Epidemiology of atrial fibrillation

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.

Non-valvular atrial fibrillation in patients on peritoneal dialysis, prevalence, treatment and professionals involved

Atrial fibrillation is the most frequent chronic arrhythmia in patients with chronic kidney disease. Oral anticoagulation with vitamin K antagonists and now direct oral anticoagulants have been and are the fundamental pillars for the prevention of thromboembolic events. However, there are no randomized clinical trials on the risk-benefit profile of oral anticoagulation in patients with chronic kidney disease stage 5 on peritoneal dialysis and there is little evidence in the literature in this population. The objective of our study was to know the prevalence, treatment and professionals involved in the management of atrial fibrillation in peritoneal dialysis patients. For this purpose, we performed a descriptive analysis through a survey sent to different peritoneal dialysis units in Spain. A total of 1,403 patients on peritoneal dialysis were included in the study, of whom 186 (13.2%) had non-valvular atrial fibrillation. In addition, the assessment of the scores of thromboembolic and bleeding risks for the indication of oral anticoagulation was mainly carried out by the cardiologist (60% of the units), as well as its prescription (cardiologist 47% or in consensus with the nephrologist 43%). In summary, patients on peritoneal dialysis have a remarkable prevalence of non-valvular atrial fibrillation. Patients frequently receive oral anticoagulation with vitamin K antagonists, as well as direct oral anticoagulants. The data obtained regarding the scores used for the assessment of thromboembolic and bleeding risk, treatment and involvement by Nephrology indicates that there is a need for training and involvement of the nephrologist in this pathology.

Metabolomics and Biomarkers for Paroxysmal and Persistent Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common type of arrhythmia worldwide and is associated with serious complications. This study investigated the metabolic biomarkers associated with AF and the differences in metabolomics and associated metabolic biomarkers between paroxysmal AF (AFPA) and persistent AF.

METHODS AND RESULTS

Plasma samples were prospectively collected from patients with AF and patients in sinus rhythm with negative coronary angiography. The patients were divided into 3 groups: AFPA, persistent AF, and sinus rhythm (N=54). Metabolomics (n=36) using ultra-high-performance liquid chromatography mass spectrometry was used to detect differential metabolites that were validated in a new cohort (n=18). The validated metabolites from the validation phase were further analyzed by receiver operating characteristic. Among the 36 differential metabolites detected by omics assay, 4 were successfully validated with area under the curve >0.8 (P<0.05). Bioinformatics analysis confirmed the enrichment pathways of unsaturated fatty acid biosynthesis, glyoxylate and dicarboxylate metabolism, and carbon metabolism. Arachidonic acid was a potential biomarker of AFPA, glycolic acid and L-serine were biomarkers of AFPA and persistent AF, and palmitelaidic acid was a biomarker of AFPA.

CONCLUSIONS

In this metabolomics study, we detected 36 differential metabolites in AF, and 4 were validated with high sensitivity and specificity. These differential metabolites are potential biomarkers for diagnosis and monitoring of disease course. This study therefore provides new insights into the precision diagnosis and management of AF.

Rationale and design of the VAST-AF trial: A randomized controlled, blinded, clinical trial to evaluate transcutaneous vagal nerve stimulation for the prevention of persistent atrial fibrillation recurrence

BACKGROUND

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and is linked to significant symptoms and an elevated risk of heart failure, thromboembolism and disabling stroke. Not only do patients suffer from AF and the concomitant complications, but it is a great economic burden for healthcare systems all over the world. Despite remarkable progress in the field of AF, the basic mechanisms of AF development remain unresolved. Data suggests that the (cardiac) autonomous nervous system (ANS) plays a significant role in AF. Recent studies have shown that stimulating the ANS could have a beneficial effect on paroxysmal and postoperative AF. Consequently, this therapy could provide another viable target for treating persistent AF, as well.

METHODS

The VAST-AF trial is a prospective, double-blinded, randomized, and sham-controlled clinical trial. One hundred and twenty patients diagnosed with persistent AF and cardioversion in sinus rhythm (SR) will be randomly assigned to either transcutaneous vagal nerve stimulation (tVNS) or sham treatment in a 1:1 ratio. The primary objective of this study is to examine whether a daily tVNS reduces the recurrence rate of AF. Secondary endpoints include quality of life, time to first AF recurrence and ECG parameters of the ANS. Follow-up is scheduled at 30 days, 3 and 6 months. After 3 months, stimulation is withdrawn, and patients evaluated regarding a still detectable effect of tVNS.

CONCLUSION

The VAST-AF trial represents the first randomized and sham-controlled study to investigate the potential benefits of transcutaneous vagal nerve stimulation on the recurrence of atrial fibrillation. Patients with persistent atrial fibrillation and successful electrical cardioversion will be assessed. A decrease in the rate of recurrence and consecutive hospitalizations could decidedly enhance the quality of life of patients and decrease healthcare expenses. Nevertheless, it does not compete with treatments such as catheter ablation, but rather serves as an additional tool in the armamentarium of the electrophysiologist.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The Impact of Positive Inotropic Therapy on Hemodynamics and Organ Function in Acute Heart Failure: A Differentiated View

BACKGROUND

Little is known about the impact of treatment with inotropic drugs on the interaction of hemodynamics, biomarkers, and end-organ function in patients with acute decompensated heart failure (HF) of different origins and heart rhythms.

METHODS

Fifty patients with different causes of acute decompensated HF (dilated cardiomyopathy DCM, ischemic cardiomyopathy ICM, atrial fibrillation AF, sinus rhythm/pacemaker lead rhythm SR/PM) were treated with dobutamine or levosimendan. Non-invasive hemodynamics, biomarkers, and parameters of renal organ function were evaluated at hospital admission and after myocardial recompensation (day 5 to 7).

RESULTS

Twenty-seven patients with ICM and twenty-three patients with DCM were included. Thirty-nine patients were treated with dobutamine and eleven with levosimendan. Sixteen were accompanied by persistent AF and thirty-four presented either with SR or PM. In the overall cohort, body weight and biomarkers (NT-proBNP/ST2) significantly decreased. GFR significantly increased during therapy with either dobutamine or levosimendan. However, hemodynamic parameters seem to be only improved in patients with DCM, in the levosimendan sub-group, and in patients with SR/PM.

CONCLUSION

Patients with acute decompensated HF benefit from positive inotropic therapy during short-term follow-ups. In particular, patients with DCM, those after levosimendan therapy and those with SR/PM, seem to benefit most from inotropic therapy.

Selection of Non-vitamin K Antagonist Oral Anticoagulant for Stroke Prevention in Atrial Fibrillation Based on Patient Profile: Perspectives from Vietnamese Experts. Part 1

In Asia, especially Vietnam, AF is a common arrhythmia and is linked to a higher risk of stroke and systemic embolism. Anticoagulation therapy for stroke prevention in AF patients can result in bleeding complications. To effectively manage AF, adopting appropriate anticoagulation and addressing modifiable risk factors are crucial. Vietnamese clinicians are particularly interested in non-vitamin K antagonist oral anticoagulants (NOACs), a recent development in AF treatment. However, the lack of head-to-head trials comparing NOACs makes selecting a specific NOAC challenging. This review aims to provide a comprehensive overview of the available clinical evidence on NOACs for stroke prevention in AF to assist clinicians in making informed decisions and improving treatment outcomes in patients with AF. The first part of this review will present the current landscape of AF in Vietnam, focusing on AF prevalence and highlighting gaps in clinical practice. Furthermore, this part extensively discusses the anticoagulation strategy for both primary and secondary stroke prevention in AF.

Thoracoscopic Surgical Ablation of Lone Atrial Fibrillation: Long-term Outcomes at 7 Years

BACKGROUND

Antiarrhythmic drugs and transcatheter ablation in atrial fibrillation (AF) provide suboptimal rhythm control with a not negligible rate of failure in paroxysmal AF (PAF) and nonparoxysmal AF (n-PAF) at midterm and long-term follow-up. This study evaluated the safety profile and long-term efficacy of thoracoscopic ablation in patients with lone AF.

METHODS

A consecutive 153 patients with lone AF were prospectively enrolled and underwent thoracoscopic surgical ablation. Inclusion criteria were symptomatic AF refractory to pharmacologic therapy (Vaughan-Williams class I-III), age >18 years, and absence of left atrial thrombosis. Exclusion criteria were long-standing AF >5 years, left atrial diameter >55 mm, and contraindication to oral anticoagulation. The "box lesion set" (encircling of pulmonary veins) was always used. Exclusion of the left atrial appendage was performed only in selected cases. The primary study end point was freedom from AF. Secondary end points were overall survival and cumulative incidence function of cardiac event-related death, cerebrovascular accidents, and pacemaker implantation.

RESULTS

There was no in-hospital mortality. Early postoperative complications were pacemaker implantation (4/153 [2.6%]), cerebrovascular accident (2/153 [1.3%]) with full recovery of both, and bleeding requiring surgical revision (2/153 [1.3%]). Overall freedom from AF at 7 years was 86% ± 4% (76.9% in n-PAF, 96.1% in PAF). Survival freedom from AF in patients without antiarrhythmic drugs in PAF and n-PAF groups was 79.1% and 52.2%, respectively.

CONCLUSIONS

Thoracoscopic surgical ablation of lone AF by means of an isolated left atrial box lesion provided an excellent long-term rhythm outcome, even in long-standing persistent AF. The isolated left atrial ablation showed an excellent safety profile with low incidence of pacemaker implantation and postoperative complications.

Can we collect health-related quality of life information from anticoagulated atrial fibrillation participants who have recently experienced a bleed? An observational feasibility study in primary and secondary care in Wales and through a UK online forum

OBJECTIVE

To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information.

DESIGN

Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys.

SETTING

Primary care, secondary care and via an online patient forum.

PARTICIPANTS

The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes - PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes - Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events.

RESULTS

We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study-14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study.

CONCLUSIONS

Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds.

TRIAL REGISTRATION NUMBER

The study is registered in the Clinicaltrials.gov database, NCT04921176.

Standardizing periprocedural anticoagulation management: a stewardship initiative

BACKGROUND

Study data indicates anticoagulant interruption peri-procedurally can increase the risk of anticoagulation-related bleeding and thrombosis. Management of anticoagulated patients during the peri-procedural period poses clinical challenges given the potential for thrombosis and bleeding in this complex, high risk population. As such, there is a need for enhanced emphasis on anticoagulated patient care throughout the peri-procedural period with the goal of optimizing patient safety and efficacy.

PURPOSE

To operationalize an effective, efficient, comprehensive, and standardized anticoagulation management peri-procedural process housed within the electronic health record (EHR).

DESIGN

The IPRO-MAPPP clinical decision support logic was adapted into a nurse-managed protocol to guide anticoagulation therapy use during the elective peri-procedural period at Bassett Medical Center, an Anticoagulation Forum Center of Excellence. A second phase of this initiative endorsed peri-procedural warfarin and bridging management by the Anticoagulation Management Service.

RESULTS

Outcomes revealed 30-day hospital or emergency department admissions remained at or below 1% of the surgical patient population, and below the published national standards for both phases of implementation. Further, no emergent anticoagulation reversal agent use was attributed to peri-procedural care during the assessment period.

CONCLUSIONS

The phased implementation of this Anticoagulation Stewardship initiative in elective peri-procedural anticoagulation management successfully describes the operationalization and demonstration of high-quality care and low provider practice variation from policy. The integration of clinical decision support systems, in consort with effective communication, via the EHR, provides stability, sustainability, and drives high quality care to optimize patient outcomes.

Detecting atrial fibrillation in the polysomnography-derived electrocardiogram: a software validation study

PURPOSE

The present study validated a software-based electrocardiogram (ECG) analysis tool for detection of atrial fibrillation (AF) and risk for AF using polysomnography (PSG)-derived ECG recordings.

METHODS

The Stroke Risk Analysis® (SRA®) software was applied to 3-channel ECG tracings from diagnostic PSG performed in enrolled subjects including a subgroup of subjects with previously documented AF. No subjects used positive airway pressure therapy. All ECG recordings were visually analyzed by a blinded cardiologist.

RESULTS

Of subjects enrolled in the study, 93 had previously documented AF and 178 of 186 had an ECG that could be analyzed by either method. In subjects with known history of AF, automated analysis using SRA® classified 47 out of 87 ECG as either manifest AF or showing increased risk for paroxysmal AF (PAF) by SRA® (sensitivity 0.54, specificity 0.86). On visual analysis, 36/87 ECG showed manifest AF and 51/87 showed sinus rhythm. Among the latter subgroup, an increased risk for PAF was ascribed by SRA® in 11 cases (sensitivity 0.22, specificity 0.78) and by expert visual analysis in 5 cases (sensitivity 0.1, specificity 0.90). Among 36/178 ECG with manifest AF on visual analysis, 33 were correctly identified by the SRA® software (sensitivity and specificity 0.92).

CONCLUSION

Sleep studies provide a valuable source of ECG recordings that can be easily subjected to software-based analysis in order to identify manifest AF and automatically assess the risk of PAF. For optimal evaluability of data, multiple channel ECG tracings are desirable. For assessment of PAF risk, the SRA® analysis probably excels visual analysis, but sensitivity of both methods is low, reflecting that repeated ECG recording remains essential.

Clinicians' adherence to guidelines for the preoperative management of direct oral anticoagulants in a tertiary hospital: a retrospective study

INTRODUCTION

Despite clear, relatively easy-to-use guidance, many clinicians find the preoperative management of direct oral anticoagulants (DOACs) challenging. Inappropriate management can delay procedures and lead to haemorrhagic or thromboembolic complications. We aimed to describe preoperative management practices regarding DOACs in a tertiary hospital and clinicians' adherence to in-house recommendations.

METHOD

We included all patients being treated with DOACs who underwent elective surgery in 2019 and 2020 (n = 337). In-house recommendations for perioperative management were largely comparable to the 2022 American College of Chest Physicians guidelines.

RESULTS

Typical patients were older adults with multiple comorbidities and high thrombotic risk stratification scores, and 65.6% (n = 221) had not undergone recommended preoperative anticoagulation management protocols. Patients operated on using local anaesthesia (adjusted OR = 0.30, 95%CI 0.14-0.66; p < 0.01) were less likely to have been treated following institutional recommendations, but no association between their procedure's bleeding risk and adherence was found. Clinicians' failures to adhere to recommendations mostly involved late or non-indicated interruptions of anticoagulation treatment (n = 89, 26.4%) or inappropriate heparin bridging (n = 54, 16.0%). Forty-five (13.3%) procedures had to be postponed. Incorrect preoperative anticoagulation management was directly responsible for 12/45 postponements (26.7% of postponements).

CONCLUSION

This study highlights clinicians' low adherence rates to institutional recommendations for patients treated with DOACs scheduled for elective surgery in a tertiary hospital centre. To the best of our knowledge, this is the first clinical study addressing the issue of clinicians' adherence to guidelines for the preoperative management of DOACs. Going beyond the issue of whether clinicians are knowledgeable about guidelines or have them available, this study questions how generalisable guidelines are in a tertiary hospital managing many highly polymorbid patients. Further studies should identify the causes of poor adherence.

Loss of the Atrial Fibrillation-Related Gene, Zfhx3, Results in Atrial Dilation and Arrhythmias

BACKGROUND

ZFHX3 (zinc finger homeobox 3), a gene that encodes a large transcription factor, is at the second-most significantly associated locus with atrial fibrillation (AF), but its function in the heart is unknown. This study aims to identify causative genetic variation related to AF at the ZFHX3 locus and examine the impact of Zfhx3 loss on cardiac function in mice.

METHODS

CRISPR-Cas9 genome editing, chromatin immunoprecipitation, and luciferase assays in pluripotent stem cell-derived cardiomyocytes were used to identify causative genetic variation related to AF at the ZFHX3 locus. Cardiac function was assessed by echocardiography, magnetic resonance imaging, electrophysiology studies, calcium imaging, and RNA sequencing in mice with heterozygous and homozygous cardiomyocyte-restricted Zfhx3 loss (Zfhx3 Het and knockout, respectively). Human cardiac single-nucleus ATAC (assay for transposase-accessible chromatin)-sequencing data was analyzed to determine which genes in atrial cardiomyocytes are directly regulated by ZFHX3.

RESULTS

We found single-nucleotide polymorphism (SNP) rs12931021 modulates an enhancer regulating ZFHX3 expression, and the AF risk allele is associated with decreased ZFHX3 transcription. We observed a gene-dose response in AF susceptibility with Zfhx3 knockout mice having higher incidence, frequency, and burden of AF than Zfhx3 Het and wild-type mice, with alterations in conduction velocity, atrial action potential duration, calcium handling and the development of atrial enlargement and thrombus, and dilated cardiomyopathy. Zfhx3 loss results in atrial-specific differential effects on genes and signaling pathways involved in cardiac pathophysiology and AF.

CONCLUSIONS

Our findings implicate ZFHX3 as the causative gene at the 16q22 locus for AF, and cardiac abnormalities caused by loss of cardiac Zfhx3 are due to atrial-specific dysregulation of pathways involved in AF susceptibility. Together, these data reveal a novel and important role for Zfhx3 in the control of cardiac genes and signaling pathways essential for normal atrial function.

Edoxaban treatment in atrial fibrillation in routine clinical care: One-year outcomes of the prospective observational ETNA-AF study in South Korean patients

BACKGROUND

The real-world outcomes of edoxaban treatment in patients with atrial fibrillation (AF) were analyzed in the ETNA-AF (Edoxaban Treatment in Routine Clinical Practice) study involving data from multiple regional registries. This report addresses effectiveness and safety of edoxaban in the Korean ETNA-AF population.

METHODS

One-year data from 1887 Korean ETNA-AF participants were analyzed according to edoxaban dose and patient age and compared with results of other ETNA-AF registries.

RESULTS

Approximately 70% of patients received the recommended doses of edoxaban (60 mg/30 mg); non-recommended 60 mg and 30 mg doses were prescribed to 9.6% and 19.8% of the patients, respectively. The proportions of reference age (<65 years), youngest-old (65-74 years) and middle-old/oldest-old (≥75 years) groups were 21.4%, 40.2%, and 38.4%, respectively. Incidence of major or clinically relevant nonmajor bleeding was similar within dose (0.57%-1.71%) and age subgroups (1.26%-1.63%). Incidence of net clinical outcome, a composite of stroke, systemic embolic event, major bleeding, and all-cause mortality, was also comparable among dose subgroups (1.14%-3.10%) and age subgroups (2.28%-2.78%). The percentage of Korean patients receiving non-recommended 30 mg (19.8%) was over twice that of the European population (8.4%). However, the clinical outcomes were generally similar among different populations included in the ETNA-AF study.

CONCLUSIONS

The outcomes in the Korean ETNA-AF population are like those in the global ETNA-AF population, with overall low event rates of stroke, major bleeding and all-cause mortality across age and dose subgroups. Edoxaban can be used effectively and safely in specific populations of Korean AF patients, including the elderly.

The effect of treatment strategy on long-term follow-up results in patients with nonvalvular atrial fibrillation in Turkey: AFTER-2 subgroup analysis

BACKGROUND

We performed a subanalysis of the data from the AFTER-2 registry. In our study, we aimed to compare the long-term follow-up results of nonvalvular atrial fibrillation (NVAF) patients in Turkey according to their treatment strategies.

METHODS

All consecutive patients older than 18 years of age who presented to cardiology outpatient clinics, had at least one AF attack and did not have rheumatic mitral valve stenosis or prosthetic heart valve disease were included in our prospective study. The patients were divided into two groups as rhythm control and rate control. Stroke, hospitalization and death rates were compared between the groups.

RESULTS

A total of 2592 patients from 35 centers were included in the study. Of these patients, 628 (24.2%) were in the rhythm control group and 1964 (75.8%) in the rate control group. New-onset ischemic cerebrovascular disease or transient ischemic attack (CVD/TIA) was detected at a lower rate in the rhythm control group (3.2% vs. 6.2% p = 0.004). However, there was no significant difference in one-year and five-year mortality rates (9.6% versus 9.0%, p = 0.682 and 31.8% versus 28.6%, p = 0.116, respectively). Hospitalization were found to be significantly higher in patients with rhythm control group (18% vs. 13%, p = 0.002).

CONCLUSION

It was found that rhythm control strategy is preferred in AF patients in Turkey. We found a lower rate of ischemic CVD/TIA in patients in the rhythm control group. Although no difference was observed in mortality rates, we found a higher rate of hospitalization in the rhythm control group.

Evaluating the association between dietary salt intake and the risk of atrial fibrillation using Mendelian randomization

Background

Previous studies have suggested that dietary salt intake affects atrial fibrillation (AF); however, the causal association between them still remains unclear. Thus, we conducted this Mendelian randomization (MR) study to explore the correlation between them.

Methods

Genetic instruments for dietary salt intake were from a genome-wide association study (GWAS), which included 462,630 European individuals. Summary-level data for AF were obtained from another published GWAS (22,068 cases and 116,926 controls). The inverse-variance weighting (IVW) method was performed as the primary MR analysis. Multiple MR methods, including Robust Adjusted Profile Score (MR-RAPS), maximum likelihood estimation, and Mendelian randomization pleiotropy residual sum and outlier test (MR-PRESSO) were conducted as complementary analyses. The MR-Egger regression intercept and MR-PRESSO global test were conducted to test potential horizontal pleiotropy. The IVW (Q) method and MR-Egger were performed to detect heterogeneity.

Results

Our results suggested that high dietary salt intake was significantly correlated with increased risk of AF [IVW: odds ratio (OR), 1.36; 95% confidence interval (CI), 1.04–1.77; p = 2.25E-02]. The maximum likelihood estimation (OR, 1.37; 95% CI, 1.05–1.78; p = 2.09E-02), MR-RAPS (OR, 1.37; 95% CI, 1.03–1.81; p = 2.79E-02), and MR-PRESSO method (OR, 1.36; 95% CI, 1.05–1.76; p = 2.37E-02) also showed that dietary salt intake was significantly correlated with the risk of AF.

Conclusion

The findings of this study provide robust evidence supporting the correlation between dietary salt intake and the risk of AF. Future studies are required to further clarify this relationship and translate the findings into clinical and public health practice.

Rhythm outcomes of minimally-invasive off-pump surgical versus catheter ablation in atrial fibrillation: A meta-analysis of reconstructed time-to-event data

BACKGROUND

Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment.

METHODS

A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach.

RESULTS

Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256).

CONCLUSIONS

The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA.

GAS6-AS1, a long noncoding RNA, functions as a key candidate gene in atrial fibrillation related stroke determined by ceRNA network analysis and WGCNA

BACKGROUND

Stroke attributable to atrial fibrillation (AF related stroke, AFST) accounts for 13 ~ 26% of ischemic stroke. It has been found that AFST patients have a higher risk of disability and mortality than those without AF. Additionally, it's still a great challenge to treat AFST patients because its exact mechanism at the molecular level remains unclear. Thus, it's vital to investigate the mechanism of AFST and search for molecular targets of treatment. Long non-coding RNAs (lncRNAs) are related to the pathogenesis of various diseases. However, the role of lncRNAs in AFST remains unclear. In this study, AFST-related lncRNAs are explored using competing endogenous RNA (ceRNA) network analysis and weighted gene co-expression network analysis (WGCNA).

METHODS

GSE66724 and GSE58294 datasets were downloaded from GEO database. After data preprocessing and probe reannotation, differentially expressed lncRNAs (DELs) and differentially expressed mRNAs (DEMs) between AFST and AF samples were explored. Then, functional enrichment analysis and protein-protein interaction (PPI) network analysis of the DEMs were performed. At the meantime, ceRNA network analysis and WGCNA were performed to identify hub lncRNAs. The hub lncRNAs identified both by ceRNA network analysis and WGCNA were further validated by Comparative Toxicogenomics Database (CTD).

RESULTS

In all, 19 DELs and 317 DEMs were identified between the AFST and AF samples. Functional enrichment analysis suggested that the DEMs associated with AFST were mainly enriched in the activation of the immune response. Two lncRNAs which overlapped between the three lncRNAs identified by the ceRNA network analysis and the 28 lncRNAs identified by the WGCNA were screened as hub lncRNAs for further validation. Finally, lncRNA GAS6-AS1 turned out to be associated with AFST by CTD validation.

CONCLUSION

These findings suggested that low expression of GAS6-AS1 might exert an essential role in AFST through downregulating its downstream target mRNAs GOLGA8A and BACH2, and GAS6-AS1 might be a potential target for AFST therapy.

Factors influencing self-management behavior during the "Blanking Period" in patients with atrial fibrillation: A cross-sectional study based on the information-motivation-behavioral skills model

BACKGROUND

Atrial fibrillation (AF) is becoming increasingly common. Effective self-management during the "Blanking Period" is critical. The Information-Motivation-Behavioral skills (IMB) model can be used to study health behaviors in chronic disease patients, but it has not been studied in AF patients.

OBJECTIVE

The goal of this study was to explore the influencing factors and interaction pathways of self-management behavior in AF patients during the "Blanking Period" using the IMB model.

METHODS

From June to December 2021, a cross-sectional design was conducted. Patients with AF during the "Blanking Period" (N=220) were recruited. They filled out several quantitative questionnaires, including the Jessa Atrial Fibrillation Knowledge Questionnaire, the Confidence in Atrial Fibrillation Management Scale, the Perceived Social Support Scale, the All Aspects of Health Literacy Scale, and the Self-care Scale for Chronic Atrial Fibrillation Patients. Data were analyzed using correlation analysis, multiple regression analysis, and path analysis.

RESULTS

Total score of self-management behavior was (33.83 ± 10.66). AF knowledge (β = 0.252, P < 0.001), self-management confidence (β = 0.219, P < 0.001), social support (β = 0.291, P < 0.001), and health literacy (β = 0.262, P < 0.001) were all positively correlated with patients' self-management behavior, accounting for 66.50 percent of the total variance.

CONCLUSIONS

During the "Blanking Period", the IMB model can be used to predict the factors that influence self-management behavior in AF patients. By using IMB model, interventions targeting patient-specific influencing factors could improve self-management behavior and quality of life in AF patients.

Impact of a dedicated center for atrial fibrillation on resource utilization and costs

BACKGROUND

Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays.

HYPOTHESIS

We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care.

METHODS

The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics.

RESULTS

We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days.

CONCLUSION

Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.

Direct Oral Anticoagulant (DOAC) Dosing in Patients with Non-valvular Atrial Fibrillation (NVAF) in the United Kingdom: A Retrospective Cohort Study Using CPRD Gold Database

INTRODUCTION

Per-label dosing of direct oral anticoagulants (DOACs) is important for the prevention of stroke and systemic embolism among patients with non-valvular atrial fibrillation (NVAF), especially those with poor renal function, advanced age, low body weight or concomitant P-glycoprotein inhibitors. The study described DOAC use and dosing patterns in patients with NVAF in the UK.

METHODS

Using Clinical Practice Research Datalink (CPRD Gold), patients' profiles were described at DOAC initiation (1 January 2016-31 March 2021) and followed for a mean [standard deviation (SD)] 2 (1) years. Patients were categorised as under-dosing: received a lower dose with no indication for a reduced dose; over-dosing: received a standard dose with an indication for a reduced dose; per-label dosing, according to Summary Product Characteristics (SmPC).

RESULTS

Forty thousand seven hundred forty-four adult patients with NVAF were identified (mean age: 75.3 (11.2) years; males: 55.4%); 22,827 (56.0%) initiated treatment with apixaban, 930 (2.3%) dabigatran, 5633 (13.8%) edoxaban and 11,354 (27.9%) rivaroxaban. Baseline Charlson comorbidity index ≥ 4 was 65.1%; CHA₂DS₂-VASc score ≥ 4 was 22.5%; HAS-BLED score ≥ 3 was 18.3%; ~ 2% had prior major bleed and 4.4% a stroke ≤ 2 years before DOAC initiation. Overall, 18.0% of patients received incorrect dosing (~ one in five). Under-dosing was highest for dabigatran (156, 16.8%) and over-dosing was highest for rivaroxaban (1084, 9.6%). Per-label dosing was highest for edoxaban (4773, 84.7%), followed by apixaban (18,756, 82.2%), rivaroxaban (9161, 80.7%) and dabigatran (732, 78.7%). Treatment persistence (no switching or discontinuation) was 79% among edoxaban users, followed by 75% for apixaban, 69% for rivaroxaban and 62% for dabigatran. About 15% of dabigatran users, 10% of rivaroxaban users, 5% of apixaban users and 4% of edoxaban users switched treatment to another DOAC during follow-up.

CONCLUSION

Although most patients received per-label dosing, ~ one in five patients was incorrectly dosed with DOAC, which may lead to serious clinical consequences and increased healthcare burden.

Cost effectiveness of rivaroxaban versus warfarin among nonvalvular atrial fibrillation patients in Saudi Arabia: A Single-Center retrospective cohort study

Background

Rivaroxaban is a novel oral anticoagulant (NOAC) that is commonly used for stroke prevention among patients with atrial fibrillation (AF). However, its cost effectiveness in reducing the risk of hospitalization and mortality in comparison to warfarin among nonvalvular AF patients in Saudi Arabia is largely unknown.

Methods

This was a single-center retrospective chart review of adult patients (≥18 years) with nonvalvular AF who were treated with warfarin or rivaroxaban for at least 12 months. Patients with mitral valve stenosis were excluded from the study. Multiple logistic regression was conducted to examine the risk of hospitalization and mortality as a composite outcome, and all annual healthcare costs were captured. Inverse probability treatment weighting with bootstrapping was conducted to determine the mean costs and effectiveness rates.

Results

Two-hundred and twenty-six patients (142 on rivaroxaban and 84 on warfarin) met the inclusion criteria and were included in the analysis. Most of the patients were females (65.91 %), had diabetes (50.57 %) and hypertension (73.76 %), and with a mean age of 68.95 ± 12.55 years. No significant difference in the odds of the composite outcome for rivaroxaban versus warfarin was found (OR = 0.785, 95 % CI = [0.427-1.446], p = 0.443). Rivaroxaban resulted in a mean annual cost saving of $13,260.79 with an 87.65 % confidence level that it would be more effective than warfarin with a mean difference in effectiveness rate of 0.168 % (95 % CI [-5.210-18.36]).

Conclusion

Rivaroxaban was associated with lower direct medical costs and non-inferior effectiveness among nonvalvular AF patients in comparison to warfarin.

Ability to adapt to seasonal temperature extremes among atrial fibrillation patients. A nation-wide study of hospitalizations in Israel

BACKGROUND

In recent years, temperature fluctuations and adverse weather events have become major concerns, influencing overall mortality and morbidity. While the association between extreme temperatures and atrial fibrillation (AF) has been supported by research, there is limited evidence on the ability of AF patients to adapt to the changing temperatures. We explored this question among AF patients in Israel featured by extreme temperature conditions.

METHODS

We examined the association between exposure to extreme temperatures and hospitalizations related to AF in a nationwide cohort in Israel. A case-crossover design with a distributed nonlinear model (DLNM) was applied to assess possible effects of temperature fluctuations during each season. We considered the 7 days prior to the event as the possible window period.

RESULTS

During 2004-2018 we recorded a total of 54,909 hospitalizations for AF. Low temperatures in winter and high in summer adversely affected AF-related hospitalizations. The effect recorded for the first few weeks of each season was of higher magnitude and decreased or faded off completely as the seasons progressed (OR in winter: from 1.14, 95%CI 0.98, 1.32 to 0.90, 95%CI: 0.77, 1.06;OR in summer: from 1.95, 95%CI: 1.51, 2.52 to 1.22, 95%CI: 0.90, 1.65). Patients living in the south region and patients with low socioeconomic status were more susceptible to extreme temperatures.

CONCLUSIONS

Although extreme hot and cold temperatures are associated with an increased risk of hospitalization for AF, the patients are likely to adapt to temperature change over the course of the first weeks of the season.

Atrial fibrillation and stroke

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Comparison of radiofrequency ablation and antiarrhythmic drug for the treatment of atrial fibrillation: A protocol for systematic review and meta-analysis

BACKGROUND

Antiarrhythmic drugs and radiofrequency ablation are first-line treatments of atrial fibrillation, however, there exists a paucity of data regarding the potential benefit of different catheter ablation technologies versus antiarrhythmic drugs as an early rhythm strategy. We performed a protocol for systematic review and meta-analysis to compare the efficacy and safety of radiofrequency ablation and antiarrhythmic drugs for the treatment of atrial fibrillation.

METHODS

This review protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022375095). Additionally, this review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols 2015 Statement. A computerized literature search will be performed in the following electronic databases from their inceptions to November 2022: PubMed, EMBASE, MEDLINE, Cochrane Central Register of Controlled Clinical Trials, China Knowledge Resource Integrated Database, Wanfang Data Information, and Weipu Database for Chinese Technical Periodicals. The risk of bias will be assessed independently by 2 authors using the Cochrane tool of risk of bias. All statistical analyses will be conducted using the software program Review Manager version 5.3.

RESULTS

The results of this systematic review will be published in a peer-reviewed journal.

CONCLUSION

This study provides evidence of the comparison of radiofrequency ablation and antiarrhythmic drugs for the treatment of atrial fibrillation.

Health care professionals' perceptions about atrial fibrillation care in the Brazilian public primary care system: a mixed-methods study

BACKGROUND

Atrial fibrillation (AF) negatively impacts health systems worldwide. We aimed to capture perceptions of and barriers and facilitators for AF care in Brazilian primary care units (PCUs) from the perspective of healthcare professionals (HCPs).

METHODS

This mixed-methods, cross-sectional study utilised an exploratory sequential design, beginning with the quantitative data collection (up to 18 closed questions) immediately followed by a semi-structured interview. HCPs were recruited from 11 PCUs in the Sao Paulo region and included managers, physicians, pharmacists, nurses and community health agents. Descriptive statistics were used to present findings from the quantitative questionnaire and inductive analysis was used to identify themes from the qualitative data.

RESULTS

One hundred seven HCPs were interviewed between September 2019 and May 2020. Three main themes were identified that encapsulated barriers and facilitators to AF care: access to care (appointments, equipment/tests and medication), HCP and patient roles (HCP/patient relationship and patient adherence) and the role of the organisation/system (infrastructure, training and protocols/guidelines). Findings from the qualitative analysis reinforced the quantitative findings, including a lack of AF-specific training for HCPs, protocols/guidelines on AF management, INR tests in the PCUs, patient knowledge of AF management and novel oral anticoagulants (NOACs) as key barriers to optimal AF care.

CONCLUSIONS

Development and implementation of AF-specific training for PCU HCPs are needed in Brazil, along with evidence-based protocols and guidelines, educational programmes for patients, better access to INR tests for patients taking warfarin and availability of NOACs.

Restoring the Autonomic Balance in an Atrial Fibrillation Rat Model by Electroacupuncture at the Neiguan Point

OBJECTIVES

Autonomic nervous activity imbalance plays an important role in atrial fibrillation (AF). AF can be treated by acupuncture at the Neiguan point (PC6), but the mechanism remains elusive. Here, we investigated autonomic nervous system activity in electroacupuncture (EA) at PC6 in a rat AF model.

MATERIAL AND METHODS

In this study, we established a rat AF model via tail vein injection with ACh-CaCl2 for ten consecutive days with or without EA at PC6. AF inducibility and heart rate variability (HRV) were assessed by electrocardiogram. Next, we completed in vivo recording of the activity of cervical sympathetic and vagal nerves, respectively. Finally, the activities of brain regions related to autonomic nerve regulation were assessed by c-Fos immunofluorescence and multichannel recording.

RESULTS

EA at PC6 decreased AF inducibility and prevented changes in HRV caused by ACh-CaCl2 injection. Meanwhile, EA at PC6 reversed the increased sympathetic and decreased vagal nerve activity in AF rats. Furthermore, EA treatment downregulated increased c-Fos expression in brain regions, including paraventricular nucleus, rostral ventrolateral medulla, and dorsal motor nucleus of the vagus in AF, while c-Fos expression in nucleus ambiguus was upregulated with EA.

CONCLUSION

The protective effect of EA at PC6 on AF is associated with balance between sympathetic and vagal nerve activities.

Effect of angiotensin receptor-neprilysin inhibitor on atrial electrical instability in atrial fibrillation

Background and objective

Around 33.5 million patients suffered from atrial fibrillation (AF), causing complications and increasing mortality and disability rate. Upstream treatment for AF is getting more popular in clinical practice in recent years. The angiotensin receptor-neprilysin inhibitor (ARNI) is one of the potential treatment options. Our study aimed to investigate the effect of ARNI on atrial electrical instability and structural remodeling in AF.

Methods

Our research consisted of two parts - a retrospective real-world clinical study and an animal experiment on calmness to verify the retrospective founding. In the retrospective study, we reviewed all patients (n = 110) who had undergone the first AF ablation from 1 August 2018 to 1 March 2022. Patients with ARNI (n = 36) or angiotensin II receptor antagonist (ARB) (n = 35) treatment were enrolled. Their clinical data, ultrasound cardiogram (UCG) and Holter parameters were collected before radiofrequency catheter ablation (RFCA) as baseline and at 24-week follow-up. Univariate and multivariate logistic regression analysis were performed. In the animal experiment, we established an AF model (n = 18) on canines by rapid atrial pacing. After the successful procedure of pacing, all the 15 alive beagles were equally and randomly assigned to three groups (n = 5 each): Control group, ARB group, and ARNI group. UCG was performed before the pacing as baseline. Physiological biopsy, UCG, and electrophysiological study (EPS) were performed at 8-week.

Results

Clinical data showed that the atrial arrhythmia rate at 24-week was significantly lower in ARNI group compared to ARB group (P < 0.01), and ARNI was independently associated with a lower atrial arrhythmia rate (P < 0.05) at 24-week in multivariate regression logistic analysis. In the animal experiment, ARNI group had a higher atrial electrical stability score and a shorter AF duration in the EPS compared to Control and ARB group (P < 0.05). In the left atrium voltage mapping, ARNI group showed less low voltage and disordered zone compared to Control and ARB group. Compared to Control group, right atrium diameter (RAD), left ventricle end-diastolic volume index (LVEDVI), E/A, and E/E' were lower in ARNI group (P < 0.05) at the 8-weeks follow-up, while left atrium ejection fraction (LAEF) and left ventricle ejection fraction (LVEF) were higher (P < 0.01). Compared to ARB group, LVEF was higher in ARNI group at the 8-week follow-up (P < 0.05). ARB and ARNI group had a lower ratio of fibrotic lesions in the left atrium tissues compared to Control group (P < 0.01), but no difference was found between the ARB and the ARNI group.

Conclusion

ARNI could reduce atrial electrical instability in AF in comparison with ARB in both retrospective study and animal experiment.

Perioperative Management of Vitamin K Antagonists and Direct Oral Anticoagulants: A Systematic Review and Meta-analysis

BACKGROUND

The management of patients who are receiving chronic oral anticoagulation therapy and require an elective surgery or an invasive procedure is a common clinical scenario.

RESAERCH QUESTION

What is the best available evidence to support the development of American College of Chest Physicians guidelines on the perioperative management of patients who are receiving long-term vitamin K agonist (VKA) or direct oral anticoagulant (DOAC) and require elective surgery or procedures?

STUDY DESIGH AND METHODS

A literature search including multiple databases from database inception through July 16, 2020, was performed. Meta-analyses were conducted when appropriate.

RESULTS

In patients receiving VKA (warfarin) undergoing elective noncardiac surgery, shorter (< 5 days) VKA interruption is associated with an increased risk of major bleeding. In patients who required VKA interruption, heparin bridging (mostly with low-molecular-weight heparin [LMWH]) was associated with a statistically significant increased risk of major bleed (relative risk [RR], 9.1; 95% CI, 1.62-51.3), representing a very low certainty of evidence (COE). Compared with DOAC interruption 1 to 4 days before surgery, continuing DOACs was not associated with a statistically significant difference in the risk of bleeding, representing a very low COE. Continuing dabigatran was associated with a statistically significant increased risk of thromboembolism (RR, 2.2; 95% CI, 1.3-3.8), representing a low COE. In patients who needed DOAC interruption, bridging with LMWH was associated a with statistically significant increased risk of minor bleeding compared with no bridging (RR, 1.7; 95% CI, 1.13-2.7), representing a low COE.

INTERPRETATION

The certainty in the evidence supporting the perioperative management of anticoagulants remains limited. No high-quality evidence exists to support the practice of heparin bridging during the interruption of VKA or DOAC therapy for an elective surgery or procedure or for the practice of interrupting VKA therapy for minor procedures, including cardiac device implantation, or continuation of a DOAC vs short-term interruption of a DOAC (1-4 days) in the perioperative period.

Prevalence of atrial fibrillation in Northern Sri Lanka: a study protocol for a cross-sectional household survey

INTRODUCTION

Atrial fibrillation (AF) is the most common arrhythmia globally. It is associated with a fivefold risk in stroke, but early diagnosis and effective treatment can reduce this risk. AF is often underdiagnosed, particularly in low-income and middle-income countries (LMICs) where screening for AF is not always feasible or considered common practice in primary care settings. Epidemiological data on AF in LMICs is often incomplete particularly in vulnerable populations. This LMIC research collaborative aims to identify the prevalence of AF in the Northern Sri Lankan community.

METHODS AND ANALYSIS

A cross-sectional household survey piloted and codesigned through a series of community engagement events will be administered in all five districts in Northern Province, Sri Lanka. A multistage cluster sampling approach will be used starting at district level, then the Divisional Secretariats followed by Grama Niladhari divisions. Twenty households will be selected from each cluster. The study aims to recruit 10 000 participants aged 50 years or older, 1 participant per household. Demographic and socioeconomic characteristics, well-being and lifestyle and anthropometric measurements will be collected using a digital data platform (REDCap, Research Electronic Data Capture) by trained data collectors. Participants will be screened for AF using a fingertip single-lead ECG via a smartphone application (AliveCor) with rhythm strips reviewed by a consultant cardiologist. Prevalence of AF and risk factors will be established at province and district-levels. Adjusted ORs and population attributable fractions for AF risk factors will be determined.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Review Committee of Faculty of Medicine at University of Jaffna. Written informed consent will be obtained from all participants. Findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences. The findings will enable early treatment for new AF diagnoses and inform interventions to improve community-based management of AF in LMICs.

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Executive Summary: Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Incidence of Osteoporosis in Primary Care Patients with Atrial Fibrillation Receiving Different Oral Anticoagulants

Background: Studies investigating the association between the use of oral anticoagulants (OACs) and osteoporosis are limited. We aimed to determine the risk of osteoporosis in patients with atrial fibrillation (AF) and receiving different OACs. Methods: We performed a population-based cohort study using a nationwide primary care dataset, MedicineInsight. Patients aged between 18 and 111 years with AF and newly recorded OAC prescriptions between 1 January 2013 and 31 December 2017 were included and followed until 31 December 2018. We applied propensity score matching to control for patients’ baseline characteristic differences before calculating adjusted hazard ratios (aHRs) for a new diagnosis of osteoporosis, using Cox proportional hazard models. Results: A total of 18,454 patients (1714 prescribed dabigatran, 5871 rivaroxaban, 5248 apixaban and 5621 warfarin) were included. Of these, 39.5% were females, and the overall mean age (standard deviation [SD] was 73.2(10.3) years. Over a mean follow-up of 841 days, 1627 patients (1028 receiving direct-acting oral anticoagulants (DOACs) and 599 warfarin) had a newly recorded diagnosis of osteoporosis. The weighted incidence rates (95% confidence interval; CI) per 100 person-years of treatment were 5.0 (4.7−5.2) for warfarin, 4.3 (3.8−4.8) for dabigatran, 3.6 (3.3−3.8) for rivaroxaban, and 4.4 (4.0−4.7) for apixaban. Overall, DOAC use was associated with a significantly lower risk of a new diagnosis of osteoporosis than warfarin use (aHR, 0.79, 95% confidence interval (CI) 0.74−0.85; p < 0.001). Use of each individual DOAC was associated with a significantly lower risk of osteoporosis compared with warfarin (aHRs, 0.75, 95% CI 0.69−0.82 for rivaroxaban; 0.78, 95% CI 0.71−0.86 for apixaban; 0.88, 95% CI 0.77−0.99 for dabigatran). Conclusion: Compared with warfarin, the use of DOACs was associated with a significantly lower risk of developing osteoporosis in patients with AF. This association remained significant when individual DOACs were compared with warfarin.

Cardiac resynchronization therapy in the presence of total atrioventricular block reduces long‐lasting atrial fibrillation episodes

Background

There is an ongoing debate on how cardiac resynchronization therapy (CRT) in the presence of total AV block affects atrial fibrillation (AF) episodes and symptoms in patients with AF.

Methods

Seventy‐five patients with symptomatic, drug and ablation refractory AF received, irrespective of their left ventricular ejection fraction (EF), either a CRT device and underwent subsequent atrioventricular node (AVN) ablation or already had a total AV block and underwent CRT upgrade. Long‐lasting AF episodes (>48 h), left ventricular ejection fraction (LVEF), left ventricular end‐diastolic diameter (LVEDD), left atrial diameter (LAD), NTproBNP levels, EHRA score, and NYHA class had been monitored on the follow‐up.

Results

The number of patients experiencing long‐lasting AF episodes (>48 h) and symptoms decreased significantly within 24 months after CRT implantation in the presence of total AV block (p < .001) from 57 (76%) to 25 (33.3%). Mean LAD decreased from 52 mm (IQR 48.0–56.0) to 48 mm (IQR 42.0–52.0, p < .001) and LVEDD from 54 mm (IQR 49.0–58.0) to 51 mm (IQR 46.5–54.0, p < .001).

Conclusion

A combination of total AVN block and biventricular pacing markedly reduces long‐lasting AF episodes, symptoms, left atrial diameter, and left ventricular end‐diastolic diameter.

Comparing Patient and Provider Experiences with Atrial Fibrillation to Highlight Gaps and Opportunities for Improving Care

BACKGROUND

Atrial fibrillation (AF), the most common abnormal heart rhythm, places a considerable burden on patients, providers, and the US healthcare system.

OBJECTIVE

The purpose of this qualitative study was to compare patients' and providers' interpretations and responses to AF symptoms and to identify where treatment can be improved to better address patient needs and well-being.

DESIGN

Qualitative design using focus groups with patients (3 groups) and providers (3 groups).

PARTICIPANTS

Patients with physician-confirmed AF (n=29) and cardiologists, primary care physicians, and cardiac nurses (n=24).

APPROACH

Focus groups elicited patient and provider perspectives regarding the symptom experience of AF, treatment goals, and gaps in care. Patient and provider transcripts were analyzed separately, using a thematic content analysis approach, and then compared.

KEY RESULTS

While patients and providers described similar AF symptoms, patients' illness experiences included a wider range of symptoms that elicited anxiety and impacted quality of life (QOL) across many biopsychosocial domains. Patients and providers prioritized different treatment goals. Providers tended to focus on controlling symptoms congruent with objective findings, minimizing stroke risk, and restoring sinus rhythm. Patients focused on improving QOL by reducing medication use or procedures. Both patients and providers struggled with patients' cardiac-related anxiety. Patients expressed an unmet need for education and support.

CONCLUSION

Patients with AF experience a range of symptoms and QOL issues. While guidelines recommend shared-decision making, discordance between patient and provider perspectives on the importance, priority, and impact of patients' perceived AF symptoms and consequent cardiac anxiety may result in differing treatment priorities. Starting from a perspective that contextualizes AF in the broader context of patients' lives, prioritizes QOL, and addresses symptom-specific anxiety as a prime concern may better address patients' unmet needs.

A Novel Orderset Driven Emergency Department Atrial Fibrillation Algorithm to Increase Discharge and Risk-appropriate Anticoagulation

INTRODUCTION

Patients with atrial fibrillation (AF) are frequently admitted from the emergency department (ED), and when discharged, are not reliably prescribed indicated anticoagulation. We report the impact of a novel computerized ED AF pathway orderset on discharge rate and risk-appropriate anticoagulation in patients with primary AF.

METHODS

The orderset included options for rate and rhythm control of primary AF, structured risk assessment for thrombotic complications, recommendations for anticoagulation as appropriate, and follow up with an electrophysiologist. All patients discharged from the ED in whom the AF orderset was utilized over an 18-month period comprised the primary study population. The primary outcome was the rate of appropriate anticoagulation or not according to confirmed CHADS-VASC and HASBLED scores. Additionally, the percentage of primary AF patients discharged directly from the ED was compared in the 18-month periods before and after introduction of the orderset.

RESULTS

A total of 56 patients, average age 57.8 years and average initial heart rate 126 beats/minute, were included in the primary analysis. All 56 (100%; 95% confidence interval, 94-100) received guideline-concordant anticoagulation. The discharge rates in the pre- and postorderset implementation periods were 29% and 41%, respectively (95% confidence interval for 12% difference, 5-18).

CONCLUSIONS

Our novel AF pathway orderset was associated with 100% guideline-concordant anticoagulation in patients discharged from the ED. Availability of the orderset was associated with a significant increase in the proportion of ED AF patients discharged.

Systemic lupus erythematosus increases risk of incident atrial fibrillation: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Patients with systemic lupus erythematosus (SLE) might have increased risk of atrial fibrillation (AF) as a result of initiating chronic and systematic inflammation. However, the prevalence of AF in patients with SLE have not been well quantified. The aim of this systematic review and meta-analysis was to collect and identify available clinical data to explore this possible correlation.

METHODS

Articles were searched based on electronic databases (PubMed, Scopus, ScienceDirect, Cochrane Library, Web of Science). Review Manager 5.4 was used to perform meta-analysis of all selected studies and subgroup analyses (pooled separately by geographical distribution). Pooled risk ratio (RR) and 95% confidence intervals (95% CI) were calculated by random-effect model or fix-effect model.

RESULTS

Six cohort studies were involved in this meta-analysis, including 311 844 participants, 78 134 cases of SLE and 347 883 non-SLE controls. Pooled studies indicated increased risk of AF development in patients with SLE compared to participants without SLE (I²  = 96%, RR = 1.85; 95% CI: 1.23-2.79; P = .003). Four clinical trials including only European/ American populations were analyzed in subgroups. Heterogeneity analysis showed that I²  = 9% and there was an increase in the risk of AF development in European/ American patients with SLE (RR = 1.79; 95% CI: 1.61-1.98; P < .001), while in 2 Korean studies, the heterogeneity was 98% and there was no correlation between AF and SLE (RR = 1.81, 95% CI: 0.39-8.43). Five clinical studies were involved in subgroup analysis after excluding the Beak study, with I²  = 96% and they suggested that SLE increased the risk of AF development (RR = 2.13, 95% CI: 1.42-3.21, P = .002).

CONCLUSION

This meta-analysis suggested that SLE may be a risk factor for AF development and the results may vary with geographic distribution.

Atrioventricular node ablation and pacing for atrial tachyarrhythmias: A meta-analysis of postoperative outcomes

BACKGROUND

Atrioventricular node ablation (AVNA) and pacemaker (PM) is performed in symptomatic atrial fibrillation (AF) unresponsive to medical treatment and percutaneous ablation. This meta-analysis evaluated results after AVNA and PM.

METHODS

Primary and secondary endpoints were early/late overall/cardiac-related mortality and early/late postoperative complications. Meta-regression explored mortality and preoperative characteristics relation.

RESULTS

We selected 93 studies with 11,340 patients: 9105 right ventricular (RV)-PM, and 2235 biventricular PM (cardiac resynchronization therapy, CRT). Malignant arrhythmia (2.5%), heart failure (2.4%), and lead dislodgement (2.0%) were most common periprocedural complications. Pooled estimated 30-day mortality was 1.08% (95%CI:0.65-1.77). At 19.9 months median follow-up (IQR: 10.3-34 months), rehospitalization (0.79%/month) and heart failure (0.48%/month) were the most frequent complications. Overall mortality incidence rate (IR) was 0.43%/month (95%CI:0.36-0.51), and cardiac death IR 0.27%/month (95%CI:0.22-0.32). No mortality determinants emerged in the AVNA CRT subgroup. AVNA RV-PM subgroup univariable meta-regression showed inverse relationship between age, ejection fraction (EF), and late cardiac death (Beta = -0.0709 ± 0.0272; p = 0.0092 and Beta = -0.0833 ± 0.0249; p = 0.0008). Coronary artery disease (CAD) was directly associated to follow-up overall/cardiac mortality at univariable (Beta = 0.0550 ± 0.0136, p < 0.0001; Beta = 0.0540 ± 0.0130, p < 0.0001) and multivariable (Beta = 0.0460 ± 0.0189, p = 0.152; Beta = 0.0378 ± 0.0192, p = 0.0491) meta-regression.

CONCLUSIONS

Solid long-term evidence supporting AVNA and pace is lacking. Younger patients with reduced LVEF% have increased follow-up cardiac mortality after AVNA RV and may require CRT. Alternative strategies to maintain sinus rhythm and ventricular synchronism should be compared to AVNA to support future treatment strategies.

Mechanism of Action of Zhi Gan Cao Decoction for Atrial Fibrillation and Myocardial Fibrosis in a Mouse Model of Atrial Fibrillation: A Network Pharmacology-Based Study

Atrial fibrillation (AF), a commonly seen cardiac disease without optimal curative treatment option, is usually treated by traditional Chinese medicine in China. The Zhi-Gan-Cao decoction (ZGCD) is an alternative medicine for clinical use and has definitive effects. It remains to be defined regarding the specific components and related mechanisms of ZGCD for the treatment of AF. We determined the primary constituents and major targets of the herbs in ZGCD using the TCMSP, HERB, and BATMAN-TCM databases. The UniProt databank database amended and combined the prospective names to supply objective data and records. Every target connected to AF was generated using the GeneCards databank, Drugbank database, TTD, Disgenet database, and OMIM. After identifying possible common targets between ZGCD and AF, the interface network illustration “ZGCD component-AF-target” was created using Cytoscape. We obtained 175 constituents and 839 targets for seven herbal drug categories in the ZGCD and identified 1008 targets of AF. After merging and removing repetitions, 136 collective targets between the ZGCD and AF were removed using the Cytoscape system. These renowned targets were generated from 38 suitable components from among the 157 components. GO enhancement examination and KEGG enrichment analysis by Metascape identified the close connection between the critical target genes and 20 signaling pathways. Then, we injected isoproterenol subcutaneously into the mouse and gave gavage with roasted licorice soup. Two weeks later, mouse were processed and sampled for testing. The results of HE and Masson staining showed that ZGCD effectively alleviated the degree of myocardial fibrosis. As indicated by qRT-PCR and Western blotting, ZGCD significantly reduced COL1A1, COL1A2, COL3A1, and TGF-β1 in myocardial fibrotic tissue to reduce myocardial fibrosis and treat AF by interfering with the expression of COL1A1, COL1A2, COL3A1, and TGF-β1 in myocardial tissue. ZGCD may treat AF by lowering the degree of myocardial fibrosis.

Safety Evaluation of Cervical Dorsal Instrumentation in Geriatric Patients: Experience at a Level 1 Center for Spinal Surgery-A Single Center Cohort Study

Objective

Dorsal instrumentation of the cervical spine is an established treatment in spine surgery. However, careful planning is required, particularly in elderly patients. This study evaluates early clinical outcomes in geriatric patients undergoing complex spine surgery.

Methods

In this retrospective, single center cohort study, we included all geriatric patients (aged ≥65 years) who underwent dorsal instrumentation between January 2013 and December 2020. We analyzed postoperative complications and the 30-day in-hospital mortality rate. Furthermore, the Charlson comorbidity index (CCI) and Clavien-Dindo grading system (CDG) were used to assess the patients' comorbidity burden.

Results

In total, 153 patients were identified and included. The mean age of patients was 78 years (SD ± 7). Traumatic injury (53.6%) was the most common reason for surgery. 60.8% of the patients underwent dorsal instrumentation with 3 or more levels. The most common comorbidities were arterial hypertension (64%), diabetes mellitus (22.2%), coronary heart disease and atrial fibrillation (19.6%). The most common adverse event (AE) was pneumonia (4%) and the most common surgery-related complication was wound infection (5.2%). Among patients categorized as high risk for AE (CCI > 5), 14.6% suffered a postoperative AE. In our univariate analysis, we found no risk factors for high rates of complications or mortality.

Conclusion

Our data demonstrates that older patients were at no significant risk of postoperative complications. The CCI/CDG scores may identify patients at higher risk for adverse events after dorsal instrumentation, and these assessments should become an essential component of stratification in this older patient population.

The Patient Pathway Review for Atrial Fibrillation

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

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study

BACKGROUND

Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs.

METHODS AND FINDINGS

We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs.

CONCLUSIONS

The incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.

Validation of an algorithm for atrial fibrillation detection with an analog smartwatch: prospective interventional clinical study

BACKGROUND

Atrial Fibrillation (AF) affects about 4% of the World's population and is one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. It can be difficult to diagnose when asymptomatic or in the paroxysmal stage, and its natural history is not well understood. New wearables and connected devices offer an opportunity to improve on this situation.

OBJECTIVE

To validate an algorithm for the automatic detection of AF from a single-lead electrocardiogram (ECG) taken with a smartwatch.

METHODS

Eligible patients were recruited from 4 sites in Paris, France. Twelve-lead reference ECGs and single-lead ECG were captured simultaneously. The ECGs were reviewed by independent, blinded board-certified cardiologists. The sensitivity and specificity of the algorithm to detect AF and normal sinus rhythm (NSR) were calculated. The quality of single-lead ECGs (visibility and polarity of waves, interval durations, heart rate) was assessed by comparison to the gold standard.

RESULTS

Two hundred and sixty two patients were included in the final analysis: 100 AF, 113 NSR, 45 Other arrhythmia, 4 presented unreadable ECGs. Mean age was of 74.3 years ± 12.3 in the AF group versus 61.8 years old ± 14.3 and 66.9 years old ± 15.2 in the NSR and other arrhythmia groups respectively. 6.9% (18/262) were classified as "Noise" by the algorithm. Excluding "Other" arrhythmia and "Noise", the sensitivity to detect AF was of SeAF/NSR = 0.963 (0.894), and specificity of SpAF/NSR = 1.000 (0.967). Visibility and polarity accuracies (1-lead ECG vs 12-lead ECG) were respectively: P-waves: 96.9%/100%, QRS-complexes: 99.2%/98.8%, and T-waves: 91.2%/99.5% . P-wave visibility accuracy was of 99% (99/100) in AF patients and of 95.7% (155/162) when excluding AF patients. The absolute values of the mean difference in PR duration and QRS width were below 3ms, and more than 97% of these differences were below 40ms. The mean difference between the HR calculated by the algorithm and the device 1-lead ECG read by cardiologists was 0.55 bpm.

CONCLUSIONS

Withings algorithm demonstrated great diagnostic performance for AF detection. The smartwatch single-lead ECGs also demonstrated good quality for physician use in daily routine care.

CLINICALTRIAL

ClinicalTrials.gov registration number: NCT04351386.

Epicardial adipose tissue, obesity and the occurrence of atrial fibrillation: an overview of pathophysiology and treatment methods

INTRODUCTION

Obesity is a chronic disease, which has significant health consequences and is a staggering burden to health care systems. Obesity can have harmful effects on the cardiovascular system, including heart failure, hypertension, coronary heart disease, and atrial fibrillation (AF). One of the possible substrates might be epicardial adipose tissue (EAT), which can be the link between AF and obesity. EAT is a fat deposit located between the myocardium and the visceral pericardium. Numerous studies have demonstrated that EAT plays a pivotal role in this relationship regarding atrial fibrillation.

AREAS COVERED

This review will focus on the role of obesity and the occurrence of atrial fibrillation (AF) and examine the connection between these and epicardial adipose tissue (EAT). The first part of this review will explain the pathophysiology of EAT and its association with the occurrence of AF. Secondly, we will review bariatric and metabolic surgery and its effects on EAT and AF.

EXPERT COMMENTARY

In this review, the epidemiology, pathophysiology, and treatments methods of AF are explained. Secondly the effects on EAT were elucidated. Due to the complex pathophysiological link between EAT, AF, and obesity, it is still uncertain which treatment strategy is superior.

Remodeling and Fibrosis of the Cardiac Muscle in the Course of Obesity-Pathogenesis and Involvement of the Extracellular Matrix

Obesity is a growing epidemiological problem, as two-thirds of the adult population are carrying excess weight. It is a risk factor for the development of cardiovascular diseases (hypertension, ischemic heart disease, myocardial infarct, and atrial fibrillation). It has also been shown that chronic obesity in people may be a cause for the development of heart failure with preserved ejection fraction (HFpEF), whose components include cellular hypertrophy, left ventricular diastolic dysfunction, and increased extracellular collagen deposition. Several animal models with induced obesity, via the administration of a high-fat diet, also developed increased heart fibrosis as a result of extracellular collagen accumulation. Excessive collagen deposition in the extracellular matrix (ECM) in the course of obesity may increase the stiffness of the myocardium and thereby deteriorate the heart diastolic function and facilitate the occurrence of HFpEF. In this review, we include a rationale for that process, including a discussion about possible putative factors (such as increased renin–angiotensin–aldosterone activity, sympathetic overdrive, hemodynamic alterations, hypoadiponectinemia, hyperleptinemia, and concomitant heart diseases). To address the topic clearly, we include a description of the fundamentals of ECM turnover, as well as a summary of studies assessing collagen deposition in obese individuals.