into high volume (HV) (≥ 180 procedures/year), medium volume (MV) (<180 and ≥74/year), and low volume (LV) (<74/year). A total of 91 centres in 26 European countries enrolled in 3368 patients. There was a significantly higher reporting of cardiovascular complications and stroke incidence in LV centres compared with HV and MV (P = 0.039 and 0.008, respectively) and a lower success rate after AF ablation (55.3% in HV vs. 57.2% in LV vs. 67.4% in MV centres, P < 0.001), despite lower CHA2DS2-VASc score of patients, enrolled in LVs and less complex ablation techniques used. Adjustments of confounding factors (including type of AF ablation) led to elimination of these differences.

CONCLUSION

Low-volume centres tended to present slightly higher cardiovascular complications' and stroke incidence and a lower unadjusted success rate after AF ablation, despite the fact that ablation procedures and patients were of lower risk compared with MV and HV centres. On the other hand, adjusted overall complication and recurrence rates were non-significantly different among different volume centres, a fact reflecting the heterogeneity of patient and procedural profiles, and a counterbalance between expertise and risk level among participating centres.

Clinical Outcomes in Asymptomatic and Symptomatic Atrial Fibrillation Presentations in GARFIELD-AF: Implications for AF Screening

BACKGROUND

Asymptomatic atrial fibrillation is often detected incidentally. Prognosis and optimal therapy for asymptomatic compared with symptomatic atrial fibrillation is uncertain. This study compares clinical characteristics, treatment, and 2-year outcomes of asymptomatic and symptomatic atrial fibrillation presentations.

METHODS

Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) is a global, prospective, observational study of newly diagnosed atrial fibrillation with ≥1 stroke risk factors (http://www.clinicaltrials.gov, unique identifier: NCT01090362). Patients were characterized by atrial fibrillation-related symptoms at presentation and the CHA₂DS₂-VASc score. Two-year follow-up recorded anticoagulation patterns (vitamin K antagonist, direct oral anticoagulants, parenteral therapy) and outcomes (stroke/systemic embolism, all-cause mortality, and bleeding).

RESULTS

At presentation, of 52,032 eligible patients, 25.4% were asymptomatic and 74.6% symptomatic. Asymptomatic patients were slightly older (72 vs 70 years), more often male (64.2% vs 52.9%), and more frequently initiated on anticoagulation ± antiplatelets (69.4% vs 66.0%). No difference in events (adjusted hazard ratios, 95% confidence interval) for nonhemorrhagic stroke/systemic embolism (1.19, 0.97-1.45), all-cause mortality (1.06, 0.94-1.20), or bleeding (1.02, 0.87-1.19) was observed. Anticoagulation was associated with comparable reduction in nonhemorrhagic stroke/systemic embolism (0.59, 0.43-0.82 vs 0.78, 0.65-0.93) and all-cause mortality (0.69, 0.59-0.81 vs 0.77, 0.71-0.85) in asymptomatic versus symptomatic, respectively.

CONCLUSIONS

Major outcomes do not differ between asymptomatic and symptomatic atrial fibrillation presentations and are comparably reduced by anticoagulation. Opportunistic screening-detected asymptomatic atrial fibrillation likely has the same prognosis as asymptomatic atrial fibrillation at presentation and likely responds similarly to anticoagulation thromboprophylaxis.

Many Good Reasons to Switch from Vitamin K Antagonists to Non-Vitamin K Antagonists in Patients with Non-Valvular Atrial Fibrillation

Non-vitamin K oral anticoagulants (NOACs) are the first choice for prophylaxis of cardioembolism in patients with non-valvular atrial fibrillation (AF) who are anticoagulant-naïve, as well as the preferable anticoagulation strategy in those who are on vitamin K antagonists (VKAs), but with a low time in therapeutic range (TTR). Nonetheless, there are many good reasons to consider switching from VKAs to NOACs also when TTR is >70%. From the pharmacological standpoint, anticoagulation with VKAs may remain erratic even in those patients who have high TTR values, owing to the mode of action of this drug class. Furthermore, experimental data suggest that, unlike VKAs, NOACs favorably modulate the effects of factor Xa and thrombin in the cardiovascular system through the protease-activated receptor family. Clinically, the most striking advantage provided by NOACs over VKAs, irrespective of the TTR, is the substantially lower risk of intracranial hemorrhage. NOACs have also been associated with less deterioration of renal function as compared with VKAs and may confer protection against cardiovascular events not strictly related to AF, especially the acute complications of peripheral artery disease. In this narrative review, we discuss the evidence according to which it is warranted to systematically substitute NOACs for VKAs for the prevention of AF-related stroke and systemic embolism.

'Real-world' observational studies in arrhythmia research: data sources, methodology, and interpretation. A position document from European Heart Rhythm Association (EHRA), endorsed by Heart Rhythm Society (HRS), Asia-Pacific HRS (APHRS), and Latin America HRS (LAHRS)

The field of observational studies or "real world studies" is in rapid development with many new techniques introduced and increased understanding of traditional methods. For this reason the current paper provides an overview of current methods with focus on new techniques. Some highlights can be emphasized: We provide an overview of sources of data for observational studies. There is an overview of sources of bias and confounding. Next There is an overview of causal inference techniques that are increasingly used. The most commonly used techniques for statistical modelling are reviewed with focus on the important distinction of risk versus prediction. The final section provides examples of common problems with reporting observational data.

Patients with symptomatic permanent atrial fibrillation show quantitative signs of pain sensitisation

Objective

Most patients with atrial fibrillation (AF) report symptoms, while one-third are asymptomatic. We hypothesised that sensory processing, in particular pain, differs in patients with symptomatic and asymptomatic AF.

Methods

Thirty individuals with permanent AF (15 symptomatic and 15 asymptomatic) completed the Atrial Fibrillation 6 (AF6) and short form 36 Health Survey questionnaires and underwent quantitative pain sensitisation testing using pressure algometry at the sternum (referred pain area) and the tibialis anterior muscle (generalised pain area). The primary objective was to assess differences in pressure pain thresholds (PPT), temporal summation of pain (TSP) and conditioned pain modulation (CPM) in the two groups. The secondary objective was to determine association of demographic and clinical parameters to measures of pain sensitisation.

Results

The symptomatic group had lower PPTs at both tibialis (p=0.004) and sternum (p=0.01), and impaired CPM (p=0.025) and facilitated TSP (p=0.008) at the tibialis but not sternum, compared with the asymptomatic group. The AF6 sum score was negatively correlated to PPT on both tibialis (r=−0.50, p=0.005) and sternum (r=−0.42, p=0.02) and positively correlated to TSP on both tibialis (r=0.57, p=0.001) and sternum (r=0.45, p=0.01), but not to CPM. The physical component summary score was positively correlated to the PPT on both tibialis (r=0.52, p=0.003) and sternum (r=0.40, p=0.03) and negatively to TSP on the tibialis (r=−0.53, p=0.003) but not sternum.

Conclusions

Patients with symptomatic AF exhibit lower pain tolerance than patients with asymptomatic AF, as well as impaired pain inhibitory control and facilitated summation of pain, indicating that pain sensitisation may be of importance in symptomatic AF.

Trial registration number

NCT04649437.

Symptom management strategies: Rhythm vs rate control in patients with atrial fibrillation in the Balkan region: Data from the BALKAN-AF survey

BACKGROUND

Symptom-focused management is one of the cornerstones of optimal atrial fibrillation (AF) therapy.

OBJECTIVES

To evaluate the use of rhythm control and rate control strategy. Second, to identify predictors of the use of amiodarone in patients with rhythm control and of the use of rhythm control strategy in patients with paroxysmal AF in the Balkans.

METHODS

Prospective enrolment of consecutive patients from seven Balkan countries to the BALKAN-AF survey was performed.

RESULTS

Of 2712 enrolled patients, 2522 (93.0%) with complete data were included: 1622 (64.3%) patients were assigned to rate control strategy and 900 (35.7%) to rhythm control. Patients with rhythm control were younger, more often hospitalised for AF and with less comorbidities (all P < .05) than those with rate control. Symptom score [European Heart Rhythm Association (EHRA)] was not an independent predictor of a rhythm control strategy [odds ratio (OR) 0.99, 95% confidence interval (CI) 0.90-1.10, P = .945]. The most commonly chosen antiarrhythmic agents were amiodarone (49.7%), followed by propafenone (24.3%).

CONCLUSION

More than one-third of patients in the BALKAN-AF survey received a rhythm control strategy, and these patients tended to be younger with less comorbidities than those managed with rate control. EHRA symptom score is not significantly associated with rhythm control strategy. The most commonly used antiarrhythmic agents were amiodarone, followed by propafenone.

Anticoagulant therapy in patients with atrial fibrillation and an implanted cardiac resynchronization therapy device

Aim. To study the efficacy and safety of direct oral anticoagulant (DOAC) therapy after implantation of cardiac resynchronization therapy (CRT) devices in atrial fibrillation (AF) patients with coronary artery disease (CAD) and dilated cardiomyopathy (DCM).

Material and methods. The study included 93 patients followed up from 2014 to 2016 (71 men and 22 women) aged 33-85 years (59,7±10,6) with stable CAD (group 1, n=44) and DCM (group 2, n=49). All patients were diagnosed with AF. The left ventricular ejection fraction (LVEF) was 30,6±3,8%; the left ventricular end-diastolic dimension was 230,9±60,8 mm. All patients received anticoagulants for the prevention of thromboembolic events: a vitamin K antagonist (warfarin) or DOAC. The analysis of medical records, as well as ECG records, echocardiographic, 24-hour ECG monitoring data and information from implanted device was carried out. The follow-up period lasted 24 months.

Results. After 24-month follow-up, positive dynamics was noted in all patients — LVEF increased from 30,6±3,7% to 39,5±5,8%). In patients with DCM, a more pronounced increase in myocardial contractile function was noted. Stroke within time interval from 12 to 24 months developed in two patients taking warfarin, from different groups. Transient ischemic attacks were observed in 6 patients: in one patient from group 1 during the period from inclusion and 12-month visit, and in 5 patients from 12 to 24 months. Out of 5 patients, two belonged to group 1 and three — to group 2, while one patient took aspirin and the other 4 — warfarin. One patient from group 1 with persistent AF and vitamin K antagonist therapy had left atrial appendage thrombosis. Hemorrhagic strokes and major bleeding have not been reported.

Conclusion. Among patients taking DOAC, regardless of the underlying disease (CAD or DCM) and response to CRT, bleeding events were less often recorded, and there were no thromboembolic events.

Edoxaban and the Issue of Drug-Drug Interactions: From Pharmacology to Clinical Practice

Edoxaban, a direct factor Xa inhibitor, is the latest of the non-vitamin K antagonist oral anticoagulants (NOACs). Despite being marketed later than other NOACs, its use is now spreading in current clinical practice, being indicated for both thromboprophylaxis in patients with non-valvular atrial fibrillation (NVAF) and for the treatment and prevention of venous thromboembolism (VTE). In patients with multiple conditions, the contemporary administration of several drugs can cause relevant drug-drug interactions (DDIs), which can affect drugs' pharmacokinetics and pharmacodynamics. Usually, all the NOACs are considered to have significantly fewer DDIs than vitamin K antagonists; notwithstanding, this is actually not true, all of them are affected by DDIs with drugs that can influence the activity (induction or inhibition) of P-glycoprotein (P-gp) and cytochrome P450 3A4, both responsible for the disposition and metabolism of NOACs to a different extent. In this review/expert opinion, we focused on an extensive report of edoxaban DDIs. All the relevant drugs categories have been examined to report on significant DDIs, discussing the impact on edoxaban pharmacokinetics and pharmacodynamics, and the evidence for dose adjustment. Our analysis found that, despite a restrained number of interactions, some strong inhibitors/inducers of P-gp and drug-metabolising enzymes can affect edoxaban concentration, just as it happens with other NOACs, implying the need for a dose adjustment. However, our analysis of edoxaban DDIs suggests that given the small propensity for interactions of this agent, its use represents an acceptable clinical decision. Still, DDIs can be significant in certain clinical situations and a careful evaluation is always needed when prescribing NOACs.

Incidence and predictors of hospitalization in patients with atrial fibrillation: results from the Chinese atrial fibrillation registry study

Background

Patients with atrial fibrillation (AF) underwent a high risk of hospitalization, which has not been paid much attention to in practice. Therefore, we aimed to assess the incidence, causes and predictors of hospitalization in AF patients.

Methods

From August 2011 to December 2017, a total number of 20,172 AF patients from the Chinese Atrial Fibrillation Registry (China-AF) Study were prospectively selected for this study. We described the incidence, causes of hospitalization by age groups and sex. The Fine-Gray competing risk model was employed to identify predictors of first all-cause and first cause-specific hospitalization.

Results

After a mean follow-up of 37.3 ± 20.4 months, 7,512 (37.2%) AF patients experienced one or more hospitalizations. The overall incidence of all-cause hospitalization was 24.0 per 100 patient-years. Patients aged < 65 years were predominantly hospitalized for AF (42.1% of the total hospitalizations); while patients aged 65–74 and ≥ 75 years were mainly hospitalized for non-cardiovascular diseases (43.6% and 49.3%, respectively). We found patients complicated with heart failure (HF)[hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.02–1.18], established coronary artery disease (CAD) (HR 1.24, 95%CI 1.17–1.33), ischemic stroke/transient ischemic attack (TIA) (HR 1.22, 95%CI 1.15–1.30), diabetes (HR 1.14, 95%CI 1.08–1.20), chronic obstructive pulmonary disease (COPD) (HR 1.28, 95%CI 1.02–1.62), gastrointestinal disorder (HR 1.37, 95%CI 1.21–1.55), and renal dysfunction (HR 1.24, 95%CI 1.09–1.42) had higher risks of hospitalization.

Conclusions

More than one-third of AF patients included in this study were hospitalized at least once during over 3-year follow-up. The main cause for hospitalization among the elderly patients (≥ 65 years) is non-cardiovascular diseases rather than AF. Multidisciplinary management of comorbidities should be advocated to reduce hospitalization in AF patients older than 65 years old.

Clinical Registryhttp://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729. The registration date is October 22, 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01951-5.

Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF)

BACKGROUND

Contemporary registries on atrial fibrillation (AF) are scare in North African countries.

HYPOTHESIS

In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal.

METHODS

NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described.

RESULTS

A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA₂ DS₂ VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died.

CONCLUSIONS

NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.

Symptomatic and Asymptomatic Patients in the Polish Atrial Fibrillation (POL-AF) Registry

BACKGROUND

Atrial fibrillation (AF) can cause severe symptoms, but it is frequently asymptomatic. We aimed to compare the clinical features of patients with asymptomatic and symptomatic AF.

METHODS

A prospective, observational, multicenter study was performed (the Polish Atrial Fibrillation (POL-AF) registry). Consecutive hospitalized AF patients over 18 years of age were enrolled at ten centers. The data were collected for two weeks during each month of 2019.

RESULTS

A total of 2785 patients were analyzed, of whom 1360 were asymptomatic (48.8%). Asymptomatic patients were more frequently observed to have coronary artery disease (57.5% vs. 49.1%, p < 0.0001), heart failure with preserved ejection fraction (39.8% vs. 26.5%, p < 0.0001), a previous thromboembolic event (18.2% vs. 13.1%, p = 0.0002), and paroxysmal AF (52.3% vs. 45.2%, p = 0.0002). In multivariate analysis, history of electrical cardioversion, paroxysmal AF, heart failure, coronary artery disease, previous thromboembolic event, and higher left ventricular ejection fraction were predictors of a lack of AF symptoms. First-diagnosed AF was a predictor of AF symptoms.

CONCLUSIONS

In comparison to symptomatic patients, more of those hospitalized with asymptomatic AF had been previously diagnosed with this arrhythmia and other cardiovascular diseases. However, they presented with better left ventricular function and were more frequently treated with cardiovascular medicines.

Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry

INTRODUCTION

Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple strategy of integrated approach of AF management: A-Avoid stroke; B-Better symptom control; C-Cardiovascular comorbidity risk management.

AIMS

Evaluation of the AF treatment compliance to ABC pathway in DM patients in the Middle East. Assessment of the impact of ABC pathway adherence on all-cause mortality and the composite outcome of stroke/systemic embolism, all-cause death and cardiovascular hospitalisations.

METHODS

From 2043 patients in the Gulf SAFE registry, 603 patients (mean age 63; 48% male) with DM were included in an analysis of ABC pathway compliance: A-appropriate use of anticoagulation according to CHA₂ DS₂ -VASc score; B-AF symptoms management according to the European Heart Rhythm Association (EHRA) scale; C-Optimised cardiovascular comorbidities management.

RESULTS

86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC group vs non-ABC (5.8% vs 15.9%, P = .0014, respectively). On multivariate analysis, ABC compliance was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI: 0.42-0.75 and OR 0.54; 95% Cl: 0.30-1.00, respectively) and at 1 year (OR 0.30; 95% Cl: 0.11-0.76 and OR 0.57; 95% Cl: 0.33-0.97, respectively) vs the non-ABC group.

CONCLUSIONS

Compliance with the ABC pathway care was independently associated with the reduced risk of all-cause death and the composite outcome in DM patients with AF, highlighting the importance of an integrated approach to AF management.

Cost-Effectiveness of Direct Non-Vitamin K Oral Anticoagulants Versus Vitamin K Antagonists for the Management of Patients with Non-Valvular Atrial Fibrillation Based on Available "Real-World" Evidence: The Italian National Health System Perspective

BACKGROUND AND OBJECTIVE

The increasing availability of real-world evidence (RWE) about safety and effectiveness of direct non-vitamin K oral anticoagulants (DOACs) for the management of atrial fibrillation (AF) offers the opportunity to better understand the clinical and economic implications of DOACs versus vitamin K antagonists (VKAs). The objective of this study was to compare the economic implications of DOACs and VKAs using data from real-world evidence in patients with AF.

METHODS

A Markov model simulating the lifetime course of patients diagnosed with non-valvular AF was used to evaluate the cost-effectiveness of DOACs (i.e., rivaroxaban, dabigatran and apixaban) versus VKAs from the Italian National Health System (INHS) perspective. The model was made up of data from the literature and a meta-analysis of RWE on the incidence of stroke/systemic embolism (SE), major bleeding (MB), intracranial haemorrhage (ICH) and all-cause mortality (ACM); direct costs included drug costs, costs for drug monitoring, and management of events from official national lists. One-way and probabilistic sensitivity analyses (PSA) were used to assess the robustness of the results.

RESULTS

Results from the meta-analysis showed that apixaban had a high probability of being the most effective for stroke/SE, MB and ACM. Despite their higher acquisition costs, the cost-effectiveness analysis showed all DOACs involved a saving when compared with VKAs, with per-patient savings ranging between €4647 (rivaroxaban) to €6086 (apixaban). Moreover, all DOACs indicated a gain both in quality-adjusted life-years and life-years. According to PSA, findings related to apixaban were consistent, while for dabigatran and rivaroxaban PSA revealed a higher degree of uncertainty.

CONCLUSIONS

The beneficial effect of DOACs on containing events showed in RWE had the potential to offset drug-related costs, thus improving the sustainability of treatment for non-valvular AF in daily clinical practice.

The Key Role of Uric Acid in Oxidative Stress, Inflammation, Fibrosis, Apoptosis, and Immunity in the Pathogenesis of Atrial Fibrillation

Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia that leads to numerous adverse outcomes including stroke, heart failure, and death. Hyperuricemia is an important risk factor that contributes to atrium injury and AF, but the underlying molecular mechanism remains to be elucidated. In this review, we discussed the scientific evidence for clarifying the role of hyperuricemia in the pathogenesis of AF. Experimental and Clinical evidence endorse hyperuricemia as an independent risk factor for the incidence of AF. Various in vivo and in vitro investigations showed that hyperuricemia might play a critical role in the pathogenesis of AF at different UA concentrations through the activation of oxidative stress, inflammation, fibrosis, apoptosis, and immunity.

Quality indicators in the management of atrial fibrillation: the BALKAN-AF survey

BACKGROUND

The implementation of quality indicators in the atrial fibrillation (AF) care should be considered to improve quality of management and patient outcome.

METHODS

In the post-hoc analysis of the BALKAN-AF dataset, we assessed concordance with quality indicators for AF management. Available domains for AF management [patient assessment (baseline), anticoagulation, rate control strategy, rhythm control strategy and risk factor management] were identified and assessed at baseline visit.

RESULTS

Among 132 patients with a CHA₂DS₂-VASc score of 0 (men) or 1 (women), 75 (56.8%) were prescribed oral anticoagulation (OAC). Of 2539 patients with a CHA₂DS₂-VASc score ≥ 1 for men and ≥ 2 for women, 1890 (74.4%) were prescribed OAC. Among 1088 patients with permanent AF, 110 (10.1%) individuals were prescribed antiarrhythmic drugs (AADs). Of 1616 patients with structural heart disease, 37 (2.2%) were prescribed class IC AADs. Of 1624 patients with paroxysmal or persistent AF, 59 (3.6%) were offered catheter ablation. Among 2712 AF patients, 2121 (78.2%) had hypertension, 671 (24.7%) were obese, 53 (2.0%) had obstructive sleep apnoea, 110 (4.0%) had alcohol abuse and 340 (12.5%) were smokers.

CONCLUSIONS

In the BALKAN-AF cohort, the use of OAC for stroke prevention was poorly associated with patients stroke risk. The use of AADs in patients with permanent AF was low. The prescription of class IC AADs to patients with structural heart disease was infrequent. A large proportion of AF patients had their modifiable risk factors identified.

Relation of outcomes to ABC (Atrial Fibrillation Better Care) pathway adherent care in European patients with atrial fibrillation: an analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry

AIMS

There has been an increasing focus on integrated, multidisciplinary, and holistic care in the treatment of atrial fibrillation (AF). The 'Atrial Fibrillation Better Care' (ABC) pathway has been proposed to streamline integrated care in AF. We evaluated the impact on outcomes of an ABC adherent management in a contemporary real-life European-wide AF cohort.

METHODS AND RESULTS

Patients enrolled in the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry with baseline data to evaluate ABC criteria and available follow-up data were considered for this analysis. Among the original 11 096 AF patients enrolled, 6646 (59.9%) were included in this analysis, of which 1996 (30.0%) managed as ABC adherent. Patients adherent to ABC care had lower CHA2DS2-VASc and HAS-BLED scores (mean ± SD, 2.68 ± 1.57 vs. 3.07 ± 1.90 and 1.26 ± 0.93 vs. 1.58 ± 1.12, respectively; P < 0.001). At 1-year follow-up, patients managed adherent to ABC pathway compared to non-adherent ones had a lower rate of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death (3.8% vs. 7.6%), CV death (1.9% vs. 4.8%), and all-cause death (3.0% vs. 6.4%) (all P < 0.0001). On Cox multivariable regression analysis, ABC adherent care showed an association with a lower risk of any TE/ACS/CV death [hazard ratio (HR): 0.59, 95% confidence interval (CI): 0.44-0.79], CV death (HR: 0.52, 95% CI: 0.35-0.78), and all-cause death (HR: 0.57, 95% CI: 0.43-0.78).

CONCLUSION

In a large contemporary cohort of European AF patients, a clinical management adherent to ABC pathway for integrated care is associated with a significant lower risk for cardiovascular events, CV death, and all-cause death.

Preclinical assessment of a modified Occlutech left atrial appendage closure device in a porcine model

Left atrial appendage (LAA) closure is being developed as an alternative for stroke prevention in patients with atrial fibrillation that cannot tolerate long-term oral anticoagulation. To assess the feasibility, safety, and performance of a novel modified Occlutech LAA closure device in a preclinical porcine model, the modified Occlutech modified Occlutech Plus LAA closure device was implanted in 12 female pigs (25-39 kg body weight) under fluoroscopic and transesophageal echocardiography (TEE) guidance. Procedural and technical success, as well as safety of LAA closure, were evaluated peri-procedurally and after 4, 8, and 12 weeks. Moreover, after 4, 8 and, 12 weeks animals were sacrificed for pathological analysis (e.g., thrombus formation, device ingrowth, endothelialization, and inflammation). All LAA closure devices were successfully implanted. On follow-up, no serious adverse events such as device-associated thrombus or translocalization/embolization were observed. A clinically non-significant pericarditis was observed in 4 animals at the time of autopsy. Endothelialization of the device was visible after 4 weeks, advanced after 8 weeks and completed after 12 weeks. Immunohistochemistry showed low amounts of inflammatory infiltration on the edges of the device. The results of this study indicate that implantation of a modified Occlutech LAA closure device is feasible with rapid endothelialization and low inflammatory infiltration in a porcine model. Human data are needed to further characterize safety and efficacy.

Atrial Fibrillation and Stroke

Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.