Risk Factor Management in Atrial Fibrillation

Left atrial strain measured by three-dimensional echocardiography predicts atrial fibrillation in the general population

BACKGROUND

Left atrial (LA) strain by three-dimensional echocardiography (3DE), has been proposed as a more accurate measure of LA function, providing incremental prognostic benefits over traditional two-dimensional approaches.

OBJECTIVES

Our aim was to evaluate the prognostic value of LA strain by 3DE in predicting incident atrial fibrillation (AF) in the general population.

METHODS

The study included 4466 participants from a prospective longitudinal cohort study in the general population, among these 3DE LA strain was analysed in 1935 participants. The endpoint was incident AF. Adjustments were made for the CHARGE-AF clinical risk score.

RESULTS

Mean age was 54 ± 17 years, 43 % were male. During a median follow-up time of 4.8 years (interquartile range 4.3-5.5 years) 59 participants (3.0 %) developed AF. In univariable analysis, all three parameters were associated with incident AF (p value for all <0.01). After multivariable adjustments, only LA reservoir strain (LASr) and LA contractile strain (LASct) were associated with incident AF (LASr: HR 1.12 (1.07-1.17), p < 0.001, per 1 % decrease; LASct: HR 1.16 (1.09-1.24), p < 0.001, per 1 % decrease), whereas LA conduit strain (LAScd) was not (HR 1.04 (0.98-1.10), p = 0.17, per 1 % decrease). Both LASr (continuous net reclassification index 0.37 ± 0.14; p = 0.003) and LASct (continuous net reclassification index 0.41 ± 0.14; p = 0.002) provided incremental prognostic information beyond the CHARGE-AF risk score.

CONCLUSION

LASr and LASct measured by 3DE are independently associated with incident AF and provided incremental prognostic information beyond existing risk scores.

Exploring Diet-Based Treatments for Atrial Fibrillation: Patient Empowerment and Citizen Science as a Model for Quality-of-Life-Centered Solutions

Atrial fibrillation (AF) is the most common heart rhythm disorder in the Western world. Between the years 2010 and 2019, the global prevalence of AF rose from 33.5 million to 59 million, highlighting the importance of developing equitable treatments for patients. The disease is associated with symptoms such as palpitations, dizziness, fatigue, shortness of breath, and cognitive dysfunction. In addition, AF increases the risk of developing a stroke and heart failure. Despite new insights into risk factors that can lead to the development of AF, the success of current treatments is suboptimal. Numerous risk factors, such as hypertension, diabetes, and obesity, have been associated with the development and progression of AF. As these can be lifestyle-related risk factors, lifestyle modification may be a solution to reduce AF-related symptoms as well as episodes. Research results show that certain dietary changes can reduce AF and numerous risk factors for AF. Increasing attention is being given to Mediterranean and whole, plant-based eating patterns, which emphasize eating grains, legumes, vegetables, fruits, and nuts, while excluding most-or all-animal products. Hence, what are the beneficial aspects of a Mediterranean and plant-based diet which consists mainly of unprocessed foods? In the current review, we discuss the outcomes of diet-based treatments. Moreover, other diet-related treatments, brought up by patient initiatives, are highlighted. These patient-initiated studies include L-glutamine and electrolytes as options to manage AF. Also, we highlight the emerging importance of valuing patient needs and a quality-of-life-centered approach to medicine. As indicated by recent studies and patient experiences, citizen science can create inclusive solutions that lead to patient empowerment and a holistic approach for AF management.

Trends in atrial fibrillation-related mortality in Europe, 2008-2019

AIMS

Update data regarding the atrial fibrillation (AF)-related mortality trend in Europe remain scant. We assess the age- and sex-specific trends in AF-related mortality in the European states between the years 2008 and 2019.

METHODS AND RESULTS

Data on cause-specific deaths and population numbers by sex for European countries were retrieved through the publicly available World Health Organization mortality dataset for the years 2008-2019. Atrial fibrillation-related deaths were ascertained when the International Classification of Diseases, 10th Revision code I48 was listed as the underlying cause of death in the medical death certificate. To calculate annual trends, we assessed the average annual % change (AAPC) with relative 95% confidence intervals (CIs) using Joinpoint regression. During the study period, 773 750 AF-related deaths (202 552 males and 571 198 females) occurred in Europe. The age-adjusted mortality rate (AAMR) linearly increased from 12.3 (95% CI: 11.2-12.9) per 100 000 population in 2008 to 15.3 (95% CI: 14.7-15.7) per 100 000 population in 2019 [AAPC: +2.0% (95% CI: 1.6-3.5), P < 0.001] with a more pronounced increase among men [AAPC: +2.7% (95% CI: 1.9-3.5), P < 0.001] compared with women [AAPC: +1.7% (95% CI: 1.1-2.3), P < 0.001] (P for parallelism 0.01). Higher AAMR increases were observed in some Eastern European countries such as Latvia, Lithuania, and Poland, while the lower increases were mainly clustered in Central Europe.

CONCLUSION

Over the last decade, the age-adjusted AF-related mortality has increased in Europe, especially among males. Disparities still exist between Western and Eastern European countries.

Intracerebral hemorrhage mortality in individuals with atrial fibrillation: a nationwide analysis of mortality trends in the United States

BACKGROUND

Atrial fibrillation (AF) is a risk factor for intracerebral hemorrhage (ICH), both with and without use of anticoagulation. Limited data exists on mortality trends and disparities related to this phenomenon. We aimed to assess ICH mortality trends and disparities based on demographic factors in individuals with atrial fibrillation in the United States (US).

METHODS

Our cross-sectional analysis utilized mortality data from the CDC database through death certificate queries from the years 1999 to 2020 in the US. We queried for all deaths with ICH as the underlying cause of death and atrial fibrillation as the multiple causes of death. Mortality data was obtained for overall population and demographic subpopulations based on sex, race and ethnicity, and geographic region. Trend analysis and average annual-mortality percentage change (AAPC) were completed using log-linear regression models.

RESULTS

ICH age-adjusted mortality rate (AAMR) in patients with AF increased from 0.27 (95% CI 0.25-0.29) in 1999 to 0.30 (95% CI 0.29-0.32) in 2020. A higher mortality rate was observed in males (AAMR 0.33) than in females (AAMR 0.26). The highest mortality was found in Asian/Pacific Islander (AAMR: 0.32) populations, followed by White (AAMR: 0.30), Black (AAMR: 0.15), and American Indian/Alaska Native (AAMR: 0.11) populations. Southern (AAPC: 1.3%) and non-metropolitan US regions (AAPC: + 1.9%) had the highest increase in annual mortality change.

CONCLUSION

Our findings highlight the disparities in ICH mortality in patients with AF. Further investigation is warranted to confirm these findings and evaluate for contributors to the observed disparities.

Direct oral anticoagulants for stroke prevention in patients with device-detected atrial fibrillation: assessing net clinical benefit

Subclinical, device-detected atrial fibrillation (AF) is frequently recorded by pacemakers and other implanted cardiac rhythm devices. Patients with device-detected AF have an elevated risk of stroke, but a lower risk of stroke than similar patients with clinical AF captured with surface electrocardiogram. Two randomized clinical trials (NOAH-AFNET 6 and ARTESiA) have tested a direct oral anticoagulant (DOAC) against aspirin or placebo. A study-level meta-analysis of the two trials found that treatment with a DOAC resulted in a 32% reduction in ischaemic stroke and a 62% increase in major bleeding; the results of the two trials were consistent. The annualized rate of stroke in the control arms was ∼1%. Several factors point towards overall net benefit from DOAC treatment for patients with device-detected AF. Strokes in ARTESiA were frequently fatal or disabling and bleeds were rarely lethal. The higher absolute rates of major bleeding compared with ischaemic stroke while on treatment with a DOAC in the two trials are consistent with the ratio of bleeds to strokes seen in the pivotal DOAC vs. warfarin trials in patients with clinical AF. Prior research has concluded that patients place a higher emphasis on stroke prevention than on bleeding. Further research is needed to identify the characteristics that will help identify patients with device-detected AF who will receive the greatest benefit from DOAC treatment.

Racial and Gender Differences in Cardiorespiratory Fitness and Atrial Fibrillation

The expanding field of cardiorespiratory fitness (CRF) in individuals with and without atrial fibrillation (AF) presents a complex landscape, demanding careful interpretation of the existing research. AF, characterized by significant mortality and morbidity, prompts the exploration of strategies to mitigate its impact. Increasing physical activity (PA) levels emerges as a promising avenue to address AF risk factors, such as obesity, hypertension, and diabetes mellitus, through mechanisms of reduced vasoconstriction, endothelin-1 modulation, and improved insulin sensitivity. However, caution is warranted, as recent investigations suggest a heightened incidence of AF, particularly in athletes engaged in high-intensity exercise, due to the formation of ectopic foci and changes in cardiac anatomy. Accordingly, patients should adhere to guideline-recommended amounts of low-to-moderate PA to balance benefits and minimize adverse effects. When looking closer at the current evidence, gender-specific differences have been observed and challenged conventional understanding, with women demonstrating decreased AF risk even at extreme exercise levels. This phenomenon may be rooted in divergent hemodynamic and structural responses to exercise between men and women. Existing research is predominantly observational and limited to racially homogenous populations, which underscores the need for comprehensive studies encompassing diverse, non-White ethnic groups in athlete and non-athlete populations. These individuals exhibit a disproportionately high burden of AF risk factors that could be addressed through improved CRF. Despite the limitations, randomized control trials offer promising evidence for the efficacy of CRF interventions in patients with preexisting AF, showcasing improvements in clinically significant AF outcomes and patient quality of life. The potential of CRF as a countermeasure to the consequences of AF remains an area of great promise, urging future research to delve deeper to explore its role within specific racial and gender contexts. This comprehensive understanding will contribute to the development of tailored strategies for optimizing cardiovascular health and AF prevention in all those who are affected.

Association between estimated glucose disposal rate and atrial fibrillation recurrence in patients undergoing radiofrequency catheter ablation: a retrospective study

OBJECTIVE

Previous studies have shown a clear link between insulin resistance (IR) and an elevated risk of atrial fibrillation (AF). However, the relationship between the estimated glucose disposal rate (eGDR), which serves as a marker for IR, and the risk of AF recurrence after radiofrequency catheter ablation (RFCA) remains uncertain. Therefore, this study aimed to examine the potential association between the eGDR and the risk of AF recurrence following RFCA.

METHODS

This retrospective study was conducted at Nanchang University Affiliated Second Hospital. The study enrolled 899 patients with AF who underwent RFCA between January 2015 and January 2022. The formula used to calculate the eGDR was as follows: 19.02 - (0.22 * body mass index) - (3.26 * hypertension) - (0.61 * HbA1c). Cox proportional hazard regression models and exposure-effect curves were used to explore the correlation between the baseline eGDR and AF recurrence. The ability of the eGDR to predict AF recurrence was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

The study observed a median follow-up period of 11.63 months, during which 296 patients experienced AF recurrence. K‒M analyses revealed that the cumulative incidence AF recurrence rate was significantly greater in the group with the lowest eGDR (log-rank p < 0.01). Participants with an eGDR ≥ 8 mg/kg/min had a lower risk of AF recurrence than those with an eGDR < 4 mg/kg/min, with a hazard ratio (HR) of 0.28 [95% confidence interval (CI) 0.18, 0.42]. Additionally, restricted cubic spline analyses demonstrated a linear association between the eGDR and AF recurrence (p nonlinear = 0.70). The area under the curve (AUC) for predicting AF recurrence using the eGDR was 0.75.

CONCLUSIONS

The study revealed that a decrease in the eGDR is associated with a greater AF recurrence risk after RFCA. Hence, the eGDR could be used as a novel biomarker for assessing AF recurrence risk.

Ablation Compared to Pharmacological Treatment for the Reduction of Atrial Fibrillation Recurrence: A Meta-Analysis

Atrial fibrillation (AF) is one of the most common heart arrhythmias, and due to its variable presentation, detecting and treating AF appropriately can reduce some of its serious complications. Among treatment options, surgical ablation and antiarrhythmic drug therapy are two of the most widely used choices. A systematic review and meta-analysis were conducted to examine the rates of AF recurrence in those treated with ablation compared to pharmacological treatment. Google Scholar and PubMed were searched for study trials published within the last decade that calculated the recurrence of AF symptoms in patient groups that received ablation or pharmacological treatment. Selected studies were analyzed in RevMan 5.4 software (The Cochrane Collaboration, London, England, UK), and each study's odds ratio and overall odds ratio were calculated using a 95% confidence interval. A total of seven studies with 2324 patients were analyzed for the meta-analysis, with 1162 patients receiving ablation and 1162 patients receiving pharmacological treatment. There was a statistically significant decrease in the recurrence of AF in the ablation group compared to the pharmacological treatment group, with a pooled odds ratio of 0.24 (CI 95% 0.14-0.39). AF treated with ablation was more effective in reducing AF recurrence than general pharmacological treatment.

NSTEMI mortality and hospital outcomes in patients with atrial fibrillation: A propensity score-matched analysis

Background

Atrial fibrillation (AF) is associated with increased cardiovascular mortality. Data regarding the relationship between coronary artery disease (CAD) and AF is mixed. It is uncertain if AF directly increases the risk for future coronary events and if such patients are appropriately evaluated for CAD.

Methods

This cross-sectional study was performed on hospitalized patients with NSTEMI and concurrent AF in 2019 using the National Inpatient Sample. In-hospital mortality, rates of diagnostic cardiac angiography, percutaneous coronary intervention, ventricular tachycardiac (VT), ventricular fibrillation (VF), cardiogenic shock, cardiac arrest, length of stay (LOS), and total hospitalization charges were studied.

Results

A total of 433,965 patients met inclusion criteria (169,725 females [39.1 %], 307,985 Caucasian [71 %], 51,570 African American [11.8 %], 37,265 Hispanic [8.6 %]; mean [SD] age, 67.9 [6.2] years). 86,200 (19.8 %) patients with NSTEMI had AF, including 32,775 (38 %) female patients before propensity matching. Patients with NSTEMI and AF had increased odds of mortality (adjusted Odds ratio, 1.32; CI, 1.21-1.43; p < 0.001). AF patients were less likely to undergo diagnostic coronary angiography and PCI and had higher odds of VT, VF, cardiogenic shock, cardiac arrest, tracheal intubation, mechanical ventilation, increased LOS, and higher hospital charges than those without AF.

Conclusion

AF was independently associated with increased mortality and serious cardiac complications in patients admitted with NSTEMI.

Atrial Fibrillation and Chronic Kidney Disease: Aetiology and Management

Chronic kidney disease (CKD) and atrial fibrillation (AF) are associated with significant cardiovascular morbidity and mortality. Recent studies have highlighted an increased prevalence and incidence of AF in patients with CKD. This article aims to provide a comprehensive review of current management strategies and considerations of treating atrial fibrillation with concomitant CKD. Potential electrophysiological mechanisms between AF and CKD are explored. Current evidence and literature focusing on pharmacological rate and rhythm control along with procedural intervention is reviewed and presented. The management of AF and CKD together is complex, but particularly pertinent when considering the close cyclical relationship in the progression of both diseases.

Genetic Susceptibility to Arrhythmia Phenotypes in a Middle Eastern Cohort of 14,259 Whole-Genome Sequenced Individuals

Background: The current study explores the genetic underpinnings of cardiac arrhythmia phenotypes within Middle Eastern populations, which are under-represented in genomic medicine research. Methods: Whole-genome sequencing data from 14,259 individuals from the Qatar Biobank were used and contained 47.8% of Arab ancestry, 18.4% of South Asian ancestry, and 4.6% of African ancestry. The frequency of rare functional variants within a set of 410 candidate genes for cardiac arrhythmias was assessed. Polygenic risk score (PRS) performance for atrial fibrillation (AF) prediction was evaluated. Results: This study identified 1196 rare functional variants, including 162 previously linked to arrhythmia phenotypes, with varying frequencies across Arab, South Asian, and African ancestries. Of these, 137 variants met the pathogenic or likely pathogenic (P/LP) criteria according to ACMG guidelines. Of these, 91 were in ACMG actionable genes and were present in 1030 individuals (~7%). Ten P/LP variants showed significant associations with atrial fibrillation p < 2.4 × 10-10. Five out of ten existing PRSs were significantly associated with AF (e.g., PGS000727, p = 0.03, OR = 1.43 [1.03, 1.97]). Conclusions: Our study is the largest to study the genetic predisposition to arrhythmia phenotypes in the Middle East using whole-genome sequence data. It underscores the importance of including diverse populations in genomic investigations to elucidate the genetic landscape of cardiac arrhythmias and mitigate health disparities in genomic medicine.

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.

Oxidative Stress, Inflammation, and Mitochondrial Dysfunction: A Link between Obesity and Atrial Fibrillation

The adipose tissue has long been thought to represent a passive source of triglycerides and fatty acids. However, extensive data have demonstrated that the adipose tissue is also a major endocrine organ that directly or indirectly affects the physiological functions of almost all cell types. Obesity is recognized as a risk factor for multiple systemic conditions, including metabolic syndrome, type 2 diabetes mellitus, sleep apnea, cardiovascular disorders, and many others. Obesity-related changes in the adipose tissue induce functional and structural changes in cardiac myocytes, promoting a wide range of cardiovascular disorders, including atrial fibrillation (AF). Due to the wealth of epidemiologic data linking AF to obesity, the mechanisms underlying AF occurrence in obese patients are an area of rich ongoing investigation. However, progress has been somewhat slowed by the complex phenotypes of both obesity and AF. The triad inflammation, oxidative stress, and mitochondrial dysfunction are critical for AF pathogenesis in the setting of obesity via multiple structural and functional proarrhythmic changes at the level of the atria. The aim of this paper is to provide a comprehensive view of the close relationship between obesity-induced oxidative stress, inflammation, and mitochondrial dysfunction and the pathogenesis of AF. The clinical implications of these mechanistic insights are also discussed.

Inflammation and Coagulation are Two Interconnected Pathophysiological Pathways in Atrial Fibrillation Pathogenesis

Introduction

Atrial fibrillation (AF) is associated with elevated levels of clotting factors such as tissue factor (TF) and factor XII (FXII). Various inflammation markers, such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF- α), and high-sensitive C-reactive protein (hs-CRP), have also been associated with AF. This study explores the relationship between inflammation markers and coagulation activity, including their impact on heart structural changes in these patients.

Methods

We observed 283 patients with nonvalvular AF who underwent a complete examination at admission, but only 183 patients have successful cardioversion. As a control group, similar patients without AF were examined. The markers of the coagulation and inflammation were studied by ELISA on the analyzer "Stat Fax 303 Plus". Studies were conducted using l statistical package SPSS 13.0.

Results

It was revealed that patients with AF had significantly higher levels of hs-CRP, IL-6, and TNF-α and had elevated levels of TF and FXII compared with control group. The moderate correlations were observed between IL-6 and left atrial diameter (LAD), IL-6 and LA stiffness, hs-CRP and left atrial volume (LAV), TF and LAV.

Conclusion

We have demonstrated that patients with AF have the relationship between elevated levels of inflammatory markers and coagulation activity, which contributes to structural atrial remodeling.

Risk factor modification as a treatment pillar in managing atrial fibrillation

ABSTRACT

Atrial fibrillation (AF) is common, with many modifiable and nonmodifiable risk factors contributing to its increasing prevalence. Pharmacologic management and invasive procedures are the mainstays of treatment, but cardiovascular risk modification is overlooked as a key adjuvant treatment strategy. This article describes the clinical effects of implementing a risk factor modification strategy to reduce dysrhythmia load.

Incidental parasympathetic cardiac denervation during atrial fibrillation ablation using high power short duration: a marker of long-term success

BACKGROUND

There are multiple factors in both technique and substrate that lead to recurrence of atrial fibrillation after ablation. We sought to examine whether the degree of heart rate increase (HRI) caused by concurrent high-power-short-duration (HPSD) incidental parasympathetic denervation during AF ablation predicts long term success. Between December 2018 and December 2021, prospectively enrolled 214 patients who presented in sinus rhythm at AF ablation. Used 50 W of power and contact force (CF) of 5-15 g and 10-20 g at a flow rate of 40 mL/min on the anterior and posterior left atrial walls, respectively.

RESULTS

Males were 143 (66.8%) and paroxysmal was 124 (57.9%) patients. Mean age 61.1 ± 12.3 years and follow-up time was 32.8 ± 13.2 months. Arrhythmia occurred after 90 days in 39 (18.2%) patients, 19 (48.7%) from the paroxysmal and 20 (51.3%) from the persistent AF patients. Recurrence group showed a lower HRI from a mean of 57 ± 7.7 to 64.4 ± 10.4 bpm (12.3%) while in success group HRI was from 53.8 ± 9.7 to 66.8 ± 11.6 bpm [(24.2%) p = 0.04]. We divided HRI in 3 percentiles of ≤ 8%, > 8 ≤ 37% and > 37%. A predictor of recurrence was identified in those in the first (< 8%, p = 0.006) and a predictor of success in the later (> 37%, p = 0.01) HRI percentile.

CONCLUSION

Atrial fibrillation ablation with HPSD incidental cardiac parasympathetic denervation identified that patients with lower heart rate increase are prone to recurrence while those with higher heart rate increase had higher maintenance of sinus rhythm at a long-term follow-up.

The Combination of Beta-Blockers and ACE Inhibitors Across the Spectrum of Cardiovascular Diseases

Cardiovascular disease is the leading cause of mortality worldwide, affecting a wide range of patients at different stages across the cardiovascular continuum. Hypertension is one of the earliest risk factors in this continuum and can be controlled in most patients with currently available antihypertensive agents. However, goals are often not met because treatments are not optimized in terms of tailoring therapy to individual patients based on their hypertension subclass and cardiovascular risk profile and initiating early use of adapted-dose, single-pill combinations. In this context, beta-blockers in combination with angiotensin-converting enzyme (ACE) inhibitors are of special interest as a result of their complementary actions on the sympathetic nervous system and renin-angiotensin-aldosterone system, two interlinked pathways that influence cardiovascular risk and disease outcomes. In addition to their antihypertensive actions, beta-blockers are used to manage arrhythmias and treat angina pectoris and heart failure, while ACE inhibitors provide cardioprotection in patients with acute coronary syndromes and treat congestive heart failure. A broad range of patients may therefore receive the combination in routine clinical practice. This paper examines the supporting evidence for beta-blockers and ACE inhibitors in each of the above indications and considers the rationale for combining these agents into a single pill, using data from bisoprolol and perindopril randomized controlled trials as supporting evidence. Combining these established antihypertensive agents into a single pill continues to provide effective blood pressure lowering and improved cardiovascular outcomes while allowing a greater proportion of patients to rapidly achieve treatment targets.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Neurohumoral Markers of Cardiac Autonomic Denervation after Surgical Ablation of Long-Standing Persistent Atrial Fibrillation

Although the autonomic nervous system has an evident impact on cardiac electrophysiology and radiofrequency ablation (RFA) is the conventional technique for treating persistent atrial fibrillation, the specific effects of RFA have been insufficiently studied to date. Here, we investigated whether RFA affects neurohumoral transmitter levels and myocardial 123I-metaiodobenzylguanidine (123I-MIBG) uptake. To perform this task, we compared two groups of patients with acquired valvular heart disease: patients who had undergone surgical AF ablation and patients with sinus rhythm. The decrease in norepinephrine (NE) level in the coronary sinus had a direct association with the heart-to-mediastinum ratio (p = 0.02) and a negative correlation with 123I-MIBG uptake defects (p = 0.01). The NE level decreased significantly after the main surgery, both in patients with AF (p = 0.0098) and sinus rhythm (p = 0.0039). Furthermore, the intraoperative difference between the norepinephrine levels in the ascending aorta and coronary sinus (ΔNE) of -400 pg/mL was determined as a cut-off value to evaluate RFA efficacy, as denervation failed in all patients with ΔNE < -400 pg/mL. Hence, ΔNE can be utilized to predict the efficacy of the "MAZE-IV" procedure and to assess the risk of AF recurrence after RFA.

Impact of Pulmonary Hypertension Hemodynamic Phenotype on Incident Atrial Fibrillation

INTRODUCTION

Atrial fibrillation/flutter (AF) is common among patients with pulmonary hypertension (PH) and is associated with poor clinical outcomes. AF has been shown to occur more commonly among patients with postcapillary PH, although AF also occurs among patients with precapillary PH. The goal of this study was to evaluate the independent impact of PH hemodynamic phenotype on incident AF among patients with PH.

METHODS

We retrospectively identified 262 consecutive patients, without a prior diagnosis of atrial arrhythmias, seen at the PH clinic at Mayo Clinic, Florida, between 1997 and 2017, who had right heart catheterization and echocardiography performed, with follow-up for outcomes through 2021. Kaplan-Meier analysis and Cox-proportional hazards regression modeling were used to evaluate the independent effect of PH hemodynamic phenotype on incident AF.

RESULTS

Our study population was classified into two broad PH hemodynamic groups: precapillary (64.9%) and postcapillary (35.1%). The median age was 59.5 years (Q1: 48.4, Q3: 68.4), and 72% were female. In crude models, postcapillary PH was significantly associated with incident AF (HR 2.17, 95% CI: 1.26-3.74, p = 0.005). This association was lost following multivariable adjustment, whereas left atrial volume index remained independently associated with incident AF (aHR 1.30, 95% CI: 1.09-1.54, p = 0.003).

CONCLUSION

We found PH hemodynamic phenotype was not significantly associated with incident AF in our patient sample; however, echocardiographic evidence of left atrial remodeling appeared to have a greater impact on AF development. Larger studies are needed to validate these findings and identify potential modifiable risk factors for AF in this population.

Clinical outcomes of a short-term family-focused intervention for patients with atrial fibrillation-A randomised clinical trial

AIMS

To evaluate a family-focused intervention for patients with atrial fibrillation (AF) in addition to conventional care and to establish its effect on health-related quality of life (HRQoL), anxiety, depression, AF symptoms, and family support.

BACKGROUND

AF is a widespread heart disease affecting the well-being of patients and their family members physically and psychologically. Supporting patients and their family members could potentially facilitate regaining family strength and improve HRQoL.

METHODS

Patients with newly diagnosed AF were randomised to standard care or additional family-focused intervention with change in global score of the Atrial Fibrillation Quality of Life Questionnaire (AFEQT) as primary outcome after six months' follow-up. Secondary outcomes included the Hospital Anxiety and Depression Score, the European Heart Rhythm Association score, the Ice Expressive Family Functioning Questionnaire, and the Ice Family-Perceived Support Questionnaire (ICE-FPSQ).

RESULTS

Sixty-eight patients received standard care (n = 35) or family focused intervention (n = 33). The median change at the six-month follow-up on the global AFEQT score was 4.17 (-1.46-9.17) in the control group and 5.83 (-2.5-30) in the intervention group, yielding a median difference of -1.67 (p = 0.500). Change in ICE-FPSQ showed significant positive scores in favour of intervention (p < 0.001); other secondary outcome changes were non-significant.

CONCLUSION

The family-focused intervention had a small positive but non-significant effect on HRQoL compared to standard care. To address the impact of AF on the patients and family members seems to improve anxiety and depression scores and perceived family support.

The effectiveness of atrial fibrillation special clinic on oral anticoagulant use for high risk atrial fibrillation patients managed in the community

BACKGROUND

Service gaps exist in oral anticoagulant (OAC) use among patients with atrial fibrillation (AF) in primary care. The purpose of this study was to explore the clinical effectiveness of a community dwelling Atrial Fibrillation Special Clinic (AFSC) run by primary care physicians by evaluating its impact on OAC use and the control of modifiable cardiovascular disease (CVD) risk factors in high risk AF patients.

METHOD

Quasi-experimental study was conducted in AFSC run by public primary care physicians in Hong Kong. Study subjects were high risk AF patients with CHA₂DS₂-VASc scores ≥ 2, who had been followed up (FU) at AFSC for at least one year from 01 August, 2019 to 31 October, 2020. OAC usage and modifiable CVD risk factor control were compared before and after one year of FU at AFSC. Drug-related adverse events, emergency attendance or hospitalisation episodes, survival and mortality rates after one year FU at AFSC were also reviewed.

RESULTS

Among the 299 high risk AF patients included in the study, significant increase in OAC use was observed from 58.5% at baseline to 82.6% after one year FU in AFSC (P < 0.001). Concerning CVD risk factor control, the average diastolic blood pressure level was significantly reduced (P = 0.009) and the satisfactory blood pressure control rate in non-diabetic patients was markedly improved after one year FU (P = 0.049). However, the average HbA1c and LDL-c levels remained static. The annual incidence rate of ischaemic stroke/systemic embolism was 0.4%, intra-cranial haemorrhage was 0.4%, major bleeding episode was 3.2% and all-cause mortality was 4.3%, all of which were comparable to reports in the literature.

CONCLUSION

AFSC is effective in enhancing OAC use and maintaining optimal modifiable CVD risk factor control among high risk AF patients managed in primary care setting, and therefore may reduce AF-associated morbidity and mortality in the long run.

The association of coagulation and atrial fibrillation: a systematic review and meta-analysis

AIMS

While atrial fibrillation (AF) is suggested to induce a prothrombotic state, increasing thrombotic risk, it is also hypothesized that coagulation underlies AF onset. However, conclusive evidence is lacking. With this systematic review and meta-analysis, we aimed to summarize and combine the evidence on the associations between coagulation factors with AF in both longitudinal and cross-sectional studies.

METHODS AND RESULTS

We systematically searched for longitudinal cohort and cross-sectional studies investigating AF and thrombosis. For longitudinal studies, pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. For cross-sectional studies, we determined pooled standardized mean differences (SMDs) and 95% CIs. A total of 17 longitudinal and 44 cross-sectional studies were included. In longitudinal studies, we found significant associations between fibrinogen (HR 1.05, 95% CI 1.00-1.10), plasminogen activator inhibitor 1 (PAI-1) (HR 1.06, 95% CI 1.00-1.12), and D-dimer (HR 1.10, 95% CI 1.02-1.19) and AF incidence. In cross-sectional studies, we found significantly increased levels of fibrinogen (SMD 0.47, 95% CI 0.20-0,74), von Willebrand factor (SMD 0.96, 95% CI 0.28-1.66), P-selectin (SMD 0.31, 95% CI 0.08-0.54), ß-thromboglobulin (SMD 0.82, 95% CI 0.61-1.04), Platelet Factor 4 (SMD 0.42, 95% CI 0.12-0.7), PAI-1 (1.73, 95% CI 0.26-3.19), and D-dimer (SMD 1.74, 95% CI 0.36-3.11) in AF patients, as opposed to controls.

CONCLUSION

These findings suggest that higher levels of coagulation factors are associated with prevalent and incident AF. These associations are most pronounced with prevalent AF in cross-sectional studies. Limited evidence from longitudinal studies suggests a prothrombotic state underlying AF development.

The Relation between Atrial Fibrillation Cardioversion Success Rate with Vitamin D Level in Patients Underwent Elective Cardioversion in King Abdulaziz Cardiac Center, King Abdulaziz Medical City for National Guards, Riyadh Saudi Arabia

Objectives

To investigate the relation between serum Vitamin D (Vit-D) levels and the success rate of cardioversion for atrial fibrillation (AF). To examine the association between Vit-D level and successful cardioversion. This study also describes the general characteristics of patients with successful cardioversion.

Materials and Methods

In this retrospective study, patients with AF who were treated using electrical cardioversion at King Abdulaziz Cardiovascular Center (KACC) between 2010 and 2021 were included. The information on demographic and clinical characteristics as well as outcome variables was collected.

Results

Of 100 patients who were admitted to KACC during the study period, 63% were females and 9% were diagnosed with Vit-D deficiency. Furthermore, 66% of patients had successful cardioversion. Moreover, no significant difference in Vit-D deficiency was observed between patients who had successful cardioversion and those with unsuccessful outcomes (P = 0.485).

Conclusions

There is no association between serum Vit-D levels and the success rate of cardioversion in patients with AF. However, further studies are needed for more conclusive evidence.

Predicting Atrial Fibrillation after Ischemic Stroke: Clinical, Genetics, and Electrocardiogram Modelling

INTRODUCTION

Detection of atrial fibrillation (AF) is challenging in patients after ischaemic stroke due to its paroxysmal nature. We aimed to determine the utility of a combined clinical, electrocardiographic, and genetic variable model to predict AF in a post-stroke population.

MATERIALS AND METHODS

We performed a cohort study at a single comprehensive stroke centre from November 09, 2009, to October 31, 2017. All patients recruited were diagnosed with acute ischaemic stroke or transient ischaemic attacks. Electrocardiographic variables including p-wave terminal force (PWTF), corrected QT interval (QTc), and genetic variables including single nucleotide polymorphisms (SNPs) at the 4q25 (rs2200733) were evaluated. Clinical, electrocardiographic and genetic variables of patients without AF and those who developed AF were compared. Multiple logistic regression analysis and receiver operating characteristics were performed to identify parameters and determine their ability to predict the occurrence of AF.

RESULTS

Out of 709 patients (median age of 59 years, inter-quartile range 52-67) recruited, sixty (8.5%) were found to develop AF on follow-up. Age (odds ratio [OR]): 3.49, 95% confidence interval [CI]: 2.03-5.98, p < 0.0001), hypertension (OR: 2.76, 95% CI: 1.36-5.63, p = 0.0052), and valvular heart disease (OR: 8.49, 95% CI: 2.62-27.6, p < 0.004) were the strongest predictors of AF, with an area under receiver operating value of 0.76 (95% CI: 0.70-0.82), and 0.82 (95% CI: 0.77-0.87) when electrocardiographic variables (PWTF and QTc) were added. SNP did not improve prediction modelling.

CONCLUSION

We demonstrated that a model combining clinical and electrocardiographic variables provided robust prediction of AF in our post-stroke population. Role of SNP in prediction of AF was limited.

Development and validation of a novel risk model for predicting atrial fibrillation recurrence risk among paroxysmal atrial fibrillation patients after the first catheter ablation

AIMS

Several models have been developed to predict the risk of atrial fibrillation (AF) recurrence after radiofrequency catheter ablation (RFCA). However, these models are of poor quality from the start. We, therefore, aimed to develop and validate a predictive model for post-operative recurrence of AF.

MATERIALS AND METHODS

In a study including 433 patients undergoing the first circumferential pulmonary vein isolation (CPVI) procedure, independent predictors of AF recurrence were retrospectively identified. Using the Cox regression of designated variables, a risk model was developed in a random sample of 70% of the patients (development cohort) and validated in the remaining (validation cohort) 30%. The accuracy and discriminative power of the predictive models were evaluated in both cohorts.

RESULTS

During the established 12 months follow-up, 134 patients (31%) recurred. Six variables were identified in the model including age, coronary artery disease (CAD), heart failure (HF), hypertension, transient ischemic attack (TIA) or cerebrovascular accident (CVA), and left atrial diameter (LAD). The model showed good discriminative power in the development cohort, with an AUC of 0.77 (95% confidence interval [CI], 0.69-0.86). Furthermore, the model shows good agreement between actual and predicted probabilities in the calibration curve. The above results were confirmed in the validation cohort. Meanwhile, decision curve analysis (DCA) for this model also demonstrates the advantages of clinical application.

CONCLUSION

A simple risk model to predict AF recurrence after ablation was developed and validated, showing good discriminative power and calibration.

Paraoxonase 1 and atrial fibrillation: Is there a relationship?

Atrial fibrillation (AF) is associated with oxidative stress and inflammation. Paraoxonase-1 (PON1), circulates in blood bound to high-density lipoproteins and reduces systemic oxidative stress. The aim of this study was to evaluate PON1 serum concentration and PON1 arylesterase activity (AREase) in patients with AF. We studied a group of 67 patients with symptomatic paroxysmal or persistent AF admitted for cardioversion and a control group of 59 patients without AF. Clinical parameters, lipid profile, PON1 concentration and AREase were evaluated. A significant difference in serum PON1 concentration and in AREase was found among the two groups. In a multivariate linear regression model, the presence of AF was associated with low PON1 concentration (P = .022). The body mass index was also independently associated with PON1 values (P < .001). Only the high-density lipoproteins-cholesterol level was independently associated with AREase (P = .002). PON1 serum concentrations and AREase were diminished in patients with AF, and the presence of AF was independently associated with low PON1 values.

Current Understanding of Atrial Fibrillation Recurrence After Atrial Fibrillation Ablation: From Pulmonary Vein to Epicardium

Recurrence of atrial fibrillation (AF) after catheter ablation is common, with pulmonary vein (PV) reconnection considered the most likely cause. However, technologies such as contact force-sensing, irrigated catheters, and ablation index (AI)-guided ablation strategies have resulted in more durable PV isolation. As a result, it is difficult to predict which patients will develop AF recurrence despite durable PV isolation, with evolving non-PV atrial substrates thought to be a key contributor to late recurrences. Deciphering the complex mechanisms of AF recurrence beyond the cornerstone of PV isolation therefore remains challenging. Recently, there have been several important advances that may lead to better understanding and treatment of this challenging clinical entity: percutaneous epicardial access and mapping, late gadolinium enhancement magnetic resonance imaging (LGE-MRI), improvements in high-resolution electroanatomic mapping, and new ablation energy sources, specifically pulsed-field ablation. This review aims to synthesize the current literature in an effort to better understand arrhythmia mechanisms and treatment targets in patients with AF/Atrial tachycardia (AT) recurrence post-ablation. This article is protected by copyright. All rights reserved.

Association between comorbidities and left and right atrial dysfunction in patients with paroxysmal atrial fibrillation: Analysis of AF-RISK

BACKGROUND

To identify the association between comorbidities and left atrial (LA) and right atrial (RA) function in patients with paroxysmal atrial fibrillation (AF).

METHODS

This is a cross-sectional study. Speckle-tracking echocardiography was performed in 344 patients with paroxysmal AF at baseline, and available in 298 patients after 1-year follow-up. The number of comorbidities (hypertension, diabetes mellitus, coronary artery disease, body mass index > 25 kg/m², age > 65 years, moderate to severe mitral valve regurgitation and kidney dysfunction (estimated glomerular filtration rate < 60 ml/min/1.73 m²)) was determined and the association with atrial strain was tested.

RESULTS

Mean age of the patients was 58 (SD 12) years and 137 patients were women (40%). Patients with a higher number of comorbidities had larger LA volumes (p for trend <0.001), and had a decrease in all strain phases from the LA and RA, except for the RA contraction phase (p for trend 0.47). A higher number of comorbidities was associated with LA reservoir and conduit strain decrease independently of LA volume (p < 0.001, p < 0.001 respectively). Patients with 1-2 comorbidities, but not patients with 3 or more comorbidities, showed a further progression of impaired LA and RA function in almost all atrial strain phases at 14 [13-17] months follow-up.

CONCLUSIONS

In patients with paroxysmal AF, individual and combined comorbidities are related to lower LA and RA strain. In patients with few comorbidities, impairment in atrial function progresses during one year of follow-up. Whether comorbidity management prevents or reverses decrease in atrial function warrants further study.

Population Attributable Risks of Potential Modifiable Factors for Atrial Fibrillation in China: A National Survey

Background

There is an association between atrial fibrillation (AF) and overall mortality as well as mobility. It is not known, however, what the preventable burden of AF in China is. This study aims to identify what proportion of the burden of AF may be avoided by modifiable risk factors.

Methods

As part of the China National Stroke Screening and Prevention Project, 726,451 adults aged ≥40 years were enrolled in a representative cross-sectional study. The following seven factors have been categorized as modifiable risk factors for AF: body mass index, smoking, alcohol consumption, physical inactivity, hypertension, diabetes mellitus, and dyslipidemia. In order to calculate population-attributable risks (PARs), odds ratios (ORs) were calculated for selected risk factors.

Results

The crude ORs increased with age (ORs ranged from 1.92 to 4.02). A total of 18,736 cases of prevalent AF have been identified. The overall prevalence of AF was 2.6%. The crude ORs increased with age (ORs range 1.92–4.03). The adjusted ORs and the corresponding confidence intervals (CIs) for these seven modifiable factors were 1.16 (95% confidence interval [CI]: 1.12–1.19), 1.56 (95% CI: 1.49–1.62), 2.15 (95% CI: 2.02–2.28), 2.07 (95% CI: 2.01–2.14), 2.71 (95% CI: 2.62–2.79), 2.10 (95% CI: 2.02–2.19), 2.52 (95% CI: 2.44–2.60), and 3.32 (95% CI: 3.18–3.48), respectively. Accordingly, 59.3% of all cases of AF could be explained by having these modifiable risk factors, among which hypertension accounted for the greatest share.

Conclusion

In China, hypertension is the leading preventable cause of AF, and more than half of these cases can be prevented through improving those modifiable risk factors.

Genetic and non-genetic risk factors associated with atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmic disorder and its prevalence in the United States is projected to increase to more than twelve million cases in 2030. AF increases the risk of other forms of cardiovascular disease, including stroke. As the incidence of atrial fibrillation increases dramatically with age, it is paramount to elucidate risk factors underlying AF pathogenesis. Here, we review tissue and cellular pathways underlying AF, as well as critical components that impact AF susceptibility including genetic and environmental risk factors. Finally, we provide the latest information on potential links between SARS-CoV-2 and human AF. Improved understanding of mechanistic pathways holds promise in preventative care and early diagnostics, and also introduces novel targeted forms of therapy that might attenuate AF progression and maintenance.

Expert Opinion on the Use of Novel Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation for the Primary Care Setting in India: A Literature Review

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia encountered in clinical practice, is linked with substantial morbidity and mortality due to accompanying risk of stroke and thromboembolism. Patients with AF are at a five-fold higher risk of suffering from a stroke. Anticoagulation therapy, with either vitamin K antagonists or novel oral anticoagulants (NOACs), is a standard approach to reduce the risk. Consultant physicians (CPs) in India are the primary point of contact for the majority of patients before they approach a specialist. The CPs may face challenges in screening and diagnosing AF patients. The apprehensions associated with managing AF patients with anticoagulants, further add to the challenges of a CP. This review aimed to identify the key decision points for the CPs to diagnose AF and initiate anticoagulation in patients with non-valvular AF (NVAF) and bring to the table a simplified recommendation supported by expert opinion and guidelines for stroke prevention in NVAF patients.

The pre-ablation triglyceride-glucose index predicts late recurrence of atrial fibrillation after radiofrequency ablation in non-diabetic adults

Background

Current prognostic risk scoring systems and biomarkers are routinely used as non-invasive methods for assessing late recurrence of atrial fibrillation (AF) in patients who have undergone radiofrequency catheter ablation (RFCA). This study aimed to investigate the predictive value of the triglyceride-glucose (TyG) index for late AF recurrence after RFCA in non-diabetic patients.

Methods

In total, 275 patients with AF who underwent RFCA at the Fuwai hospital (Beijing, China) between January 2016 and December 2018 were enrolled in this study. During follow up, patients were divided into late and non-late AF recurrence groups, based on whether they had experienced late AF recurrence determined by electrocardiography (ECG) examine or 48 h Holter monitoring. The TyG index was calculated using the following equation: ln [fasting triglycerides [mg/dL] × fasting glucose [mg/dL]/2].

Results

During a median follow-up of 26.1 months, late AF recurrence event rates significantly increased in the highest TyG index tertile group (tertile 3) compared to the lowest group (tertile 1) (54% versus 12%, respectively; p < 0.001). The mean TyG index was higher in the late AF recurrence group compared to the non- late AF recurrence group (9.42 ± 0.6 versus 8.68 ± 0.70, respectively; p < 0.001). On multivariate Cox regression analysis, the pre-ablation TyG index was an independent risk factor for late recurrence of AF after RFCA (hazard ratio [HR] 2.015 [95% confidence interval (CI): 1.408–4.117]; p = 0.009). Receiver operating characteristic (ROC) curve analysis revealed that TyG index was a significant predictor of late AF recurrence after RFCA, with an area under the ROC curve (AUC) of 0.737 (95% CI: 0.657–0.816; p < 0.001). In addition, the AUC of left atrial diameter (LAD) was 0.780 (95%CI: 0.703–0.857, p < 0.001). Finally, the TyG index positively correlated with LAD (r = 0.133, p = 0.027), high sensitivity C-reactive protein (r = 0.132, p = 0.028) and N-terminal pro B-type natriuretic peptide (r = 0.291, p < 0.001) levels.

Conclusions

An elevated pre-ablation TyG index was associated with an increased risk of late AF recurrence after RFCA in non-diabetic patients. The TyG index may be potentially useful as a novel biomarker for the risk stratification of late AF recurrence in non-diabetic patients.

Arrhythmogenic influence of mutations in a myocyte-based computational model of the pulmonary vein sleeve

In the heart, electrophysiological dysregulation arises from defects at many biological levels (from point mutations in ion channel proteins to gross structural abnormalities). These defects disrupt the normal pattern of electrical activation, producing ectopic activity and reentrant arrhythmia. To interrogate mechanisms that link these primary biological defects to macroscopic electrophysiologic dysregulation most prior computational studies have utilized either (i) detailed models of myocyte ion channel dynamics at limited spatial scales, or (ii) homogenized models of action potential conduction that reproduce arrhythmic activity at tissue and organ levels. Here we apply our recent model (EMI), which integrates electrical activation and propagation across these scales, to study human atrial arrhythmias originating in the pulmonary vein (PV) sleeves. These small structures initiate most supraventricular arrhythmias and include pronounced myocyte-to-myocyte heterogeneities in ion channel expression and intercellular coupling. To test EMI's cell-based architecture in this physiological context we asked whether ion channel mutations known to underlie atrial fibrillation are capable of initiating arrhythmogenic behavior via increased excitability or reentry in a schematic PV sleeve geometry. Our results illustrate that EMI's improved spatial resolution can directly interrogate how electrophysiological changes at the individual myocyte level manifest in tissue and as arrhythmia in the PV sleeve.

Determinants of Atrial Fibrillation Development among Patients undergoing Ibrutinib Therapy

Objective: Within the last decade, the use of ibrutinib, a first-generation, non-selective, irreversible Burton's tyrosine kinase inhibitor for the treatment of hematological malignancies has proven highly effective in improving patient outcomes.Background: Ibrutinib has been associated with an increase in atrial fibrillation (AF). The predisposing factors are thought to be pre-existing cardiovascular risk factors, but these have not been directly evaluated.Methods: We conducted a nested case-control study, recruiting consecutive ibrutinib treated subjects to evaluate cardiovascular risk factors associated with the development of AF in patients diagnosed with hematological B-cell malignancies.Results: Of the 189 patients treated with ibrutinib and without AF at baseline, 54 (29%) developed AF. Cardiovascular risk factors associated with AF development were, older age, prior hypertension (HTN), history of heart failure (HF) and congenital heart disease. A patient with HF at baseline had a 1, 2, 6, and 12 month cumulative hazard of AF of 40%, 48%, 64%, and 71%, respectively. Patients with prior HTN without HF at baseline had a 1, 2, 6, and 12 month cumulative hazard of AF of 5%, 10%, 23%, and 31%, respectively while on ibrutinib therapy.Conclusions: The relationship between ibrutinib, cardiovascular comorbidities, and AF is through pre-existing cardiovascular disease. An individualized, multidisciplinary approach involving cardiologists should be considered when initiating ibrutinib, particularly when there is a history of HTN, HF or congenital heart disease. In such patients, there should be close cardiovascular monitoring and prompt intervention when AF develops to improve patient outcomes.

Effectiveness of an algorithm-based care pathway for patients with non-valvular atrial fibrillation presenting to the emergency department

OBJECTIVE

Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures.

METHODS

We deployed a voluntary-use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous "usual care" controls, using a propensity-score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non-valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion.

RESULTS

Preimplementation (January 1, 2016-December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017-June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29-0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46-0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P < 0.001) and be referred to a cardiologist (93% vs 29%, P < 0.001) versus the comparator group.

CONCLUSION

EDAFMP use is associated with decreased hospital admission during an index ED encounter for non-valvular AF, and improved delivery of AF care processes.

The Association between Treatment with Bisphosphonates and the Risk of Atrial Fibrillation: A Meta-Analysis of Observational Studies

Background: Osteoporosis is one of the most common diseases of the skeletal system, particularly occurring in older adults. Bisphosphonates are frequently used to treat osteoporosis and prevent bone fractures. Studies evaluating the association between treatment with bisphosphonate and the risk of atrial fibrillation have reported conflicting results. This meta-analysis of observational studies was performed to assess this association.Methods: Databases were searched to find relevant observational studies, and the identified articles were selected according to the selection criteria. Sensitivity and subgroup analysis based on various confounding factors were performed. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of atrial fibrillation were estimated using a random-effects model.Results: We selected 12 studies, including four case-control and eight cohort studies, for the meta-analysis. Assessment of the estimated effect size yielded an OR of 1.171 (95% CI, 1.011–1.356; P=0.035), with substantial heterogeneity (I 2 =84.74%, P<0.001). When the studies were excluded one-after-another, the pooled OR remained unchanged in only six studies. In addition, subgroup analyses found that treatment with bisphosphonates was positively associated with the risk of atrial fibrillation in studies performed in Western countries (OR, 1.263; 95% CI, 1.092–1.462) and lower-quality studies (OR, 1.214; 95% CI, 1.035–1.423). No publication bias was observed.Conclusion: This meta-analysis showed that treatment with bisphosphonates may be associated with an increased risk of atrial fibrillation. Therefore, bisphosphonates should be carefully prescribed to patients at a high risk of atrial fibrillation.

Circulatory MicroRNAs in Plasma and Atrial Fibrillation in the General Population: The Rotterdam Study

Background: MicroRNAs (miRNAs), small non-coding RNAs regulating gene expression, have been shown to play an important role in cardiovascular disease. However, limited population-based data regarding the relationship between circulatory miRNAs in plasma and atrial fibrillation (AF) exist. Moreover, it remains unclear if the relationship differs by sex. We therefore aimed to determine the (sex-specific) association between plasma circulatory miRNAs and AF at the population level. Methods: Plasma levels of miRNAs were measured using a targeted next-generation sequencing method in 1999 participants from the population-based Rotterdam Study. Logistic regression and Cox proportional hazards models were used to assess the associations of 591 well-expressed miRNAs with the prevalence and incidence of AF. Models were adjusted for cardiovascular risk factors. We further examined the link between predicted target genes of the identified miRNAs. Results: The mean age was 71.7 years (57.1% women), 98 participants (58 men and 40 women) had prevalent AF at baseline. Moreover, 196 participants (96 men and 100 women) developed AF during a median follow-up of 9.0 years. After adjusting for multiple testing, miR-4798-3p was significantly associated with the odds of prevalent AF among men (odds ratio, 95% confidence interval, 0.39, 0.24–0.66, p-value = 0.000248). No miRNAs were significantly associated with incident AF. MiR-4798-3p could potentially regulate the expression of a number of AF-related genes, including genes involved in calcium and potassium handling in myocytes, protection of cells against oxidative stress, and cardiac fibrosis. Conclusions: Plasma levels of miR-4798-3p were significantly associated with the odds of prevalent AF among men. Several target genes in relation to AF pathophysiology could potentially be regulated by miR-4798-3p that warrant further investigations in future experimental studies.

Identifying patients with atrial fibrillation recurrences after two pulmonary vein isolation procedures

INTRODUCTION

Pulmonary vein isolation (PVI) is an important treatment for atrial fibrillation (AF). However, many patients need more than one procedure to maintain long-term sinus rhythm. Even after two PVIs some may suffer from AF recurrences. We aimed to identify characteristics of patients who fail after two PVI procedures.

METHODS AND RESULTS

We included 557 consecutive patients undergoing a first PVI procedure with a second-generation 28 mm cryoballoon. Follow-up procedures were performed using radiofrequency ablation targeting reconnected PVs only. Recurrent AF was defined as any episode of AF lasting >30 s on ECG or 24 hour Holter monitoring performed at 3, 6 and 12 months post procedure. Mean age was 59.1±10.2 years, 383 (68.8%) were male, 448 (80.4%) had paroxysmal AF and the most common underlying condition was hypertension (36.6%). A total of 140/557 (25.1%) patients underwent redo procedure with PVI only. Of these patients 45 (32.4%) had recurrence of AF. These patients were comparable regarding age and sex to those in sinus rhythm after one or two procedures. Multivariate logistic regression showed that non-paroxysmal AF (OR 1.08 (95% CI 1.01 to 1.15), estimated glomerular filtration rate (OR 0.96, 95% CI 0.94 to 0.99), bundle branch block (OR 4.17, 95% CI 1.38 to 12.58), heart failure (OR 4.17, 95% CI 1.38 to 12.58) and Left Atrium Volume Index (OR 1.04, 95% CI 1.01 to 1.08) were associated with AF recurrence after two PVIs. The area under the curve for the identified risk factors was 0.74.

CONCLUSIONS

Using a PVI-only approach, recurrence of AF after two AF ablation procedures is associated with more advanced underlying disease and persistent types of AF.

Residual Stroke Risk in Atrial Fibrillation

AF contributes to increased stroke risk via various mechanisms, including deranged blood constituents, vessel wall abnormalities and abnormal blood flow. This excess risk is frequently managed with anticoagulation therapy, aimed at preventing thromboembolic complications. Yet, a significant proportion of patients with AF remain at high residual stroke risk despite receiving appropriate dose-adjusted anticoagulation. This article explores the residual stroke risk in AF and potential therapeutic options for these patients.

Impact of the Look-Back Period on Identifying Recurrent Myocardial Infarctions in the Danish National Patient Registry

Purpose

Studies examining myocardial infarction (MI) often seek to include only incident MIs by excluding recurrent MIs. When based on historical data, identification of previous MI depends on the length of the look-back period. However, international registries often cover a short time period, consequently containing left-censored data, making it impossible to determine if a first MI in a period is truly an incident MI. We evaluated whether the proportion of MIs identified as recurrent MIs depends on the look-back period, and how including recurrent MIs in a planned incident MI cohort impacts survival estimates.

Patients and Methods

We used the Danish National Patient Registry, covering all Danish hospitals since 1977 to identify first MIs during 2010–2016 (index events). The hospital registry history preceding the index event was then searched for previous MIs. We plotted the proportion of index events identified as recurrent MIs as a function of the look-back period. Moreover, we calculated 5-year all-cause mortality and confidence intervals (CIs) using the 1-Kaplan–Meier method for five cohorts based on the index events and defined by look-back periods of 0, 5, 10, 20, and up to 39 years.

Results

Among 63,885 index events, 3.4% were identified as recurrent MIs with 5 years of look-back, 7.9% with 10 years, 14% with 24 years, and 15% with up to 39 years. All-cause mortality risk was 36% (95% CI: 36–37%) with 0 years of look-back, 35% (95% CI: 35–36%) with 5 years, 35% (95% CI: 35–36%) with 10 years, 34% (95% CI: 34–35%) with 20 years, and 34% (95% CI: 33–34%) with up to 39 years.

Conclusion

Most recurrent MIs were identified with a look-back period of 24 years. Including recurrent MIs in a planned incident MI cohort, due to shorter look-back periods, overestimated the mortality risk.

Impact of atrial fibrillation on inflammatory bowel disease hospitalizations-a nationwide retrospective study

Systemic inflammation seen in inflammatory bowel disease (IBD) may cause electrophysiological changes in the atria leading to atrial fibrillation (AF). We analyzed data from the National Inpatient Sample for 2018 to identify all adult hospitalizations with a primary diagnosis of IBD, which were further divided based on the presence or absence of AF. The primary outcome was inpatient mortality while the secondary outcomes included inpatient complications, mean length of stay, and mean total hospital charge. We identified 92,055 IBD hospitalizations, of which 3900 (4.2%) had AF and 88,155 (95.8%) served as controls. IBD hospitalizations with AF were older (70.9 vs. 45.0 years, P < 0.001) and had a higher association with comorbidities compared to the non-AF cohort. Furthermore, the AF cohort had significantly higher adjusted odds of inpatient mortality (2.05% vs. 0.24%; adjusted odds ratio 2.07; 95% confidence interval [CI] 1.09-3.90; P = 0.025), longer length of stay (6.5 vs. 4.9 days; incidence rate ratio 1.23; 95% CI 1.14-1.33; P < 0.001), and higher total hospital charge ($14,587 vs. $11,475; incidence rate ratio 1.26; 95% CI 1.15-1.38; P < 0.001). Additionally, complications such as acute respiratory failure, pulmonary embolism, and necessity of blood product transfusion were more common for IBD hospitalizations with AF than those without.

Sex-Specific Exposure-Effect Relationship Between Physical Activity and Incident Atrial Fibrillation in the General Population: A Dose-Response Meta-Analysis of 16 Prospective Studies

Background: Since evidence regarding the relationship between physical activity (PA) and atrial fibrillation (AF) incidence is inconsistent among studies, we performed a dose-response meta-analysis to comprehensively evaluate the exposure-effect association between PA and incident AF and the potential sex difference in the general population. Methods: The PubMed and Embase databases were searched for eligible studies published up to July 2020 (PROSPERO: CRD42018091692). The non-linear or linear exposure-effect relationship between PA and AF was examined using the robust error meta-regression method. Results: A total of 16 prospective studies involving 1,449,017 individuals and 39,884 AF cases were included. We observed an inverse non-linear association between PA level and incident AF (I ² = 0%, p _{non-linearity} < 0.001). In the linear model, a 5 metabolic equivalent of task (MET)-h/week increase in PA was associated with a decreased risk of AF [risk ratio (RR) = 0.992, 95% confidence interval (CI): 0.988-0.996, I ² = 0%]. In the sex-stratified analysis, we observed an inverse non-linear relationship between PA level and AF risk in females (I ² = 90%, p _{non-linearity} < 0.0001) but not in males (I ² = 0%, p _{non-linearity} = 0.40). In the linear model, a 5 MET-h/week increase in PA was associated with a reduced risk of AF in females (RR = 0.982, 95% CI: 0.975-0.989, I ² = 71%) but not in males (RR = 0.998, 95% CI: 0.994-1.002, I ² = 0%), with a significant interaction observed between the two groups (p _interaction < 0.0001). Conclusion: There was an inverse non-linear relationship between PA level and incident AF in the general population. The beneficial effect of PA in reducing AF risk might be predominantly observed in females.

Estimation of the economic burden of atrial fibrillation-related stroke in Greece

Background: Stroke is aleading cause of death and disability, with atrial fibrillation (AF) being among key risk factors and AF-related stroke inflicting significant burden on healthcare systems and society. The present study was undertaken for estimating the total annual socioeconomic burden of AF-related stroke in Greece and identifying the key cost contributors.Research design and methods: A cost-of-illness model was developed for estimating the total annual economic burden of AF-related stroke in Greece, from asocietal perspective (year 2018). Atargeted literature review and an advisory board consisting of key experts in the management of AF and AF-related stroke were performed for collecting local resource use and epidemiological data.Results: The total annual socioeconomic burden of AF-related stroke was estimated at €175million, in 2018. Direct and indirect costs accounted for 59% and 41%, respectively. Main contributors were informal care (21.1%), patients' productivity losses (19.7%) and hospitalizations (15.0%), accounting for more than half of the total costs of AF-related stroke events.Conclusion: A F-related stroke imposes asignificant socioeconomic burden in Greece. Despite results relying on estimations, it seems that ensuring efficient reallocation of resources in appropriate prevention and early intervention strategies could decrease AF-related stroke's burden but also enhance healthcare systems' efficiency.Abbreviations: AF=atrial fibrillation.

Efficacy of Extensive Ablation for Persistent Atrial Fibrillation With Trigger-Based vs. Substrate-Based Mechanisms - A Prespecified Subanalysis of the EARNEST-PVI Trial

BACKGROUND

Extensive ablation in addition to pulmonary vein isolation (PVI) would be effective for modification of non-pulmonary vein (non-PV) substrates, whereas PVI might be sufficient for elimination of PV triggers. This study aimed to test the hypothesis that in patients with reproducible atrial fibrillation (AF) triggered by premature atrial contractions originating only from PVs, PVI alone can be sufficient to maintain sinus rhythm.Methods and Results:This study is a prespecified subanalysis of the EARNEST-PVI randomized controlled trial. This study investigated the efficacy of the PVI-alone strategy (PVI-alone) in comparison with the extensive strategy (PVI-plus) for persistent AF with a trigger-based mechanism vs. a substrate-based mechanism. Patients were stratified into 3 groups based on AF mechanisms: (1) Substrate group (N=236); (2) PV trigger group (N=236); and (3) non-PV trigger group (N=24). The hazard ratios for AF recurrence of the PVI-alone strategy with reference to the PVI-plus strategy were 1.456 (95% confidence interval [CI] [0.864-2.452]) in the substrate group, 1.648 (95% CI 0.969-2.801) in the PV trigger group, and 0.937 (95% CI 0.252-3.488) in the non-PV trigger group. No significant interaction between ablation strategy and AF mechanism was observed (P for interaction=0.748).

CONCLUSIONS

This study indicated that the efficacies of the PVI-alone strategy compared with the PVI-plus strategy were consistent across persistent AF with trigger-based and substrate-based mechanisms.

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

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

Atrial fibrillation recurrence and spontaneous conversion to sinus rhythm after cardiac surgery: Insights from 426 patients with continuous rhythm monitoring

INTRODUCTION

Cardiac surgery may influence occurrence and persistence of atrial fibrillation (AF). In patients with a history of cardiac surgery and postoperative pacemaker or implantable cardioverter defibrillator implantation we attempted to quantify AF characteristics and investigate factors that influence AF recurrence.

METHODS

In 426 patients (319 male; age: 73 SD: 9 years) with a history of cardiac surgery (364 CABG; 69 mitral valve; 57 aortic valve and 59 combination procedures) the heart rhythm history (mean: 351 days SD: 54 days) was reconstructed and investigated for AF recurrence patterns.

RESULTS

AF developed and subsequently recurred in 75% of patients (n = 320). The mean AF burden in these patients was 0.21 (21% of the total observed time spent in AF) and 4085 episodes of AF were observed and analyzed. AF episodes spontaneously terminated within 24 h (n = 2509), 48 h (n = 700), 72 h (n = 279), and 1 week (n = 31). The probability of spontaneous conversion to sinus rhythm (SR) decreased with time spent in AF and plateaued after approximately 7 days. Patient age, LVEF and presence of coronary artery disease significantly influenced the probability of spontaneous conversion to SR. Type of cardiac surgery also significantly influenced AF episode characteristics.

CONCLUSION

AF episodes are common in patients with a history of cardiac surgery. Spontaneous conversion to SR diminishes with increasing time spent in AF and is influenced by AF characteristics and several patient-related factors. Continuous monitoring can provide detailed information about AF recurrence that may immensely improve our understanding and influence the clinical management of AF.

Cross-ethnic comparison of the association between central sleep apnea and atrial fibrillation/flutter: The Kuakini Honolulu-Asia Aging Study and the Osteoporotic Fractures in Men (Mr.OS) study

Introduction

Few studies indicated the impact of ethnicity on an association between central sleep apnea (CSA) and atrial fibrillation/flutter (AF) in older populations. We assessed possible ethnic differences in the association among elderly Japanese-American and White-American men.

Methods

We performed a cross-sectional analysis using two population studies of Japanese-American and White-American men. The Kuakini Honolulu-Asia Aging Study is a longitudinal cohort study of Japanese-American men living in Hawaii. Sleep data were collected between 1999 and 2000. The Osteoporotic Fractures in Men (Mr.OS) Sleep Study was conducted between 2003 and 2005 on the continental U.S. The majority of Mr.OS participants were White-American. We selected 79-90 year old males, who had overnight polysomnography from both studies. Total participants were 690 Japanese-American and 871 White-American men. The central apnea index (CAI) was the measure of the number of central apneas. CSA was defined by CAI>=5. Cheyne-Stokes breathing (CSB) was defined as a minimum consecutive 5-10 min period of a crescendo-decrescendo respiratory pattern associated with CSA.

Results

The prevalence of AF was 5.7% in Japanese-American men and 9.0% in White-American men. The prevalence of CSA and CSB in White-Americans were higher than in Japanese-Americans (11.5% vs 6.5% and 5.7% vs 3.3%, respectively). In multivariable-adjusted logistic regression models, CSA was associated with higher odds of AF, and the association was stronger in Japanese-Americans [Odds Ratio (OR) = 4.77, 95% confidence interval (CI): 1.95-11.67] than in White-Americans (OR = 2.09, 95 %CI: 1.09-4.01). CSB showed similar trends as CSA.

Conclusions

After adjustment, CSA and CSB were significantly associated with AF in both Japanese-American and White-American men.