Treatment of Patients With Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction

The value of phenylalanine in predicting atrial fibrillation risk in chronic heart failure

Backgrounds

Atrial fibrillation (AF) is a common complication of chronic heart failure (HF). Serum phenylalanine (Phe) levels are related to inflammation disorder. It is meaningful to study the circulating Phe with AF occurrence in HF.

Methods

The cross-sectional study recruited 300 patients (78.0% male; mean age, 65 ± 13 years) with HF (left ventricular ejection fraction of ≤50%, containing 70 AF patients) and 100 normal controls. Serum Phe value was measured by liquid chromatography-tandem mass spectrometry. Logistic regression analysis was conducted to measure the association between Phe and AF risk in HF. The association between Phe and high-sensitivity C-reactive protein (hsCRP) was assessed by simple correlation analysis. In the prospective study, the 274 HF subjects (76.6% male; mean age, 65 ± 13 years) were followed up for a mean year (10.99 ± 3.00 months).

Results

Serum Phe levels increased across the control, the HF without AF, and the HF with AF groups (77.60 ± 8.67 umol/L vs. 95.24 ± 28.58 umol/L vs. 102.90 ± 30.43 umol/L, ANOVA P < 0.001). Serum Phe value was the independent risk factor for predicting AF in HF [odds ratio (OR), 1.640; 95% CI: 1.150-2.339; P = 0.006]. Phe levels were correlated positively with hsCRP value in HF patients with AF (r = 0.577, P < 0.001). The elevated Phe levels were associated with a higher risk of HF endpoint events in HF patients with AF (log-rank P = 0.005).

Conclusions

In HF with AF subjects, elevated Phe value confers an increased risk for prediction AF and was more related to poor HF endpoint events. Phe can be a valuable index of AF in HF.

Impact of COVID-19 infection on the in-hospital outcome of patients hospitalized for heart failure with comorbid atrial fibrillation: Insight from the National Inpatient Sample (NIS) database 2020

Introduction

Atrial fibrillation (AF) and heart failure (HF) commonly coexist, resulting in adverse health and economic consequences such as declining ventricular function, heightened mortality, and reduced quality of life. However, limited information exists on the impact of COVID-19 on AF patients that hospitalized for HF.

Methods

We analyzed the 2020 U.S. National Inpatient Sample to investigate the effects of COVID-19 on AF patients that primarily hospitalized for HF. Participants aged 18 and above were identified using relevant ICD-10 CM codes. Adjusted odds ratios for outcomes were calculated through multivariable logistic regression. The primary outcome was inpatient mortality, with secondary outcomes including system-based complications.

Results

We identified 322,090 patients with primary discharge diagnosis of HF with comorbid AF. Among them, 0.73% (2355/322,090) also had a concurrent diagnosis of COVID-19. In a survey multivariable logistic and linear regression model adjusting for patient and hospital factors, COVID-19 infection was associated with higher in-hospital mortality (aOR 3.17; 95% CI 2.25, 4.47, p < 0.001), prolonged length of stay (β LOS 2.82; 95% CI 1.71, 3.93, p < 0.001), acute myocarditis (aOR 6.64; 95% CI 1.45, 30.45, p 0.015), acute kidney injury (AKI) (aOR 1.48; 95% CI 1.21, 1.82, p < 0.001), acute respiratory failure (aOR 1.24; 95% CI 1.01, 1.52, p 0.045), and mechanical ventilation (aOR 2.00; 95% CI 1.28, 3.13, p 0.002).

Conclusion

Our study revealed that COVID-19 is linked to higher in-hospital mortality and increased adverse outcomes in AF patients hospitalized for HF.

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

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

Ischemic Stroke and Reduced Left Ventricular Ejection Fraction: A Multidisciplinary Approach to Optimize Brain and Cardiac Health

Reduced left ventricular ejection fraction ≤40%, a known risk factor for adverse cardiac outcomes and recurrent acute ischemic stroke, may be detected during an acute ischemic stroke hospitalization. A multidisciplinary care paradigm informed by neurology and cardiology expertise may facilitate the timely implementation of an array of proven heart failure-specific therapies and procedures in a nuanced manner to optimize brain and cardiac health.

Effects of Phenylacetylglutamine on the Susceptibility of Atrial Fibrillation in Overpressure-Induced HF Mice

Phenylacetylglutamine (PAGln), a gut metabolite is substantially elevated in heart failure (HF). The increase of PAGln in plasma is associated with atrial fibrillation (AF), and contributes to AF pathogenesis. However, the role of PAGln in AF with HF remains uncertain. Therefore, this study aimed to determine the effect of PAGln on AF after HF. Thoracic aortic coarctation (TAC) created overpressure-induced HF mice for 4 weeks. Histopathology, biochemical, echocardiographic for assessment of cardiac function, and electrophysiological examination of several electrophysiological indexes (ERP, SNRT, and the occurrence rate of AF) were performed at the end of the HF mice model. We found that plasma PAGln levels were significantly elevated in PAGln-treated HF mice and that PAGln aggravated maladaptive structural remodeling and electrical remodeling, which aggravated the vulnerability of AF, shortened the ERP duration, prolonged the SNRT, increased the occurrence rate of AF in HF mice. Mechanistically, PAGln exacerbated ROS accumulation and increased the levels of phosphorylated PLB and CAMK II. Overall, PAGln played a vital role in promoting the occurrence of AF in HF mice by activating the CAMK II signaling pathway.

Predictive characteristics and model development for acute heart failure preceding hip fracture surgery in elderly hypertensive patients: a retrospective machine learning approach

BACKGROUND

Hip fractures are a serious health concern among the elderly, particularly in patients with hypertension, where the incidence of acute heart failure preoperatively is high, significantly affecting surgical outcomes and prognosis. This study aims to assess the risk of preoperative acute heart failure in elderly patients with hypertension and hip fractures by constructing a predictive model using machine learning on potential risk factors.

METHODS

A retrospective study design was employed, collecting preoperative data from January 2018 to December 2019 of elderly hypertensive patients with hip fractures at the Third Hospital of Hebei Medical University. Using SPSS 24.0 and R software, predictive models were established through LASSO regression and multivariable logistic regression analysis. The models' predictive performance was evaluated using metrics such as the concordance index (C-index), receiver operating characteristic curve (ROC curve), and decision curve analysis (DCA), providing insights into the nomogram's predictive accuracy and clinical utility.

RESULTS

Out of 1038 patients screened, factors such as gender, age, history of stroke, arrhythmias, anemia, and complications were identified as independent risk factors for preoperative acute heart failure in the study population. Notable predictors included Sex (OR 0.463, 95% CI 0.299-0.7184, P = 0.001), Age (OR 1.737, 95% CI 1.213-2.488, P = 0.003), Stroke (OR 1.627, 95% CI 1.137-2.327, P = 0.008), Arrhythmia (OR 2.727, 95% CI 1.490-4.990, P = 0.001), Complications (OR 2.733, 95% CI 1.850-4.036, P < 0.001), and Anemia (OR 3.258, 95% CI 2.180-4.867, P < 0.001). The prediction model of acute heart failure was Logit(P) = -2.091-0.770 × Sex + 0.552 × Age + 0.487 × Stroke + 1.003 × Arrhythmia + 1.005 × Complications + 1.181 × Anemia, and the prediction model nomogram was established. The model's AUC was 0.785 (95% CI, 0.754-0.815), Decision curve analysis (DCA) further validated the nomogram's excellent performance, identifying an optimal cutoff value probability range of 3% to 58% for predicting preoperative acute heart failure in elderly patients with hypertension and hip fractures.

CONCLUSION

The predictive model developed in this study is highly accurate and serves as a powerful tool for the clinical assessment of the risk of preoperative acute heart failure in elderly hypertensive patients with hip fractures, aiding in the optimization of preoperative risk assessment and patient management.

Updates in the management of atrial fibrillation: Emerging therapies and treatment

OBJECTIVE

The most common and clinically important cardiac arrhythmia is atrial fibrillation (AF), which has a large negative impact on public health due to higher fatalities, morbidity, and healthcare expenditure rates. This study aims to provide valuable insights into the effectiveness and outcomes of various treatment approaches and interventions for AF.

STUDY DESIGN

Systematic review.

METHOD

The most pertinent published research (original papers and reviews) in the scientific literature were searched for and critically assessed using the online, internationally indexed databases PubMed, Medline, and Cochrane Reviews. These studies are summarised in this review. Keywords like "Atrial Fibrillation", "emerging therapies", "treatment", "catheter ablation", and "atrial appendage" were used to search the papers. The papers were researched and examined to be relevant to the topic.

CONCLUSION

A lot of work has gone into enhancing AF management to deal with this expanding public health concern. Significant developments and advances in the treatment of AF during the past few years have aided clinicians in giving AF patients better care. The most recent treatments for AF include medication, catheter ablation, cryo-balloon ablation, and left atrial appendage closure.

Causal effects between atrial fibrillation and heart failure: evidence from a bidirectional Mendelian randomization study

BACKGROUND

Observational studies have suggested a close association between atrial fibrillation (AF) and heart failure (HF), yet the causal effect remains uncertain. In this study, we employed a bidirectional Mendelian randomization analysis to investigate the causal effect of one disease on the other.

METHODS

Genetic instrumental variables were obtained from large-scale summary-level genome-wide association studies of AF (n = 1,030,836) and HF(n = 1,665,481), respectively. Two-sample Mendelian randomization was conducted to establish causal inferences. Inverse-variance weighted (IVW) was the primary estimate, while additional analyses including MR Pleiotropy RESidual Sum and Outlier (MR-PRESSO), MR-Egger, and Weighted median were performed to validate robustness and identify pleiotropy.

RESULTS

After accounting for confounding variables, MR analysis suggested a potential causal relationship between AF and HF. An augmented genetic predisposition to atrial fibrillation was associated with an elevated risk of heart failure (odds ratio (OR) = 1.18, 95% confidence interval (CI):1.14-1.22). Likewise, genetically determined heart failure also increased the risk of heart failure (OR = 1.44, 95%CI:1.23-1.68). The robustness of the findings was corroborated through MR sensitivity analyses, and the causal estimates remained consistent when the instrument P-value threshold was tightened.

CONCLUSIONS

Our bidirectional Mendelian randomization study supports a reciprocal causal relationship between AF and HF. The shared genetic profile of these conditions may provide crucial insights into potential therapeutic targets for the prevention and progression of both disorders. These findings underscore the necessity for further investigation into the underlying molecular mechanisms linking AF and HF, as well as the potential for personalized treatment strategies grounded in genetic profiling.

Effectiveness of Catheter Ablation in Left Ventricular Ejection Fraction, Stroke, Quality of Life, All-Cause Mortality, Sinus Rhythm Maintenance, and Hospitalization Rates as Compared to Medical Therapy

Atrial fibrillation (AF) in the setting of heart failure (HF) accounts for a significant proportion of mortality. AF can be managed either with rate control or rhythm control strategies. Rate control involves the use of beta blockers or calcium channel blockers. Rhythm control methods use antiarrhythmic drugs or catheter ablation (CA) to abolish the rhythm. Articles from PubMed and Google Scholar were chosen for review. The literature was reviewed for data from the last 10 years to be chosen for interpretation. Clinical trials, meta-analyses, and systematic analysis were included in this study. Various health parameters such as all-cause mortality, hospitalization rates, sinus rhythm (SR) maintenance, quality of life improvement, stroke risk, left ventricular ejection fraction (LVEF) improvement, and healthcare costs were analyzed. We demonstrated that CA was superior to medical therapy in reducing all-cause mortality and hospitalization. It leads to significant improvement in LVEF as SR was maintained consistently. Overall, quality of life improved in those who underwent ablation as compared to those who did not. Stroke risk reduction was seen in observational studies only. We recommend CA as first-line therapy for treating patients with AF in the setting of HF. More clinical trials are needed to determine the effectiveness of ablation in reducing stroke risk.

Association between sodium-glucose cotransporter-2 inhibitors and incident atrial fibrillation/atrial flutter in heart failure patients with reduced ejection fraction: a meta-analysis of randomized controlled trials

Atrial fibrillation (AF) and atrial flutter (AFL) are associated with adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF). We investigated the effects of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on the incidence of AF and/or AFL in HFrEF patients. PubMed and ClinicalTrials.gov were systematically searched until March 2022 for randomized controlled trials (RCTs) that enrolled patients with HFrEF. A total of six RCTs with 9467 patients were included (N = 4731 in the SGLT2i arms; N = 4736 in the placebo arms). Compared to placebo, SGLT2i treatment was associated with a significant reduction in the risk of AF [relative risk (RR) 0.62, 95% confidence interval CI 0.44-0.86; P = 0.005] and AF/AFL (RR 0.64, 95% CI 0.47-0.87; P = 0.004). Subgroup analysis showed that empagliflozin use resulted in a significant reduction in the risk of AF (RR 0.55, 95% CI 0.34-0.89; P = 0.01) and AF/AFL (RR 0.50, 95% CI 0.32-0.77; P = 0.002). By contrast, dapagliflozin use was not associated with a significant reduction in the risk of AF (RR 0.69, 95% CI 0.43-1.11; P = 0.12) or AF/AFL (RR 0.82, 95% CI 0.53-1.27; P = 0.38). Additionally, a "shorter" duration (< 1.5 years) of treatment with SGLT2i remained associated with a reduction in the risk of AF (< 1.5 years; RR 0.58, 95% CI 0.36-0.91; P = 0.02) and AF/AFL (< 1.5 years; RR 0.52, 95% CI 0.34-0.80; P = 0.003). In conclusion, SGLT2i therapy was associated with a significant reduction in the risk of AF and AF/AFL in patients with HFrEF. These results reinforce the value of using SGLT2i in this setting.

Sodium-glucose cotransporter 2 inhibitor may not prevent atrial fibrillation in patients with heart failure: a systematic review

BACKGROUND

Atrial fibrillation (AF) and heart failure (HF) frequently coexist because of their similar pathological basis. However, whether sodium-glucose cotransporter 2 inhibitor (SGLT2i), a novel class of anti-HF medication, decreases the risk of AF in HF patients remains unclear.

OBJECTIVES

The aim of this study was to assess the relationship between SGLT2i and AF in HF patients.

METHODS

A meta-analysis of randomized controlled trails evaluating the effects of SGLT2i on AF in HF patients was performed. PubMed and ClinicalTrails.gov were searched for eligible studies until 27 November 2022. The risk of bias and quality of evidence were assessed through the Cochrane tool. Pooled risk ratio of AF for SGLT2i versus placebo in eligible studies was calculated.

RESULTS

A total of 10 eligible RCTs examining 16,579 patients were included in the analysis. AF events occurred in 4.20% (348/8292) patients treated with SGLT2i, and in 4.57% (379/8287) patients treated with placebo. Meta-analysis showed that SGLT2i did not significantly reduce the risk of AF (RR 0.92; 95% CI 0.80-1.06; p = 0.23) in HF patients when compared to placebo. Similar results remained in the subgroup analyses, regardless of the type of SGLT2i, the type of HF, and the duration of follow-up.

CONCLUSIONS

Current evidences showed that SGLT2i may have no preventive effects on the risk of AF in patients with HF.

TRANSLATIONAL PERSPECTIVE

Despite HF being one of the most common heart diseases and conferring increased risk for AF, affective prevention of AF in HF patients is still unresolved. The present meta-analysis demonstrated that SGLT2i may have no preventive effects on reducing AF in patients with HF. How to effectively prevent and early detect the occurrence of AF is worth discussing.

Optimal rate control in dogs with atrial fibrillation-ORCA study-Multicenter prospective observational study: Prognostic impact and predictors of rate control

BACKGROUND

The optimal heart rate (HR) in dogs with atrial fibrillation (AF) is unknown. Impact of HR on survival needs elucidation.

HYPOTHESIS/OBJECTIVES

Dogs with a 24 hours Holter-derived meanHR ≤125 beats per minute (bpm; rate controlled) survive longer than dogs with higher meanHR. We further aimed to determine which variables predict ability to achieving rate control.

ANIMALS

Sixty dogs with AF.

METHODS

Holter-derived meanHR, clinical, echocardiographic, and biomarker variables were analyzed prospectively. Survival was recorded from time of rate control, with all-cause mortality as primary endpoint. Cox proportional hazards analysis identified variables independently associated with survival; Kaplan-Meier survival analysis estimated the median survival time of dogs with meanHR ≤125 bpm vs >125 bpm. Logistic regression explored baseline variables associated with inability to achieve rate control.

RESULTS

Structural heart disease was present in 56/60 dogs, 50/60 had congestive heart failure, and 45/60 died. Median time to all-cause death was 160 days (range, 88-303 days), dogs with meanHR >125 bpm (n = 27) lived 33 days (95% confidence interval [CI], 15-141 days), dogs with meanHR ≤125 bpm (n = 33) lived 608 days (95% CI, 155-880 days; P < .0001). Congenital heart disease and N-terminal pro-B-type natriuretic peptide were independently associated with higher risk of death (P < .01 and <.0001, respectively) whereas meanHR ≤125 bpm decreased the risk of death (P < .001). Increased left atrial size, increased C-reactive protein concentration and lower blood pressure at admission were associated with failure to achieve rate control.

CONCLUSIONS AND CLINICAL IMPORTANCE

Rate control affects survival; an optimal target meanHR <125 bpm should be sought in dogs with AF. Baseline patient variables can help predict if rate control is achievable.

Catheter ablation vs. drug therapy in the treatment of atrial fibrillation patients with heart failure: An update meta-analysis for randomized controlled trials

Background

Atrial fibrillation (AF) and heart failure (HF) often coexist. The treatment of AF in patients with HF has been challenging because of the ongoing debate about the merits of catheter ablation vs. drug therapy.

Methods

The Cochrane Library, PubMed, and www.clinicaltrials.gov were searched until June 14, 2022. Inclusion criteria were catheter ablation compared with drug therapy in adults with AF and HF in randomized controlled trials (RCTs). Primary outcomes consisted of all-cause mortality, re-hospitalization, change in left ventricular ejection fraction (LVEF), and AF recurrence. Secondary outcomes referred to quality of life [QoL; measured by the Minnesota Living with Heart Failure Questionnaire (MLHFQ)], six-minute walk distance (6MWD), and adverse events. The PROSPERO registration ID was CRD42022344208.

Findings

In total, nine RCTs with 2,100 patients met the inclusion criteria, with 1,062 for catheter ablation and 1,038 for medication. According to the meta-analysis, catheter ablation significantly reduced all-cause mortality compared with drug therapy [9.2% vs. 14.1%, OR: 0.62, (95% CI: 0.47-0.82), P = 0.0007, I 2   = 0%], improved LVEF [MD: 5.65%, (95% CI: 3.32-7.98), P < 0.00001, I 2   = 86%], reduced AF recurrence [41.6% vs. 61.9%, OR: 0.23, (95% CI: 0.11-0.48), P < 0.0001, I 2   = 82%], decreased the MLHFQ score [MD: -6.38, (95% CI: -11.09 to -1.67), P = 0.008, I2  = 64%] and increased 6MWD [MD: 17.55, (95% CI: 15.77-19.33), P < 0.0001, I 2   = 37%]. Catheter ablation did not increase the re-hospitalization [30.4% vs. 35.5%, OR: 0.68, (95% CI: 0.42-1.10), P = 0.12, I 2   = 73%] and adverse events [31.5% vs. 30.9%, OR: 1.06, (95% CI: 0.83-1.35), P = 0.66, I 2   = 48%].

Interpretation

In AF patients with HF, catheter ablation improves exercise tolerance, QoL, and LVEF and significantly reduced all-cause mortality and AF recurrence. Although the differences were not statistically significant, the study found lower re-hospitalization and approximate adverse events with improved catheter ablation tendency.

PROSPERO registration ID

CRD42022344208.

Exploring the pathogenesis and immune infiltration in dilated cardiomyopathy complicated with atrial fibrillation by bioinformatics analysis

Background

Atrial fibrillation (AF) is a serious complication of dilated cardiomyopathy (DCM), which increases the risk of thromboembolic events and sudden death in DCM patients. However, the common mechanism of DCM combined with AF remains unclear. This study aims to explore the molecular mechanism and analyze immune infiltration in DCM complicated with AF through comprehensive bioinformatics analysis.

Methods

The gene expression datasets of DCM (GSE141910) and AF (GSE41177 and GSE79768) were obtained from the Gene Expression Omnibus database. Gene enrichment analyses were performed after screening the common differentially expressed genes (DEGs) of DCM and AF. Protein-protein interaction network was constructed in the STRING database and visualized in Cytoscape software, which helped to further screen the central functional modules of DEGs and hub genes. In addition, ImmuCellAI algorithm was performed to estimate immune infiltration patterns, and Spearman correlation was conducted to investigate the correlation between the abundance of multiple immune cells and the expression levels of hub immune-related genes after obtaining hub immune-related genes from the ImmPort database. The hub immune-related genes expression and immune infiltration patterns were additionally verified in the validation datasets (GSE57338, GSE115574, and GSE31821). The diagnostic effectiveness of hub immune-related genes was evaluated through Receiver Operator Characteristic Curve analysis.

Results

A total of 184 common DEGs in DCM and AF were identified for subsequent analyses. The functions of hub genes were significantly associated with immune responses. We identified 7 hub immune-related genes (HLA-DRA, LCK, ITK, CD48, CD247, CD3D, and IL2RG) and a spectrum of immune cell subsets including Monocyte, Neutrophil, and follicular helper T (Tfh) cells were found to be concurrently dysregulated in both DCM and AF. 7 hub immune-related genes were predominantly favorably correlated with Tfh cells and were primarily negatively correlated with Neutrophil infiltrations in DCM and AF. CD48+CD3D were verified to diagnose DCM and AF with excellent sensitivity and specificity, showing favorable diagnostic value.

Conclusions

Our study reveals that immune cells (Tfh cells) disorders caused by hub immune-related genes (CD48 and CD3D) may be the common pathogenesis of DCM combined with AF, which lays a foundation for further immune mechanism research.

Amiodarone vs. metoprolol succinate in HFrEF complicated with persistent atrial fibrillation with rapid ventricular response: A prospective observational study

Background

β-blockers have been recommended for patients with heart failure (HF) and atrial fibrillation (AF), but studies have shown that β-blockers do not reduce all-cause mortality or cardiovascular mortality in patients with HF and AF.

Objective

To investigate the difference in efficacy between oral amiodarone and metoprolol succinate for patients with HF with reduced ejection fraction (HFrEF) and persistent atrial fibrillation (pAF) with rapid ventricular response (RVR).

Methods

Patients with HFrEF complicated with pAF with RVR treated in the People's Hospital of Chongqing Hechuan between March 2018 and March 2019 were enrolled in this prospective observational study. The primary outcomes were cardiovascular mortality and the first hospitalization for HF rate. The secondary outcomes were type B pro-brain natriuretic peptide (NT-proBNP) before/after treatment, left ventricular ejection fraction (LVEF) before/after treatment, average heart rate (AhR), and the rate of sinus rhythm after 1 year of follow-up.

Results

A total of 242 patients with HFrEF complicated with pAF with RVR were enrolled and divided into amiodarone + perindopril + spironolactone+ routine drug (amiodarone group, n = 121) and metoprolol succinate + perindopril + spironolactone +routine drug (metoprolol succinate group, n = 121) according to their treatment strategy. Cardiovascular mortality (4.9 vs. 12.4%, HR: 2.500, 95%CI: 1.002-6.237, P = 0.040) and first hospitalization for HF (52.9 vs. 67.8%, HR: 1.281, 95%CI: 1.033-1.589, P = 0.024) were significantly lower in the amiodarone group than in the metoprolol group. The mean ventricular rate in the amiodarone group was significantly lower than in the metoprolol group (64.5 ± 3.2 vs. 72.4 ± 4.2, P < 0.001). After 1 year of follow-up, the sinus rhythm rate was significantly higher in the amiodarone group than in the metoprolol group (38.8 vs. 7.4%, HR: 0.191, 95%CI: 0.098-0.374, P < 0.001). The difference in proBNP (3,914.88 vs. 2,558.07, P < 0.001) and LVEF (-6.89 vs. -0.98, P < 0.001) before and after treatment was significantly higher in the amiodarone group than in the metoprolol group.

Conclusion

In conclusion, in this prospective observational study, the amiodarone group had lower risk of cardiovascular death and the first hospitalization for HF than metoprolol in HFrEF and persistent atrial fibrillation (pAF) with RVR. The mechanism may be related to improved cardiac function, rhythm control and ventricular rate control.

Registration number

ChiCTR2200057816; Registered 7 March 2022-Retrospectively registered: http://www.medresman.org.cn/pub/cn/proj/projectshshow.aspx?proj=4222.

Comparison of catheter ablation and medical therapy for atrial fibrillation in heart failure patients: A meta-analysis of randomized controlled trials

BACKGROUND

The results of studies comparing the outcomes of catheter ablation (CA) to those of medical therapy (MT) for atrial fibrillation (AF) in heart failure (HF) patients are contradictory.

OBJECTIVES

Our objective was to conduct a meta-analysis that included randomized controlled trials (RCTs) that compared these two therapy options for AF in HF patients.

METHODS

We searched PubMed, Google Scholar, and the Cochrane Library for eligible studies. After reviewing all potential studies, we conducted this meta-analysis with the remaining 10 RCTs. We used a modified Jadad scale to assess the publications' quality, and we used the Risk of Bias 2 tool to assess the RCTs' bias risk.

RESULTS

The meta-analysis comprised 2,187 patients. Patients treated with CA had a lower risk of all-cause mortality than patients treated with MT (RR=0.64 [0.5, 0.82]; p < 0.01). The CA group had greater improvement in left ventricular ejection fraction (LVEF) than the MT group (mean difference [MD]=5.38 [1.80, 8.97]; p < 0.01). Patients in the CA group had longer 6-min walking distances than patients in the MT group (MD=20.3 [-4.37, 44.9], p < 0.01). Compared to the MT group, the CAD group demonstrated a greater reduction in scores on the Minnesota Living with Heart Failure Questionnaire (MD= -9.59 [-16.72, -2.45], p < 0.01).

CONCLUSION

This meta-analysis highlights the importance of CA in terms of all-cause mortality and includes the highest number of patients of any study on this topic. Moreover, compared to MT, CA therapy is associated with greater improvements in LVEF and quality of life.

Clinical outcomes and structural remodelling after ablation of atrial fibrillation in heart failure with mildly reduced or mid-range ejection fraction

AIMS

The efficacy of catheter ablation (CA) on clinical outcomes and cardiac structural remodelling in atrial fibrillation (AF) patients with HF with mildly reduced or mid-range ejection fraction (HFmrEF) remains unclear. We aimed to compare the efficacy of CA with medical therapy (MT) in AF patients with HFmrEF.

METHODS AND RESULTS

We retrospectively screened a total of 36 879 patients with AF between 2005 and 2020. Patients who were initially diagnosed with echocardiography-proved HFmrEF and had follow-up echocardiography were enrolled. After applying propensity score matching in a 1:1 ratio, 72 patients treated by CA (Group 1) and 72 patients receiving MT (Group 2) were taken into further analysis. The co-morbidities were similar between the two groups, except for hyperlipidaemia. After a mean follow-up duration of 58.9 ± 42.6 months, Group 1 had a lower HF hospitalization and all-cause mortality compared with Group 2 (hazard ratio (HR), 0.089 [95% confidence interval (CI), 0.011-0.747]; P = 0.026 and HR, 0.121 [95% CI, 0.016-0.894]; P = 0.038, respectively). As for cardiac structural remodelling, the Group 1 had a better improvement in left ventricular ejection fraction (LVEF) and a more decreased left atrium (LA) diameter than Group 2 (+25.0% ± 18.0% vs. +6.2% ± 21.6%, P = <0.0001 and -1.6 ± 4.7 mm vs. +1.5 ± 8.2 mm, P = 0.008, respectively).

CONCLUSIONS

In patients with HFmrEF and AF, CA of AF could reduce both HF hospitalization and all-cause mortality as compared with those with MT. A significant improvement in LVEF and decrease in LA diameter were also observed in the CA group. Early rhythm control with CA should be taken into consideration in patients with HFmrEF and AF.

Herzinsuffizienz und Vorhofflimmern – eine Zwillingsepidemie

Vorhofflimmern (VHF) und eine Herzinsuffizienz begünstigen sich gegenseitig und treten häufig in Kombination auf. Eine effektive Therapie des VHF inklusive der möglicherweise notwendigen Antikoagulation sollte zentraler Baustein bei Patienten mit eingeschränkter systolischer Funktion und VHF sein. Medikamentöse Therapieoptionen sind in der Regel wenig effektiv, sodass zunehmend Katheterablationsverfahren zur Behandlung dieser Patienten in den Vordergrund gestellt werden. Randomisierte Studien bei selektierten Patienten zeigen nicht nur einen symptomatischen Effekt auf die Herzinsuffizienz, sondern neben Verbesserung der LV-Funktion auch einen Letalitätsbenefit der effektiven Ablation von VHF. In der Zukunft gilt es, Patienten sinnvoll für die Katheterablation zu identifizieren. Ob das reine Vorhandensein von VHF oder eher die VHF-Last bei Patienten mit Herzinsuffizienz entscheidend für die Prognose ist, wird aktuell in weiteren Studien untersucht.

Cardiovascular adverse events in patients with chronic lymphocytic leukemia receiving acalabrutinib monotherapy: pooled analysis of 762 patients

Cardiovascular (CV) toxicities of the Bruton tyrosine kinase (BTK) inhibitor ibrutinib may limit use of this effective therapy in patients with chronic lymphocytic leukemia (CLL). Acalabrutinib is a second-generation BTK inhibitor with greater BTK selectivity. This analysis characterizes pooled CV adverse events (AE) data in patients with CLL who received acalabrutinib monotherapy in clinical trials (clinicaltrials gov. Identifier: NCT02029443, NCT02475681, NCT02970318 and NCT02337829). Acalabrutinib was given orally at total daily doses of 100-400 mg, later switched to 100 mg twice daily, and continued until disease progression or toxicity. Data from 762 patients (median age: 67 years [range, 32-89]; median follow-up: 25.9 months [range, 0-58.5]) were analyzed. Cardiac AE of any grade were reported in 129 patients (17%; grade ≥3, n=37 [5%]) and led to treatment discontinuation in seven patients (1%). The most common any-grade cardiac AE were atrial fibrillation/flutter (5%), palpitations (3%), and tachycardia (2%). Overall, 91% of patients with cardiac AE had CV risk factors before acalabrutinib treatment. Among 38 patients with atrial fibrillation/flutter events, seven (18%) had prior history of arrhythmia or atrial fibrillation/flutter. Hypertension AE were reported in 67 patients (9%), 43 (64%) of whom had a preexisting history of hypertension; no patients discontinued treatment due to hypertension. No sudden cardiac deaths were reported. Overall, these data demonstrate a low incidence of new-onset cardiac AE with acalabrutinib in patients with CLL. Findings from the head-to-head, randomized trial of ibrutinib and acalabrutinib in patients with highrisk CLL (clinicaltrials gov. Identifier: NCT02477696) prospectively assess differences in CV toxicity between the two agents.

DNA Methylation-Based Prediction of Post-operative Atrial Fibrillation

Background

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and post-operative atrial fibrillation (POAF) is a major healthcare burden, contributing to an increased risk of stroke, kidney failure, heart attack and death. Genetic studies have identified associations with AF, but no molecular diagnostic exists to predict POAF based on pre-operative measurements. Such a tool would be of great value for perioperative planning to improve patient care and reduce healthcare costs. In this pilot study of epigenetic precision medicine in the perioperative period, we carried out bisulfite sequencing to measure DNA methylation status in blood collected from patients prior to cardiac surgery to identify biosignatures of POAF.

Methods

We enrolled 221 patients undergoing cardiac surgery in this prospective observational study. DNA methylation measurements were obtained from blood samples drawn from awake patients prior to surgery. After controlling for clinical and methylation covariates, we analyzed DNA methylation loci in the discovery cohort of 110 patients for association with POAF. We also constructed predictive models for POAF using clinical and DNA methylation data. We subsequently performed targeted analyses of a separate cohort of 101 cardiac surgical patients to measure the methylation status solely of significant methylation loci in the discovery cohort.

Results

A total of 47 patients in the discovery cohort (42.7%) and 43 patients in the validation cohort (42.6%) developed POAF. We identified 12 CpGs that were statistically significant in the discovery cohort after correcting for multiple hypothesis testing. Of these sites, 6 were amenable to targeted bisulfite sequencing and chr16:24640902 was statistically significant in the validation cohort. In addition, the methylation POAF prediction model had an AUC of 0.79 in the validation cohort.

Conclusions

We have identified DNA methylation biomarkers that can predict future occurrence of POAF associated with cardiac surgery. This research demonstrates the use of precision medicine to develop models combining epigenomic and clinical data to predict disease.

Temporal Association of Atrial Fibrillation With Cardiac Implanted Electronic Device Detected Heart Failure Status

OBJECTIVES

This study sought to investigate the temporal association between changes in physiologic heart failure (HF) sensors, atrial fibrillation (AF) progression, and clinical HF in patients with cardiac resynchronization therapy implantable defibrillators (CRT-D) designed to monitor AF and HF daily.

BACKGROUND

AF is a common comorbidity in HF; however, it is unclear if HF triggers AF, or vice-versa. Current implantable cardiac devices have sensors capable of quantifying HF status, which permits a greater understanding of the impact of AF on HF status and may help guide treatment.

METHODS

The MultiSENSE (Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients) study collected multiple sensor data indicative of HF status in patients with CRT-D followed for up to 12 months. Patients were grouped according to their longest daily AF burden: 1) at least 24 hours of AF (HIGH AF); 2) between 6 minutes and 24 hours (MID AF); and 3) <6 minutes (NO AF). Sensor data were aligned to the first qualifying AF event or a randomly selected day for patients in the NO AF group.

RESULTS

Among 869 patients with daily AF data available, 98 patients had HIGH AF, 141 patients MID AF, and 630 patients NO AF. At baseline, history of AF, N-terminal pro hormone B-type natriuretic peptide and device-measured S3 were associated with development of AF. HeartLogic index increased before AF onset (Δ HeartLogic = 9.83 ± 2.49; P < 0.001). Multivariable time-dependent Cox regression showed an increased risk for HF events following a 24-hour AF episode compared with no 24-hour AF (hazard ratio: 1.96; 95% confidence interval: 1.03-3.74).

CONCLUSIONS

Device-measured HF indicators worsened before AF onset, whereas clinical HF deterioration only became apparent after AF occurred. Thus, the sensitivity of methods to ascertain AF and HF status appear to influence the direction of perceived causality. (Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients [MultiSENSE]; NCT01128166).

Electrochemically driven optical and SERS immunosensor for the detection of a therapeutic cardiac drug

Cardiovascular diseases pose a serious health risk and have a high mortality rate of 31% worldwide. Digoxin is the most commonly prescribed pharmaceutical preparation to cardiovascular patients particularly in developing countries. The effectiveness of the drug critically depends on its presence in the therapeutic range (0.8–2.0 ng mL⁻¹) in the patient's serum. We fabricated immunoassay chips based on QD photoluminescence (QDs-ELISA) and AuNP Surface Enhanced Raman Scattering (SERS-ELISA) phenomena to detect digoxin in the therapeutic range. Digoxin levels were monitored using digoxin antibodies conjugated to QDs and AuNPs employing the sandwich immunoassay format in both the chips. The limit of detection (LOD) achieved through QDs-ELISA and SERS-ELISA was 0.5 ng mL⁻¹ and 0.4 ng mL⁻¹, respectively. It is demonstrated that the sensitivity of QDs-ELISA was dependent on the charge transfer mechanism from the QDs to the antibody through ionic media, which was further explored using electrochemical impedance spectroscopy. We demonstrate that QDs-ELISA was relatively easy to fabricate compared to SERS-ELISA. The current study envisages replacement of conventional methodologies with small immunoassay chips using QDs and/or SERS-based tags with fast turnaround detection time as compared to conventional ELISA.

Cardiovascular diseases pose a serious health risk and have a high mortality rate of 31% worldwide.

Catheter Ablation for Persistent Atrial Fibrillation in Class IV Systolic Heart Failure: A Single-Center Case Series

Questions remain as to how aggressively catheter ablation for atrial fibrillation may be applied to patients with advanced systolic congestive heart failure, owing to a historic under-representation in multicenter clinical ablation trials. We sought to describe the experience of catheter ablation for persistent atrial fibrillation in Class IV systolic heart failure patients at our institution. All Class IV systolic heart failure patients (left ventricular assist device patients excluded) between 2017 and 2020 referred for radiofrequency ablation were included. Out of 10 patients, 7 agreed to proceed, had restoration of normal sinus rhythm upon completion of the catheter ablation procedure, and of which five (71%) remain in normal rhythm at a mean follow-up of 23 months. Catheter ablation for atrial fibrillation in patients with Class IV chronic systolic heart failure, even on advanced heart failure therapies, is feasible, and can improve heart failure status with maintenance of NSR.

Pathophysiological pathways in patients with heart failure and atrial fibrillation

Aims

Atrial fibrillation (AF) and heart failure (HF) are two growing epidemics that frequently co-exist. We aimed to gain insights into the underlying pathophysiological pathways in HF patients with AF by comparing circulating biomarkers using pathway overrepresentation analyses.

Methods and results

From a panel of 92 biomarkers from different pathophysiological domains available in 1620 patients with HF, we first tested which biomarkers were dysregulated in patients with HF and AF (n = 648) compared with patients in sinus rhythm (n = 972). Secondly, pathway overrepresentation analyses were performed to identify biological pathways linked to higher plasma concentrations of biomarkers in patients who had HF and AF. Findings were validated in an independent HF cohort (n = 1219, 38% with AF). Patient with AF and HF were older, less often women, and less often had a history of coronary artery disease compared with those in sinus rhythm. In the index cohort, 24 biomarkers were up-regulated in patients with AF and HF. In the validation cohort, eight biomarkers were up-regulated, which all overlapped with the 24 biomarkers found in the index cohort. The strongest up-regulated biomarkers in patients with AF were spondin-1 (fold change 1.18, P = 1.33 × 10⁻¹²), insulin-like growth factor-binding protein-1 (fold change 1.32, P = 1.08 × 10⁻⁸), and insulin-like growth factor-binding protein-7 (fold change 1.33, P = 1.35 × 10⁻¹⁸). Pathway overrepresentation analyses revealed that the presence of AF was associated with activation amyloid-beta metabolic processes, amyloid-beta formation, and amyloid precursor protein catabolic processes with a remarkable consistency observed in the validation cohort.

Conclusion

In two independent cohorts of patients with HF, the presence of AF was associated with activation of three pathways related to amyloid-beta. These hypothesis-generating results warrant confirmation in future studies.

The role of atrial fibrillation catheter ablation in patients with heart failure

Atrial Fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF) frequently coexist, resulting in significant morbidity and mortality. Therapeutic options for patients with AF and HFrEF are limited due to few antiarrhythmic drug (AAD) choices and historically equivocal effects of procedural interventions on mortality. However, recent randomized trials examining catheter ablation (CA) in AF patients with HFrEF have shown a beneficial effect on arrhythmic burden and HF symptoms, as well as an improvement in mortality. This review focuses on the role of CA for AF patients with HFrEF.

Angiotensin Receptor-Neprilysin Inhibitor (ARNI) and Cardiac Arrhythmias

The renin-angiotensin-aldosterone system (RAAS) plays a major role in cardiovascular health and disease. Short-term RAAS activation controls water and salt retention and causes vasoconstriction, which are beneficial for maintaining cardiac output in low blood pressure and early stage heart failure. However, prolonged RAAS activation is detrimental, leading to structural remodeling and cardiac dysfunction. Natriuretic peptides (NPs) are activated to counterbalance the effect of RAAS and sympathetic nervous system by facilitating water and salt excretion and causing vasodilation. Neprilysin is a major NP-degrading enzyme that degrades multiple vaso-modulatory substances. Although the inhibition of neprilysin alone is not sufficient to counterbalance RAAS activation in cardiovascular diseases (e.g., hypertension and heart failure), a combination of angiotensin receptor blocker and neprilysin inhibitor (ARNI) was highly effective in several clinical trials and may modulate the risk of atrial and ventricular arrhythmias. This review summarizes the possible link between ARNI and cardiac arrhythmias and discusses potential underlying mechanisms, providing novel insights about the therapeutic role and safety profile of ARNI in the cardiovascular system.

Tricuspid Regurgitation in Left Ventricular Systolic Dysfunction: Marker or Target?

Far from being historically considered a primary healthcare problem, tricuspid regurgitation (TR) has recently gained much attention from the scientific community. In fact, in the last years, robust evidence has emerged regarding the epidemiological impact of TR, whose prevalence seems to be similar to that of other valvulopathies, such as aortic stenosis, with an estimated up to 4% of people >75 years affected by at least moderate TR in the United States, and up to 23% among patients suffering from heart failure with reduced ejection fraction. This recurrent coexistence of left ventricular systolic dysfunction (LVSD) and TR is not surprising, considered the multiple etiologies of tricuspid valve disease. TR can complicate heart failure mostly as a functional disease, because of pulmonary hypertension (PH), subsequent to elevated left ventricular end-diastolic pressure, leading to right ventricular dilatation, and valve tethering. Moreover, the so-called "functional isolated" TR can occur, in the absence of PH, as a result of right atrial dilatation associated with atrial fibrillation, a common finding in patients with LVSD. Finally, TR can result as a iatrogenic consequence of transvalvular lead insertion, another frequent scenario in this cohort of patients. Nonetheless, despite the significant coincidence of these two conditions, their mutual relation, and the independent prognostic role of TR is still a matter of debate. Whether significant TR is just a marker for advanced left-heart disease, or a crucial potential therapeutical target, remains unclear. Aim of the authors in this review is to present an update concerning the epidemiological features and the clinical burden of TR in the context of LVSD, its prognostic value, and the potential benefit for early tricuspid intervention in patients affected by contemporary TR and LVSD.

Prevalence and predictors of persistent sinus rhythm after elective electrical cardioversion for atrial fibrillation

AIMS

To evaluate the prevalence and predictors of persistent sinus rhythm in a recent cohort of unselected patients undergoing electrical cardioversion for atrial fibrillation.

METHODS

We enrolled all consecutive patients undergoing elective electrical cardioversion for atrial fibrillation between January 2017 and December 2018. We analysed baseline clinical and echocardiographic data as well as pharmacological antiarrhythmic therapy. Primary endpoint was the maintenance of sinus rhythm at 12 months after electrical cardioversion.

RESULTS

Of the 300 patients enrolled, 270 (90%) had successful electrical cardioversion and among them, 201 patients have 12-month follow-up data (mean age 70 ± 10 years; 74% men). At 12 months, only 45.7% were in sinus rhythm. Patients without sinus rhythm compared with persistent sinus rhythm at 12 months had a lower baseline left ventricle ejection fraction (LVEF) (49.1 ± 16 vs. 59.7 ± 9%, P = 0.02) and had more frequently a history of atrial fibrillation more than 12 months (55 vs. 34% P = 0.003). At the multivariate analysis, only the duration of the disease beyond 12 months (OR 0.26, 95% CI: 0.08-0.88, P = 0.032), LVEF (OR 1.06, 95% CI: 1.01-1.12, P = 0.012) and the presence of sinus rhythm at 1-month follow-up (OR 18.28, 95% CI: 3.3-100, P = 0.001) were associated with the probability of maintaining sinus rhythm at 12 months.

CONCLUSION

In unselected patients with atrial fibrillation undergoing elective electrical cardioversion, only 45.7% were in sinus rhythm at 12 months. The presence of sinus rhythm at 1-month follow-up emerged as an independent predictor of maintenance of sinus rhythm. This highlights that early re-evaluation of these patients appears useful for assessing longer term outcomes also from the perspective of a possible selective approach to ablation strategies.

Update on the Impact of Comorbidities on the Efficacy and Safety of Heart Failure Medications

PURPOSE OF REVIEW

Multiple newer medications benefit patients with heart failure with reduced ejection fraction (HFrEF). While these therapies benefit the broad population with HFrEF, the efficacy and safety of these therapies have been less well characterized in patients with significant comorbidities.

RECENT FINDINGS

Common comorbidities of high interest in heart failure (HF) include diabetes mellitus, chronic kidney disease (CKD), atrial fibrillation, and obesity, and each has potential implications for clinical management. As the burden of comorbidities increases in HF populations, risk-benefit assessments of HF therapies in the context of different comorbidities are increasingly relevant for clinical practice. This review summarizes data regarding the core HFrEF therapies in the context of comorbidities, with specific attention to sodium-glucose cotransporter 2 inhibitors, sacubitril/valsartan, mineralocorticoid receptor antagonists (MRAs), and beta-blockers. In general, studies support consistent treatment effects with regard to clinical outcome benefits in the presence of comorbidities. Likewise, safety profiles are relatively consistent irrespective of comorbidities, with the exception of heightened risk of hyperkalemia with MRA therapy in patients with severe CKD. In conclusion, while HF management is complex in the context of multiple comorbidities, the totality of evidence strongly supports guideline-directed medical therapies as foundational for improving outcomes in these high-risk patients.

Hemodynamic Management of Patients with Ejection Fraction < 50% Undergoing Pulmonary Vein Ablation

There is no consensus regarding optimal methodology forblood pressure monitoring inpatients with a depressed ejection fraction undergoingcatheter ablationfor atrial fibrillation. Our goalswere to determine ifhemodynamicmanagementdifferences exist during radiofrequency ablation for atrial fibrillation in patients with and without an ejection fraction< 50%, and whether management was influenced by the utilization of invasive arterial blood pressure monitoring. This single-center trial retrospectively compared blood pressure management during catheterablation of atrial fibrillationin all patients with an ejection fraction< 50% over a 2-year span (n=44), and compared to an age-matched cohort with preserved ejection fraction ablated over the same span in time (n=44). Blood pressure was not significantly managed differently between the groups, and did not appear to be influenced by the use of invasive arterial blood pressure monitoring.Hemodynamic management is similar across the spectrum of ejection fraction, regardless of invasive arterial blood pressure monitoring, which challenges the need for invasive arterial blood pressure monitoringduringcatheter ablation ofatrial fibrillationin left ventricular systolic dysfunction.

Sex Differences in the Association between Atrial Fibrillation and 90-Day Adverse Outcomes among Older Adults with Heart Failure: A Retrospective Cohort Study

Sex differences in the prognostic impact of coexisting atrial fibrillation (AF) in older patients with heart failure (HF) have not been well-studied. This study, therefore, compared sex differences in the association between AF and its 90-day adverse outcomes (hospital readmissions and emergency room (ER) visits) among older adults with HF. Of the 250 older adult patients, the prevalence rates of coexisting AF between male and female HF patients were 46.0% and 31.0%, respectively. In both male and female older patients, patients with AF have a significantly higher readmission rate (male 46.0%, and female 34.3%) than those without AF (male 6.8%, and female 12.8%). However, there are no significant differences in the association between AF and ER visits in both male and female older HF patients. The multivariate logistic analysis showed that coexisting AF significantly increased the risk of 90-day hospital readmission in both male and female older patients. In addition, older age in males and longer periods of time after an HF diagnosis in females were associated with an increased risk of hospital readmission. Consequently, prospective cohort studies are needed to identify the impact of coexisting AF on short- and long-term outcomes in older adult HF patients by sex.

Rhythm Control in Heart Failure Patients with Atrial Fibrillation

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

Circulating exosomal microRNAs as emerging non-invasive clinical biomarkers in heart failure: Mega bio-roles of a nano bio-particle

Exosomes are nano-sized extracellular vesicles containing a cell-specific biologically active cargo of proteins and genetic materials. Exosomes are constitutively released from almost all cell-types and affect neighboring or distant cells through a complex intercellular exchange of the genetic information and/or regulation of certain gene expressions that change the function and behavior of recipient cells. Those released into body fluids are the major mediators of intercellular communications. The success of the biological functions of exosomes is highly mediated by the effective transfer of microRNAs (miRs). Exosomes secreted by a damaged or diseased heart can exhibit alterations in the miRs' profile that may reflect the cellular origin and (patho)physiological state, as a "signature" or "fingerprint" of the donor cell. It has been shown that the transportation of cardiac-specific miRs in exosomes can be rapidly detected and measured, holding great potential as biomarkers in heart diseases. Currently, the search for new biomarkers of heart diseases remains a large and increasing enterprise. Notably, circulating exosomal miRs (Exo-miRs) have successfully gained huge interests for their diagnostic and prognostic potentials. The present review highlights circulating Exo-miRs explored for diagnosis/prognosis and outcome prediction in patients with heart failure (HF). To this end, we explain the feasibility of exosomes as clinical biomarkers, discuss the priority of circulating Exo-miRs over non-exosomal ones as a biomarker, and then outline reported circulating Exo-miRs having the biomarker function in HF patients, together with their mechanism of action. In conclusion, circulating Exo-miRs represent emerging diagnostic (Exo-miR-92b-5p, Exo-miR-146a, Exo-miR-181c, and Exo-miR-495) and prognostic (Exo-miR-192, Exo-miR-194, Exo-miR-34a, Exo-miR-425, Exo-miR-744) biomarkers for HF.

Heart Failure and Atrial Fibrillation, Like Fire and Fury

Heart failure and atrial fibrillation are 2 common cardiovascular disorders that frequently complicate one another and exert a significant detrimental effect on cardiovascular health and well-being. Both heart failure and atrial fibrillation continue to increase in prevalence as the risk factors underlying each condition become more common. This review encompasses what is currently known about the epidemiology and pathophysiology of these comorbidities along with incorporation of landmark trials that have contributed to current guidelines. The focus is on clinically relevant considerations, including the contribution of inflammation in the pathophysiology of atrial fibrillation and heart failure. We explore the emerging role of catheter ablation relative to medical therapy in the management of heart failure with reduced ejection fraction, along with indications for biventricular pacing modalities in cardiac resynchronization therapy. We discuss current guideline-directed therapies and how practice models and national recommendations will likely change based on the most recent randomized controlled trials.

The clinical implication of new-onset in-hospital atrial fibrillation in patients with acute decompensated heart failure

BACKGROUND

To investigate the clinical implication of the temporal difference in atrial fibrillation (AF)-onset in acute decompensated heart failure (ADHF) and its impact on post-discharge prognosis.

METHODS

336 new-onset ADHF patients without any history of AF before admission were enrolled (201 males, 63 ± 16 year-old) and classified into two groups based on their history of AF: the Control group (No AF was detected during hospitalization, n = 278), and the In-hos-AF group (AF occurred during hospitalization, n = 58). Post discharge prognosis including rehospitalization due to worsening HF, cardiac death, all-cause death and cerebrovascular event were compared.

RESULTS

Kaplan-Meier analysis demonstrated that the incidence of rehospitalization due to HF, cardiac death, all-cause death and cerebrovascular event in the In-hos-AF group was not significantly different from that in the Control group (P > 0.05 respectively). However, when AF recurred in the In-hos-AF group patients (n = 24, 41%) after discharge, the incidence of rehospitalization due to HF and cardiac deaths were higher than those without AF recurrence (P = 0.018 and P = 0.027 respectively). Cox proportional analysis revealed that AF developing after discharge was proven to be an independent risk factor for rehospitalization due to HF (HR 1.845, P = 0.043), cardiac death (HR 3.562, P = 0.013) and all-cause deaths (HR 2.138, P = 0.020).

CONCLUSION

Clinical outcomes of new-onset in-hospital AF patients were as good as those without AF history until AF recurrence. However, AF recurrence led to worse prognosis. Therefore, treatment for new-onset in-hospital AF in ADHF patients might be postponed until AF recurrence.

Outcomes of diuretics in rheumatic heart disease with compensated chronic heart failure: a retrospective study

Aims

The purpose of this retrospective propensity score‐matched study was to evaluate the superiority of different application approaches [continuous diuretics use (CDU) vs. intermittent diuretics use (IDU)] and types [loop diuretics (LDs) vs. thiazide diuretics (TDs)] of diuretics on long‐term outcomes for rheumatic heart disease (RHD) patients with compensated chronic heart failure (CHF).

Methods and results

A total of 494 RHD patients with compensated CHF were analysed after propensity score matching. Cox proportional hazards regression model was used to investigate the associations of different diuretic application approaches and types with all‐cause mortality, cardiovascular death (CVD), and cerebrovascular death. Binary logistic regression analyses were used to evaluate the associations of different diuretic application approaches and types with 1‐, 3‐, and 5‐year heart failure (HF) re‐hospitalization as well as new‐onset atrial fibrillation (AF). In the comparison between IDU and CDU strategies for RHD patients with compensated CHF, CDU was associated with increased risks of all‐cause mortality [adjusted hazard ratio (HR) = 2.47, 95% confidence interval (CI): 1.54–3.97, P < 0.001] and CVD (adjusted HR = 3.67, 95% CI: 1.95–6.89, P < 0.001) except cerebrovascular death (adjusted HR = 1.07, 95% CI: 0.34–3.41, P = 0.905). CDU was also associated with increased risks of 3‐year [adjusted odds ratio (OR) = 1.80, 95% CI: 1.09–2.96, P = 0.022] and 5‐year (adjusted OR = 2.02, 95% CI: 1.18–3.45, P = 0.010) HF re‐hospitalization risk and new‐onset AF (adjusted OR = 2.34, 95% CI: 1.31–4.20, P = 0.004) except 1‐year HF re‐hospitalization risk (adjusted OR = 1.54, 95% CI: 0.88–2.70, P = 0.130). In the comparison between TDs and LDs among study participants receiving IDU strategy, LDs were only associated with decreased 1‐year HF re‐hospitalization risk (adjusted OR = 0.30, 95% CI: 0.12–0.77, P = 0.012) rather than all‐cause mortality, CVD, cerebrovascular death, 3‐ and 5‐year HF re‐hospitalization, and new‐onset AF (all adjusted P > 0.05). In the comparison between TDs and LDs among study participants receiving CDU strategy, LDs were not associated with cerebrovascular death and 1‐year HF re‐hospitalization (both adjusted P > 0.05) but with increased risks of all‐cause mortality (adjusted HR = 1.80, 95% CI: 1.09–2.99, P = 0.023), CVD (adjusted HR = 1.89, 95% CI: 1.04–3.44, P = 0.037), 3‐year (adjusted OR = 1.91, 95% CI: 1.06–3.43, P = 0.031) and 5‐year (adjusted OR = 2.16, 95% CI: 1.12–4.19, P = 0.022) HF re‐hospitalization, and new‐onset AF (adjusted OR = 2.66, 95% CI: 1.25–5.68, P = 0.012).

Conclusions

Continuous diuretics use (especially LDs) was associated with increased risks of all‐cause mortality, CVD, medium‐term/long‐term HF re‐hospitalization, and new‐onset AF in RHD patients with compensated CHF.

Addressing Comorbidities in Heart Failure: Hypertension, Atrial Fibrillation, and Diabetes

Heart failure (HF) is a growing global epidemic and an increasingly cumbersome burden on health care systems worldwide. As such, optimal management of existing comorbidities in the setting of HF is particularly important to prevent disease progression, reduce HF hospitalizations, and improve quality of life. In this review, the authors address 3 key comorbidities commonly associated with HF: hypertension, atrial fibrillation, and diabetes mellitus. They comprehensively describe the epidemiology, management, and emerging therapies in these 3 disease states as they relate to the overall HF syndrome.

Novel oral anticoagulant vs. warfarin in elderly atrial fibrillation patients with normal, mid-range, and reduced left ventricular ejection fraction

Aims

Patients with concomitant atrial fibrillation (AF) and reduced left ventricular ejection fraction (LVEF) have poor prognosis. Outcomes of novel oral anticoagulant (NOAC) in elderly AF patients with normal, mid‐range, and reduced LVEF were investigated.

Methods and results

Data were retrieved from Chang Gung Research Database during 2010–2017 for patients with AF. We excluded patients with venous thromboembolism within 6 months, total knee/hip replacement and heart valve replacement within 6 months, end‐stage renal disease, stroke/systemic embolism (SE)/death within 7 days, age <65 years old, or no records of LVEF. Primary outcomes were ischaemic stroke (IS)/SE, major bleeding, and death from any cause. There was a total of 50 035 elderly AF patients retrieved. After exclusion criteria, 9615 patients with normal LVEF ≥ 50%, 737 with mid‐range LVEF 41–49%, and 908 with reduced LVEF ≤ 40% were studied. At end of follow‐up, patients on NOAC had significantly reduced IS/SE compared with warfarin in LVEF ≥ 50% [adjusted hazard ration (aHR) 0.80, 95% confidence interval (CI) 0.71–0.89] and LVEF 41–49% (aHR 0.57, 95% CI 0.36–0.88) after adjusting for covariates, while there was no difference in LVEF ≤ 40%. Patients on NOAC had significantly reduced major bleeding in all LVEF groups. In addition, patients on NOAC had significantly reduced death compared with warfarin in LVEF ≥ 50% (aHR 0.81, 95% CI 0.67–0.98).

Conclusions

In elderly AF patients ≥65 years, using NOAC was associated with lower IS/SE compared with warfarin in normal and mid‐range LVEF but not in reduced LVEF. Using NOACs was associated with lower death compared with warfarin in normal LVEF.

Prospective association of obstructive sleep apnea risk factors with heart failure and its subtypes in postmenopausal women: The Women's Health Initiative

STUDY OBJECTIVES

The relationship between obstructive sleep apnea (OSA) and heart failure (HF) incidence in postmenopausal women has been understudied, given the limited representation of women in heart failure studies. We investigated the relationship between OSA risk factors and HF and its subtypes in postmenopausal women.

METHODS

We performed a prospective analysis on the adjudicated HF outcomes in the Women's Health Initiative from enrollment (1993-1998) to September 30, 2016. HF with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) were defined as adjudicated acute HF hospitalization with EF ≥ 45% or < 45%, respectively. We employed Cox regression to examine the association between OSA risk factors and symptoms (individually and using a summary risk score) and time to first hospitalized HF.

RESULTS

Of 42,362 women, 2,205 (5.21%) developed all HF, 1,162 (2.74%) women developed HFpEF, and 679 (1.60%) developed HFrEF. Individual OSA risk factors and symptoms, including obesity (hazard ratio = 1.33, 95% confidence interval [CI] 1.20-1.48), snoring (hazard ratio = 1.30, 95% CI 1.16-1.46), and hypertension (HR = 1.45, 95% CI 1.35-1.56), were positively associated with risk of HF and HFpEF, but only hypertension was associated with HFrEF. When examined as a summary risk score compared with those with none of the OSA risk factors, presence of each additional factor was significantly associated with increased risk of hospitalized HF in a dose-response fashion for HFpEF (P trend < .001), but not HFrEF (P trend = .26).

CONCLUSIONS

OSA risk factors and symptoms were associated with HFpEF, but not HFrEF, among postmenopausal women and are largely dependent on body mass index, snoring, and hypertension.

Heart failure-induced atrial remodelling promotes electrical and conduction alternans

Heart failure (HF) is associated with an increased propensity for atrial fibrillation (AF), causing higher mortality than AF or HF alone. It is hypothesized that HF-induced remodelling of atrial cellular and tissue properties promotes the genesis of atrial action potential (AP) alternans and conduction alternans that perpetuate AF. However, the mechanism underlying the increased susceptibility to atrial alternans in HF remains incompletely elucidated. In this study, we investigated the effects of how HF-induced atrial cellular electrophysiological (with prolonged AP duration) and tissue structural (reduced cell-to-cell coupling caused by atrial fibrosis) remodelling can have an effect on the generation of atrial AP alternans and their conduction at the cellular and one-dimensional (1D) tissue levels. Simulation results showed that HF-induced atrial electrical remodelling prolonged AP duration, which was accompanied by an increased sarcoplasmic reticulum (SR) Ca²⁺ content and Ca²⁺ transient amplitude. Further analysis demonstrated that HF-induced atrial electrical remodelling increased susceptibility to atrial alternans mainly due to the increased sarcoplasmic reticulum Ca²⁺-ATPase (SERCA) Ca²⁺ reuptake, modulated by increased phospholamban (PLB) phosphorylation, and the decreased transient outward K⁺ current (I_to). The underlying mechanism has been suggested that the increased SR Ca²⁺ content and prolonged AP did not fully recover to their previous levels at the end of diastole, resulting in a smaller SR Ca²⁺ release and AP in the next beat. These produced Ca²⁺ transient alternans and AP alternans, and further caused AP alternans and Ca²⁺ transient alternans through Ca²⁺→AP coupling and AP→Ca²⁺ coupling, respectively. Simulation of a 1D tissue model showed that the combined action of HF-induced ion channel remodelling and a decrease in cell-to-cell coupling due to fibrosis increased the heart tissue’s susceptibility to the formation of spatially discordant alternans, resulting in an increased functional AP propagation dispersion, which is pro-arrhythmic. These findings provide insights into how HF promotes atrial arrhythmia in association with atrial alternans.

Atrial Fibrillation (AF) is the most common arrhythmia in adults, especially in the elderly, with the increased incidence of stroke being a major complication that increases morbidity and mortality. The occurrence of AF is often accompanied by heart failure (HF). AF and HF are also known to have the bidirectional relationship that AF worsens HF and HF promotes AF. HF can induce atrial remodelling, including electrical remodelling, atrial fibrosis, stretch and dilatation, and oxidative stress, in which many factors are associated with arrhythmogenic atrial alternans. HF-induced atrial remodelling varies during various stages and complications of HF, but possible mechanisms underlying their pro-susceptibility to alternans have not been completely elucidated. In this study, we investigated the effects of HF-induced atrial remodelling with prolonged action potential duration (APD) and decreased cell-to-cell coupling on susceptibility to atrial alternans. Simulation results showed that HF-induced an increase in sarcoplasmic reticulum Ca²⁺-ATPase (SERCA) Ca²⁺ reuptake caused by increased phospholamban phosphorylation and a decrease in transient outward K⁺ current played significant roles in the genesis of Ca²⁺ transient alternans and action potential alternans at the single-cell level. The HF-induced decline of cell-to-cell coupling and APD prolongation promoted the genesis of spatially discordant alternans in atrial tissue. This provides insights into how HF facilitates atrial arrhythmia in relation to atrial alternans.

Advancing Research on the Complex Interrelations Between Atrial Fibrillation and Heart Failure: A Report From a US National Heart, Lung, and Blood Institute Virtual Workshop

The interrelationships between atrial fibrillation (AF) and heart failure (HF) are complex and poorly understood, yet the number of patients with AF and HF continues to increase worldwide. Thus, there is a need for initiatives that prioritize research on the intersection between AF and HF. This article summarizes the proceedings of a virtual workshop convened by the US National Heart, Lung, and Blood Institute to identify important research opportunities in AF and HF. Key knowledge gaps were reviewed and research priorities were proposed for characterizing the pathophysiological overlap and deleterious interactions between AF and HF; preventing HF in people with AF; preventing AF in individuals with HF; and addressing symptom burden and health status outcomes in AF and HF. These research priorities will hopefully help inform, encourage, and stimulate innovative, cost-efficient, and transformative studies to enhance the outcomes of patients with AF and HF.

The management of atrial fibrillation in heart failure: an expert panel consensus

Heart failure (HF) and atrial fibrillation (AF) often coexist, being closely interrelated as the one increases the prevalence and incidence and worsens the prognosis of the other. Their frequent coexistence raises several challenges, including under-diagnosis of HF with preserved ejection fraction in AF and of AF in HF, characterization and diagnosis of atrial cardiomyopathy, target and impact of rate control therapy on outcomes, optimal rhythm control strategy in the era of catheter ablation, HF-related thromboembolic risk and management of anticoagulation in patients with comorbidities, such as chronic kidney disease or transient renal function worsening, coronary artery disease or acute coronary syndromes, valvular or structural heart disease interventions and cancer. In the present document, derived by an expert panel meeting, we sought to focus on the above challenging issues, outlining the existing evidence and identifying gaps in knowledge that need to be addressed.

Implantable Cardioverter-Defibrillators in Trials of Drug Therapy for Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND Medical therapy for heart failure with reduced ejection fraction evolved since trials validated the use of implantable cardioverter-defibrillators (ICDs). We sought to evaluate the performance of ICDs in reducing mortality in the era of modern medical therapy by means of a systematic review and meta-analysis of contemporary randomized clinical trials of drug therapy for heart failure with reduced ejection fraction. METHODS AND RESULTS We systematically identified randomized clinical trials that evaluated drug therapy in patients with heart failure with reduced ejection fraction that reported mortality. Studies that enrolled <1000 patients, patients with left ventricular ejection fraction >40%, or patients in the acute phase of heart failure and study treatment with devices were excluded. We identified 8 randomized clinical trials, including 31 701 patients of whom 3631 (11.5%) had an ICD. ICDs were associated with a lower risk of all-cause mortality (relative risk [RR], 0.85; 95% CI, 0.78-0.94) and sudden cardiac death (RR, 0.49; 95% CI, 0.40-0.61). Results were consistent among studies published before and after 2010. In meta-regression analysis, the proportion of nonischemic etiology did not affect the associated benefit of ICD. CONCLUSIONS In our meta-analysis of contemporary randomized trials of drug therapy for heart failure with reduced ejection fraction, the rate of ICD use was low and associated with a decreased risk in both all-cause mortality and sudden cardiac death. This benefit was still present in trials with new medical therapy.

Safety of catheter ablation for atrial fibrillation in the octogenarian population

INTRODUCTION

Catheter ablation (CA) has been shown to be an effective treatment for atrial fibrillation (AF). The complication rates and outcomes among octogenarians remain poorly studied. We aimed to compare trends, morbidity, and mortality associated with CA for AF among octogenarians versus those less than 80 years old.

METHODS

Using weighted sampling from the National Inpatient Sample database, we identified patients with a primary diagnosis of AF and a primary procedure of CA (2004-2013). Our primary outcome was mortality. Secondary outcomes included incidence of major and minor complications.

RESULTS

Among 86,119 patients who underwent CA for AF, 3,482 were 80 years old or older. Complications were significantly more frequent in octogenarians; [16.2% (564 of 3,482) versus 9.8% (8,092 of 82,637), P < 0.001]. Of note, there was no significant difference for the composite of major complications; [3.6% (124 of 3482) in octogenarians versus 2.8% (2286 of 82637), P = 0.20]. The total mortality rate was not significant in a multivariate regression analysis (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.35-2.64; P = .94). The presence of chronic renal failure (OR, 4.19; 95% CI, 2.75-6.36; P < 0.001), anemia (OR, 1.75; 95% CI, 1.03-2.97; P = .04), and chronic pulmonary disease (OR, 1.75; 95% CI, 1.11-2.62; P = .015) were predictors of major complications in octogenarians.

CONCLUSION

Catheter ablation for AF in octogenarians does not confer a higher mortality risk than in those less than 80 years old. The procedure is associated with a higher rate of overall complications but there was no difference in terms of major complications or death. The presence of anemia, CKD or pulmonary disease were predictors of major complications in octogenarians.

Modelling the lifetime cost-effectiveness of catheter ablation for atrial fibrillation with heart failure

OBJECTIVES

Assessing the cost-effectiveness credentials of this intervention in patients with concomitant atrial fibrillation (AF) and heart failure (HF) compared with usual medical therapy.

DESIGN

A Markov model comprising two health states (ie, alive or dead) was constructed. The transition probabilities were directly derived from published Kaplan-Meier curves of the pivotal randomised controlled trial and extrapolated over the cohort's lifetime using recommended methods. Costs of catheter ablation, outpatient consultations, hospitalisation, medications and examinations were included. Resource use and unit costs were sourced from government websites or published literature. A lifetime horizon and a healthcare system perspective were taken. All costs and benefits were discounted at 3% annually. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were run around the key model parameters to test the robustness of the base case results.

PARTICIPANTS

A hypothetical Australian cohort of patients with concomitant AF and HF who are resistant to antiarrhythmic treatment.

INTERVENTIONS

Catheter ablation versus medical therapy.

RESULTS

The catheter ablation was associated with a cost of $A44 377 per person, in comparison to $A28 506 for the medical therapy alone over a lifetime. Catheter ablation contributed to 4.58 quality-adjusted life years (QALYs) and 6.99 LY gains compared with 4.30 QALYs and 6.53 LY gains, respectively, in the medical therapy arm. The incremental cost-effectiveness ratio was $A55 942/QALY or $A35 020/LY. The DSA showed that results were highly sensitive to costs of ablation and time horizon. The PSA yielded very consistent results with the base case.

CONCLUSIONS

Offering catheter ablation procedure to patients with systematic paroxysmal or persistent AF who failed to respond to antiarrhythmic drugs was associated with higher costs, greater benefits. When compared with medical therapy alone, this intervention is not cost-effective from an Australia healthcare system perspective.