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Fabritz L, Chua W, Cardoso VR, Al-Taie C, Borof K, Suling A, Krause L, Kany S, Magnussen C, Wegscheider K, Breithardt G, Crijns HJGM, Camm AJ, Gkoutos G, Ellinor PT, Goette A, Schotten U, Wienhues-Thelen UH, Zeller T, Schnabel RB, Zapf A, Kirchhof P. Blood-based cardiometabolic phenotypes in atrial fibrillation and their associated risk: EAST-AFNET 4 biomolecule study. Cardiovasc Res 2024:cvae067. [PMID: 38613511 DOI: 10.1093/cvr/cvae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) and concomitant cardiometabolic disease processes interact and combine to lead to adverse events such as stroke, heart failure, myocardial infarction, and cardiovascular death. Circulating biomolecules provide quantifiable proxies for cardiometabolic disease processes. Their role in defining subphenotypes of AF is not known. METHODS AND RESULTS This prespecified analysis of the EAST-AFNET4 biomolecule study assigned patients to clusters using polytomous variable latent class analysis (poLCA) based on baseline concentrations of thirteen precisely-quantified biomolecules potentially reflecting ageing, cardiac fibrosis, metabolic dysfunction, oxidative stress, cardiac load, endothelial dysfunction, and inflammation. In each cluster, rates of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome, the primary outcome of EAST-AFNET 4, were calculated and compared between clusters over median 5.1 years follow-up. Findings were independently validated in a prospective cohort of 748 patients with AF (BBC-AF; median follow up 2.9 years).Unsupervised biomolecule analysis assigned 1586 patients (71 years old, 46% women) into four clusters. The highest-risk cluster was dominated by elevated BMP10, IGFBP7, NT-proBNP, ANGPT2 and GDF15. Patients in the lowest-risk cluster showed low concentrations of these biomolecules. Two intermediate-risk clusters differed by high or low concentrations of hsCRP, IL-6, and D-dimer. Patients in the highest-risk cluster had a 5-fold higher cardiovascular event rate than patients in the low-risk cluster. Early rhythm control was effective across clusters (pinteraction = 0.63). Sensitivity analyses and external validation in BBC-AF replicated clusters and risk gradients. CONCLUSIONS Biomolecule concentrations identify cardiometabolic subphenotypes in patients with atrial fibrillation at high and low cardiovascular risk.
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Affiliation(s)
- Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
- AFNET, Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Victor R Cardoso
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Christoph Al-Taie
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Shino Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | | | - Harry J G M Crijns
- Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands
| | - A John Camm
- Clinical Sciences, St George´s University, London, UK
| | - George Gkoutos
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ulrich Schotten
- AFNET, Münster, Germany
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- AFNET, Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
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2
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Lip GYH, Nikorowitsch J, Sehner S, Becher N, Bertaglia E, Blomstrom-Lundqvist C, Brandes A, Beuger V, Calvert M, Camm AJ, Chlouverakis G, Dan GA, Dichtl W, Diener HC, Fierenz A, Goette A, de Groot JR, Hermans A, Lubinski A, Marijon E, Merkely B, Mont L, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Schnabel RB, Schotten U, Simantirakis E, Toennis T, Vardas P, Wichterle D, Zapf A, Kirchhof P. Oral anticoagulation in device-detected atrial fibrillation: effects of age, sex, cardiovascular comorbidities, and kidney function on outcomes in the NOAH-AFNET 6 trial. Eur Heart J 2024:ehae225. [PMID: 38591192 DOI: 10.1093/eurheartj/ehae225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024] Open
Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Julius Nikorowitsch
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Susanne Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | | | - Carina Blomstrom-Lundqvist
- Department of Medical Science, Uppsala University, Uppsala, Sweden
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Axel Brandes
- Department of Cardiology, Department of Regional Health Research, Esbjerg Hospital-University Hospital of Southern Denmark, University of Southern Denmark, Esbjerg, Denmark
| | | | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre and NIHR Applied Research Collaboration West Midlands, University of Birmingham, Edgbaston, Birmingham, UK
| | - A John Camm
- Cardiovascular and Genetics Research Institute, St George's, University of London, London, UK
| | | | - Gheorghe-Andrei Dan
- Medicine University 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck, Austria
| | - Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Alexander Fierenz
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
- Otto-von-Guericke Universität Magdeburg, Magdeburg, Germany
| | - Joris R de Groot
- The Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid Hermans
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | - Andrzej Lubinski
- Department of Cardiology and Internal Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Eloi Marijon
- Cardiology Division, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Lluís Mont
- Department of Cardiology, Hospital Clinic, Universtitat de Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigacion Biomedica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Kim Rajappan
- Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Austria
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Tobias Toennis
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Panos Vardas
- Department of Cardiology, Heraklion University Hospital, Heraklion, Crete, Greece
- Biomedical Research Foundation Academy of Athens (BRFAA), Greece and Hygeia Hospitals Group, Athens, Greece
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
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Ip JE, Bui H, Camm AJ, Coutu B, Noseworthy PA, Parody ML, Sears SF, Singh N, Uribe JA, Vyselaar J, Omodele S, Shardonofsky S, Bharucha DB, Stambler B. Rationale and design of the NODE-303 study: evaluating the safety of symptom-prompted, self-administered etripamil for paroxysmal supraventricular tachycardia episodes in real-world settings. Am Heart J 2024; 270:55-61. [PMID: 38266665 DOI: 10.1016/j.ahj.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/17/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Paroxysmal supraventricular tachycardia (PSVT) is a common episodic arrhythmia characterized by unpredictable onset and burdensome symptoms including palpitations, dizziness, chest pain, distress, and shortness of breath. Treatment of acute episodes of PSVT in the clinical setting consists of intravenous adenosine, beta-blockers, and calcium channel blockers (CCBs). Etripamil is an intranasally self-administered L-type CCB in development for acute treatment of AV-nodal dependent PSVT in a nonmedical supervised setting. METHODS This paper summarizes the rationale and study design of NODE-303 that will assess the efficacy and safety of etripamil. In the randomized, double-blinded, placebo-controlled, Phase 3 RAPID trial, etripamil was superior to placebo in the conversion of single PSVT episodes by 30 minutes post initial dose when administered in the nonhealthcare setting; this study required a mandatory and observed test dosing prior to randomization. The primary objective of NODE-303 is to evaluate the safety of symptom-prompted, self-administered etripamil for multiple PSVT episodes in real-world settings, without the need for test dosing prior to first use during PSVT. Secondary endpoints include efficacy and disease burden. Upon perceiving a PSVT episode, the patient applies an electrocardiographic monitor, performs a vagal maneuver, and, if the vagal maneuver is unsuccessful, self-administers etripamil 70 mg, with an optional repeat dose if symptoms do not resolve within 10 minutes after the first dose. A patient may treat up to four PSVT episodes during the study. Adverse events are recorded as treatment-emergent if they occur within 24 hours after the administration of etripamil. RESULTS Efficacy endpoints include time to conversion to sinus rhythm within 30 and 60 minutes after etripamil administration, and the proportion of patients who convert at 3, 5, 10, 20, 30, and 60 minutes. Patient-reported outcomes are captured by the Brief Illness Perception Questionnaire, the Cardiac Anxiety Questionnaire, the Short Form Health Survey 36, the Treatment Satisfaction Questionnaire for Medication and a PSVT survey. CONCLUSIONS Overall, these data will support the development of a potentially paradigm-changing long-term management strategy for recurrent PSVT.
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Affiliation(s)
- James E Ip
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY.
| | - Hanh Bui
- Blue Coast Cardiology, Vista, CA
| | - A John Camm
- St George's University of London, London, United Kingdom
| | - Benoit Coutu
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | | | | | | | | | | | - John Vyselaar
- Medical Arts Health Research, North Vancouver, BC, Canada
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4
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Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
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Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
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5
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Linz D, Andrade JG, Arbelo E, Boriani G, Breithardt G, Camm AJ, Caso V, Nielsen JC, De Melis M, De Potter T, Dichtl W, Diederichsen SZ, Dobrev D, Doll N, Duncker D, Dworatzek E, Eckardt L, Eisert C, Fabritz L, Farkowski M, Filgueiras-Rama D, Goette A, Guasch E, Hack G, Hatem S, Haeusler KG, Healey JS, Heidbuechel H, Hijazi Z, Hofmeister LH, Hove-Madsen L, Huebner T, Kääb S, Kotecha D, Malaczynska-Rajpold K, Merino JL, Metzner A, Mont L, Ng GA, Oeff M, Parwani AS, Puererfellner H, Ravens U, Rienstra M, Sanders P, Scherr D, Schnabel R, Schotten U, Sohns C, Steinbeck G, Steven D, Toennis T, Tzeis S, van Gelder IC, van Leerdam RH, Vernooy K, Wadhwa M, Wakili R, Willems S, Witt H, Zeemering S, Kirchhof P. Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference. Europace 2024; 26:euae070. [PMID: 38591838 PMCID: PMC11003300 DOI: 10.1093/europace/euae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
AIMS Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). METHODS AND RESULTS Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. CONCLUSIONS Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.
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Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jason G Andrade
- Division of Cardiology, Vancouver General Hospital, Vancouver, Canada
- Montreal Heart Institute, Montreal, Canada
| | - Elena Arbelo
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Guenter Breithardt
- Department of Cardiovascular Medicine, University Hospital, Münster, Germany
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Dobromir Dobrev
- Institute of Pharmacology, Faculty of Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicolas Doll
- Department of Cardiac Surgery, Schüchtermann-Klinik, Bad Rothenfelde, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Lars Eckardt
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | | | - Larissa Fabritz
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- University Center of Cardiovascular Science, UHZ, UKE, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Michal Farkowski
- Department of Cardiology, Ministry of Interior and Administration, National Medical Institute, Warsaw, Poland
| | - David Filgueiras-Rama
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Novel Arrhythmogenic Mechanisms Program, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, C/ Profesor Martín Lagos, Madrid, Spain
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
| | - Eduard Guasch
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Clinic Barcelona, University of Barcelona, Barcelona, Spain
| | - Guido Hack
- Bristol-Myers Squibb GmbH & Co. KGaA, Munich, Germany
| | | | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Jeff S Healey
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Hein Heidbuechel
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
| | - Ziad Hijazi
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Leif Hove-Madsen
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Biomedical Research Institute Barcelona (IIBB-CSIC), Barcelona, Spain
- IR Sant Pau, Hospital de Sant Pau, Barcelona, Spain
| | | | - Stefan Kääb
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Katarzyna Malaczynska-Rajpold
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
- Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - José Luis Merino
- La Paz University Hospital, IdiPaz, Autonomous University of Madrid, Madrid, Spain
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Lluís Mont
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ghulam Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Michael Oeff
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Cardiology Department, Medizinische Hochschule Brandenburg, Brandenburg/Havel, Germany
| | - Abdul Shokor Parwani
- Department of Cardiology, Deutsches Herzzentrum der Charité (CVK), Berlin, Germany
| | | | - Ursula Ravens
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Experimental Cardiovascular Medicine, University Clinic Freiburg, Freiburg, Germany
| | - Michiel Rienstra
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Renate Schnabel
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Christian Sohns
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Elektrophysiologie—Rhythmologie, Bad Oeynhausen, Germany
| | - Gerhard Steinbeck
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Daniel Steven
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Heart Center, Department of Electrophysiology, University Hospital Cologne, Cologne, Germany
| | - Tobias Toennis
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | | | - Isabelle C van Gelder
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Manish Wadhwa
- Medical Office, Philips Ambulatory Monitoring and Diagnostics, San Diego, CA, USA
| | - Reza Wakili
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Medicine and Cardiology, Goethe University, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Stephan Willems
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Asklepios Hospital St. Georg, Department of Cardiology and Internal Care Medicine, Faculty of Medicine, Semmelweis University Campus, Hamburg, Germany
| | | | - Stef Zeemering
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
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6
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McIntyre WF, Benz AP, Becher N, Healey JS, Granger CB, Rivard L, Camm AJ, Goette A, Zapf A, Alings M, Connolly SJ, Kirchhof P, Lopes RD. Direct Oral Anticoagulants for Stroke Prevention in Patients With Device-Detected Atrial Fibrillation: A Study-Level Meta-Analysis of the NOAH-AFNET 6 and ARTESiA Trials. Circulation 2024; 149:981-988. [PMID: 37952187 DOI: 10.1161/circulationaha.123.067512] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Device-detected atrial fibrillation (also known as subclinical atrial fibrillation or atrial high-rate episodes) is a common finding in patients with an implanted cardiac rhythm device and is associated with an increased risk of ischemic stroke. Whether oral anticoagulation is effective and safe in this patient population is unclear. METHODS We performed a systematic review of MEDLINE and Embase for randomized trials comparing oral anticoagulation with antiplatelet or no antithrombotic therapy in adults with device-detected atrial fibrillation recorded by a pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy device, or implanted cardiac monitor. We used random-effects models for meta-analysis and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). The review was preregistered (PROSPERO CRD42023463212). RESULTS From 785 citations, we identified 2 randomized trials with relevant clinical outcome data: NOAH-AFNET 6 (Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial High Rate Episodes; 2536 participants) evaluated edoxaban, and ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; 4012 participants) evaluated apixaban. Meta-analysis demonstrated that oral anticoagulation with these agents reduced ischemic stroke (relative risk [RR], 0.68 [95% CI, 0.50-0.92]; high-quality evidence). The results from the 2 trials were consistent (I2 statistic for heterogeneity=0%). Oral anticoagulation also reduced a composite of cardiovascular death, all-cause stroke, peripheral arterial embolism, myocardial infarction, or pulmonary embolism (RR, 0.85 [95% CI, 0.73-0.99]; I2=0%; moderate-quality evidence). There was no reduction in cardiovascular death (RR, 0.95 [95% CI, 0.76-1.17]; I2=0%; moderate-quality evidence) or all-cause mortality (RR, 1.08 [95% CI, 0.96-1.21]; I2=0%; moderate-quality evidence). Oral anticoagulation increased major bleeding (RR, 1.62 [95% CI, 1.05-2.50]; I²=61%; high-quality evidence). CONCLUSIONS The results of the NOAH-AFNET 6 and ARTESiA trials are consistent with each other. Meta-analysis of these 2 large randomized trials provides high-quality evidence that oral anticoagulation with edoxaban or apixaban reduces the risk of stroke in patients with device-detected atrial fibrillation and increases the risk of major bleeding.
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Affiliation(s)
- William F McIntyre
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Alexander P Benz
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Jeffrey S Healey
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | | | | | - A John Camm
- St George's University of London and Imperial College London, United Kingdom (A.J.C.)
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz Hospital Paderborn, Germany (A.G.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany (A.Z.)
| | | | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, Canada (W.F.M., A.P.B., J.S.H., S.J.C.)
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany (N.B., P.K.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
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7
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Ruskin JN, Camm AJ, Dufton C, Woite-Silva AC, Tuininga Y, Badings E, De Jong JSSG, Oosterhof T, Aksoy I, Kuijper AFM, Van Gelder IC, van Dijk V, Nuyens D, Schellings D, Lee MY, Kowey PR, Crijns HJGM, Maupas J, Belardinelli L. Orally Inhaled Flecainide for Conversion of Atrial Fibrillation to Sinus Rhythm: INSTANT Phase 2 Trial. JACC Clin Electrophysiol 2024:S2405-500X(24)00164-6. [PMID: 38613545 DOI: 10.1016/j.jacep.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND INSTANT (INhalation of flecainide to convert recent-onset SympTomatic Atrial fibrillatioN to sinus rhyThm) was a multicenter, open-label, single-arm study of flecainide acetate oral inhalation solution (FlecIH) for acute conversion of recent-onset (≤48 hours) symptomatic atrial fibrillation (AF) to sinus rhythm. OBJECTIVES This study investigated the efficacy and safety in 98 patients receiving a single dose of FlecIH delivered via oral inhalation. METHODS Patients self-administered FlecIH over 8 minutes in a supervised medical setting using a breath-actuated nebulizer and were continuously monitored for 90 minutes using a 12-lead Holter. RESULTS Mean age was 60.5 years, mean body mass index was 27.0 kg/m2, and 34.7% of the patients were women. All patients had ≥1 AF-related symptoms at baseline, and 87.8% had AF symptoms for ≤24 hours. The conversion rate was 42.6% (95% CI: 33.0%-52.6%) with a median time to conversion of 14.6 minutes. The conversion rate was 46.9% (95% CI: 36.4%-57.7%) in a subpopulation that excluded predose flecainide exposure for the current AF episode. Median time to discharge among patients who converted was 2.5 hours, and only 2 patients had experienced AF recurrence by day 5. In the conversion-no group, 44 (81.5%) patients underwent electrical cardioversion by day 5. The most common adverse events were related to oral inhalation of flecainide (eg, cough, oropharyngeal irritation/pain), which were mostly of mild intensity and limited duration. CONCLUSIONS The risk-benefit of orally inhaled FlecIH for acute cardioversion of recent-onset AF appears favorable. FlecIH could provide a safe, effective, and convenient first-line therapeutic option. (INhalation of Flecainide to Convert Recent Onset SympTomatic Atrial Fibrillation to siNus rhyThm [INSTANT]; NCT03539302).
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Affiliation(s)
| | - A John Camm
- St. George's University, London, United Kingdom
| | | | | | | | | | | | | | - Ismail Aksoy
- Admiraal de Ruyter Ziekenhuis, Goes, the Netherlands
| | | | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | | | | | | | - Peter R Kowey
- Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
| | - Harry J G M Crijns
- Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
| | - Jean Maupas
- InCarda Therapeutics, Newark, California, USA
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8
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Becher N, Toennis T, Bertaglia E, Blomström-Lundqvist C, Brandes A, Cabanelas N, Calvert M, Camm AJ, Chlouverakis G, Dan GA, Dichtl W, Diener HC, Fierenz A, Goette A, de Groot JR, Hermans ANL, Lip GYH, Lubinski A, Marijon E, Merkely B, Mont L, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Schnabel RB, Schotten U, Sehner S, Simantirakis E, Vardas P, Velchev V, Wichterle D, Zapf A, Kirchhof P. Anticoagulation with edoxaban in patients with long atrial high-rate episodes ≥24 h. Eur Heart J 2024; 45:837-849. [PMID: 37956458 PMCID: PMC10919916 DOI: 10.1093/eurheartj/ehad771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND AIMS Patients with long atrial high-rate episodes (AHREs) ≥24 h and stroke risk factors are often treated with anticoagulation for stroke prevention. Anticoagulation has never been compared with no anticoagulation in these patients. METHODS This secondary pre-specified analysis of the Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High-rate episodes (NOAH-AFNET 6) trial examined interactions between AHRE duration at baseline and anticoagulation with edoxaban compared with placebo in patients with AHRE and stroke risk factors. The primary efficacy outcome was a composite of stroke, systemic embolism, or cardiovascular death. The safety outcome was a composite of major bleeding and death. Key secondary outcomes were components of these outcomes and electrocardiogram (ECG)-diagnosed atrial fibrillation. RESULTS Median follow-up of 2389 patients with core lab-verified AHRE was 1.8 years. AHRE ≥24 h were present at baseline in 259/2389 patients (11%, 78 ± 7 years old, 28% women, CHA2DS2-VASc 4). Clinical characteristics were not different from patients with shorter AHRE. The primary outcome occurred in 9/132 patients with AHRE ≥24 h (4.3%/patient-year, 2 strokes) treated with anticoagulation and in 14/127 patients treated with placebo (6.9%/patient-year, 2 strokes). Atrial high-rate episode duration did not interact with the efficacy (P-interaction = .65) or safety (P-interaction = .98) of anticoagulation. Analyses including AHRE as a continuous parameter confirmed this. Patients with AHRE ≥24 h developed more ECG-diagnosed atrial fibrillation (17.0%/patient-year) than patients with shorter AHRE (8.2%/patient-year; P < .001). CONCLUSIONS This hypothesis-generating analysis does not find an interaction between AHRE duration and anticoagulation therapy in patients with device-detected AHRE and stroke risk factors. Further research is needed to identify patients with long AHRE at high stroke risk.
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Affiliation(s)
- Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Tobias Toennis
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Emanuele Bertaglia
- Department of Cardiac, Vascular, Thoracic and Public Health Sciences, Azienda Ospedaliera, Padua, Italy
| | - Carina Blomström-Lundqvist
- Department of Medical Science, Uppsala University, Uppsala, Sweden
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Axel Brandes
- Department of Cardiology, Esbjerg Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Nuno Cabanelas
- Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre and NIHR Applied Research Collaboration West Midlands, University of Birmingham, Edgbaston, Birmingham, UK
| | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, St George’s, University of London, and Imperial College, London, UK
| | | | - Gheorghe-Andrei Dan
- Medicine University ‘Carol Davila’, Colentina University Hospital, Bucharest, Romania
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck, Austria
| | - Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Alexander Fierenz
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
- Atrial Fibrillation NETwork (AFNET), Mendelstrasse 11, 48149 Muenster, Germany
| | - Joris R de Groot
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid N L Hermans
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Andrzej Lubinski
- Department of Cardiology and Internal Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Eloi Marijon
- Cardiology Division, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Lluís Mont
- Hospital Clinic, Universtitat de Barcelona, Catalonia, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Catalonia, Barcelona, Spain
- Centro de Investigacion Biomedica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kim Rajappan
- Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrea Sarkozy
- HRMC, University Hospital Brussels, VUB, Brussels, Belgium
| | - Daniel Scherr
- Department of Cardiology, University Hospital Graz, Graz, Austria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Mendelstrasse 11, 48149 Muenster, Germany
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | - Susanne Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Panos Vardas
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
- Biomedical Research Foundation Academy of Athens (BRFAA), Greece and Hygeia Hospitals Group, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St.Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
- Atrial Fibrillation NETwork (AFNET), Mendelstrasse 11, 48149 Muenster, Germany
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9
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Goldhaber SZ, Bassand JP, Camm AJ, Virdone S, Pieper K, Cools F, Corbalan R, Gersh BJ, Goto S, Haas S, Misselwitz F, Parkhomenko A, Steffel J, Stepinska J, Turpie AGG, Verheugt FWA, Kayani G, Kakkar AK. Clinical Outcomes in Older Patients with Atrial Fibrillation: Insights from the GARFIELD-AF Registry. Am J Med 2024; 137:128-136.e13. [PMID: 37918777 DOI: 10.1016/j.amjmed.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Oral anticoagulants (OAC) are underutilized in older patients with atrial fibrillation, despite proven clinical benefits. Our objective was to investigate baseline characteristics, treatment patterns, and impact of anticoagulation upon clinical outcomes with respect to age. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed up for 24 months. Adjusted hazard ratios (HR) were obtained via Cox proportional-hazards models with applied weights, to quantify the association of age with clinical outcomes. Comparative effectiveness of OAC vs No OAC and non-vitamin K oral anticoagulants (NOAC) vs vitamin K antagonists (VKA) were assessed using a propensity score with an overlap weighting scheme. RESULTS Of 52,018 patients, 32.6% were 65-74 years of age, 29.3% were 75-84 years, and 7.9% were ≥85 years. OAC treatment was associated with a numerical reduction in all-cause mortality among those aged 65-74 years (HR; 95% confidence interval) (0.86; 0.69-1.06) and aged 75-84 years (0.89; 0.75-1.05) and a significant reduction in patients ≥85 years (0.77; 0.63-0.95) vs no OAC. Similarly, OACs were associated with a decrease in stroke: 65-74 (0.51; 0.35-0.76) and ≥85 years (0.58; 0.34-0.99) and a numerical decrease in 75-84 years (0.84; 0.59-1.18). No increase in major bleeding was observed in patients aged ≥85 treated with OACs. Compared with VKA, NOACs were associated with a significant reduction in all-cause mortality in patients aged <65 and 65-74, with numerical reductions in those aged 75-84 and ≥85 years. CONCLUSIONS Older patients using OACs saw lower all-cause mortality and stroke risk; NOACs had less mortality and major bleeding compared with VKAs.
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Affiliation(s)
| | | | - A John Camm
- Molecular and Clinical Sciences Research Institute, Cardiology Clinical Academic Group, St George's University of London, London, UK
| | | | | | - Frank Cools
- AZ Klina, General Hospital Klina, Brasschaat, Belgium
| | - Ramon Corbalan
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Technical University of Munich, Germany
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10
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Healey JS, Lopes RD, Granger CB, Alings M, Rivard L, McIntyre WF, Atar D, Birnie DH, Boriani G, Camm AJ, Conen D, Erath JW, Gold MR, Hohnloser SH, Ip J, Kautzner J, Kutyifa V, Linde C, Mabo P, Mairesse G, Benezet Mazuecos J, Cosedis Nielsen J, Philippon F, Proietti M, Sticherling C, Wong JA, Wright DJ, Zarraga IG, Coutts SB, Kaplan A, Pombo M, Ayala-Paredes F, Xu L, Simek K, Nevills S, Mian R, Connolly SJ. Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation. N Engl J Med 2024; 390:107-117. [PMID: 37952132 DOI: 10.1056/nejmoa2310234] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Subclinical atrial fibrillation is short-lasting and asymptomatic and can usually be detected only by long-term continuous monitoring with pacemakers or defibrillators. Subclinical atrial fibrillation is associated with an increased risk of stroke by a factor of 2.5; however, treatment with oral anticoagulation is of uncertain benefit. METHODS We conducted a trial involving patients with subclinical atrial fibrillation lasting 6 minutes to 24 hours. Patients were randomly assigned in a double-blind, double-dummy design to receive apixaban at a dose of 5 mg twice daily (2.5 mg twice daily when indicated) or aspirin at a dose of 81 mg daily. The trial medication was discontinued and anticoagulation started if subclinical atrial fibrillation lasting more than 24 hours or clinical atrial fibrillation developed. The primary efficacy outcome, stroke or systemic embolism, was assessed in the intention-to-treat population (all the patients who had undergone randomization); the primary safety outcome, major bleeding, was assessed in the on-treatment population (all the patients who had undergone randomization and received at least one dose of the assigned trial drug, with follow-up censored 5 days after permanent discontinuation of trial medication for any reason). RESULTS We included 4012 patients with a mean (±SD) age of 76.8±7.6 years and a mean CHA2DS2-VASc score of 3.9±1.1 (scores range from 0 to 9, with higher scores indicating a higher risk of stroke); 36.1% of the patients were women. After a mean follow-up of 3.5±1.8 years, stroke or systemic embolism occurred in 55 patients in the apixaban group (0.78% per patient-year) and in 86 patients in the aspirin group (1.24% per patient-year) (hazard ratio, 0.63; 95% confidence interval [CI], 0.45 to 0.88; P = 0.007). In the on-treatment population, the rate of major bleeding was 1.71% per patient-year in the apixaban group and 0.94% per patient-year in the aspirin group (hazard ratio, 1.80; 95% CI, 1.26 to 2.57; P = 0.001). Fatal bleeding occurred in 5 patients in the apixaban group and 8 patients in the aspirin group. CONCLUSIONS Among patients with subclinical atrial fibrillation, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; ARTESIA ClinicalTrials.gov number, NCT01938248.).
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Affiliation(s)
- Jeff S Healey
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Renato D Lopes
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Christopher B Granger
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Marco Alings
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Lena Rivard
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - William F McIntyre
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Dan Atar
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - David H Birnie
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Giuseppe Boriani
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - A John Camm
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - David Conen
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Julia W Erath
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Michael R Gold
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Stefan H Hohnloser
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - John Ip
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Josef Kautzner
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Valentina Kutyifa
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Cecilia Linde
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Philippe Mabo
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Georges Mairesse
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Juan Benezet Mazuecos
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Jens Cosedis Nielsen
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Francois Philippon
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Marco Proietti
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Christian Sticherling
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Jorge A Wong
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - David J Wright
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Ignatius G Zarraga
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Shelagh B Coutts
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Andrew Kaplan
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Marta Pombo
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Felix Ayala-Paredes
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Lizhen Xu
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Kim Simek
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Sandra Nevills
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Rajibul Mian
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
| | - Stuart J Connolly
- From the Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., W.F.M., D.C., J.A.W., L.X., K.S., S.N., R.M., S.J.C.), the Montreal Heart Institute, University of Montreal, Montreal (L.R.), the University of Ottawa Heart Institute, Ottawa (D.H.B.), Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, QC (F.P.), the Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB (S.B.C.), and the Université de Sherbrooke, Sherbrooke, QC (F.A.-P.) - all in Canada; the Duke Clinical Research Institute, Duke University, Durham, NC (R.D.L., C.B.G.); Amphia Ziekenhuis, Breda, the Netherlands (M.A.); Oslo University Hospital and the University of Oslo, Oslo (D.A.); the University of Modena and Reggio Emilia, Modena (G.B.), and the Department of Clinical Sciences and Community Health, University of Milan, and the Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan (M. Proietti) - all in Italy; St. George's, University of London, London (A.J.C.), and Liverpool Heart and Chest Hospital, Liverpool (D.J.W.) - both in the United Kingdom; J.W. Goethe University, University Hospital Department of Cardiology, Frankfurt, Germany (J.W.E., S.H.H.); the Medical University of South Carolina, Charleston (M.R.G.); Michigan State University, Lansing (J.I.); the Institute for Clinical and Experimental Medicine, Prague, Czech Republic (J.K.); the University of Rochester, Rochester, NY (V.K.); Semmelweis University, Budapest, Hungary (V.K.); Karolinska Institutet and the Heart, Vascular, and Neurology Theme, Karolinska University Hospital, Stockholm (C.L.); the University of Rennes, Rennes, France (P.M.); Cliniques du Sud-Luxembourg, Arlon, Belgium (G.M.); Hospital Universitario La Luz, Madrid (J.B.M.), and Hospital Costa del Sol, Marbella (M. Pombo) - both in Spain; Aarhus University Hospital and Aarhus University, Aarhus, Denmark (J.C.N.); University Hospital Basel, University of Basel, Basel, Switzerland (C.S.); the Veterans Affairs Portland Health Care System, Portland, OR (I.G.Z.); and Abrazo Arrowhead Hospital, Glendale, AZ (A.K.)
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11
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Pollock KG, Dickerson C, Kainth M, Lawton S, Hurst M, Sugrue DM, Arden C, Davies DW, Martin AC, Sandler B, Gordon J, Farooqui U, Clifton D, Mallen C, Rogers J, Hill NR, Camm AJ, Cohen AT. Undertaking multi-centre randomised controlled trials in primary care: learnings and recommendations from the PULsE-AI trial researchers. BMC Prim Care 2024; 25:7. [PMID: 38166641 PMCID: PMC10759575 DOI: 10.1186/s12875-023-02246-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 12/14/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Conducting effective and translational research can be challenging and few trials undertake formal reflection exercises and disseminate learnings from them. Following completion of our multicentre randomised controlled trial, which was impacted by the COVID-19 pandemic, we sought to reflect on our experiences and share our thoughts on challenges, lessons learned, and recommendations for researchers undertaking or considering research in primary care. METHODS Researchers involved in the Prediction of Undiagnosed atriaL fibrillation using a machinE learning AlgorIthm (PULsE-AI) trial, conducted in England from June 2019 to February 2021 were invited to participate in a qualitative reflection exercise. Members of the Trial Steering Committee (TSC) were invited to attend a semi-structured focus group session, Principal Investigators and their research teams at practices involved in the trial were invited to participate in a semi-structured interview. Following transcription, reflexive thematic analysis was undertaken based on pre-specified themes of recruitment, challenges, lessons learned, and recommendations that formed the structure of the focus group/interview sessions, whilst also allowing the exploration of new themes that emerged from the data. RESULTS Eight of 14 members of the TSC, and one of six practices involved in the trial participated in the reflection exercise. Recruitment was highlighted as a major challenge encountered by trial researchers, even prior to disruption due to the COVID-19 pandemic. Researchers also commented on themes such as the need to consider incentivisation, and challenges associated with using technology in trials, especially in older age groups. CONCLUSIONS Undertaking a formal reflection exercise following the completion of the PULsE-AI trial enabled us to review experiences encountered whilst undertaking a prospective randomised trial in primary care. In sharing our learnings, we hope to support other clinicians undertaking research in primary care to ensure that future trials are of optimal value for furthering knowledge, streamlining pathways, and benefitting patients.
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Affiliation(s)
| | | | | | - Sarah Lawton
- School of Medicine, Keele University, Staffordshire, UK
| | - Michael Hurst
- Bristol Myers Squibb Pharmaceutical Ltd, Uxbridge, UK
| | | | - Chris Arden
- University Hospital Southampton, Southampton, UK
| | | | - Anne-Céline Martin
- Service de Cardiologie, Université de Paris, Innovative Therapies in Haemostasis, INSERM, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris, France
| | | | - Jason Gordon
- Health Economics and Outcomes Research Ltd, Cardiff, UK.
| | | | - David Clifton
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | | | | | - Nathan R Hill
- Bristol Myers Squibb Pharmaceutical Ltd, Uxbridge, UK
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK
| | - Alexander T Cohen
- Department of Haematological Medicine, Guys and St Thomas' NHS Foundation Trust, King's College London, London, UK
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12
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Camm AJ, Piccini JP, Alings M, Dorian P, Gosselin G, Guertin MC, Ip JE, Kowey PR, Mondésert B, Prins FJ, Roux JF, Stambler BS, van Eck JWM, Al Windy N, Thermil N, Shardonofsky S, Bharucha DB, Roy D. Multicenter, Phase 2, Randomized Controlled Study of the Efficacy and Safety of Etripamil Nasal Spray for the Acute Reduction of Rapid Ventricular Rate in Patients With Symptomatic Atrial Fibrillation (ReVeRA-201). Circ Arrhythm Electrophysiol 2023; 16:639-650. [PMID: 37950726 PMCID: PMC10734780 DOI: 10.1161/circep.123.012567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Despite chronic therapies, atrial fibrillation (AF) leads to rapid ventricular rates (RVR) often requiring intravenous treatments. Etripamil is a fast-acting, calcium-channel blocker administered intranasally affecting the atrioventricular node within minutes. METHODS Reduction of Ventricular Rate in Patients with Atrial Fibrillation evaluated the efficacy and safety of etripamil for the reduction of ventricular rate (VR) in patients presenting urgently with AF-RVR (VR ≥110 beats per minute [bpm]), was randomized, double-blind, placebo-controlled, and conducted in Canada and the Netherlands. Patients presenting urgently with AF-RVR were randomized (1:1, etripamil nasal spray 70 mg: placebo nasal spray). The primary objective was to demonstrate the effectiveness of etripamil in reducing VR in AF-RVR within 60 minutes of treatment. Secondary objectives assessed achievement of VR <100 bpm, reduction by ≥10% and ≥20%, relief of symptoms and treatment effectiveness; adverse events; and additional measures to 360 minutes. RESULTS Sixty-nine patients were randomized, 56 dosed with etripamil (n=27) or placebo (n=29). The median age was 65 years; 39% were female patients; proportions of AF types were similar between groups. The difference of mean maximum reductions in VR over 60 minutes, etripamil versus placebo, adjusting for baseline VR, was -29.91 bpm (95% CI, -40.31 to -19.52; P<0.0001). VR reductions persisted up to 150 minutes. Significantly greater proportions of patients receiving etripamil achieved VR reductions <100 bpm (with longer median duration <100 bpm), or VR reduction by ≥10% or ≥20%, versus placebo. VR reduction ≥20% occurred in 66.7% of patients in the etripamil arm and no patients in placebo. Using the Treatment Satisfaction Questionnaire for Medication-9, there was significant improvement in satisfaction on symptom relief and treatment effectiveness with etripamil versus placebo. Serious adverse events were rare; 1 patient in the etripamil arm experienced transient severe bradycardia and syncope, assessed as due to hypervagotonia. CONCLUSIONS Intranasal etripamil 70 mg reduced VR and improved symptom relief and treatment satisfaction. These data support further development of self-administered etripamil for the treatment of AF-RVR. REGISTRATION URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04467905.
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Affiliation(s)
- A. John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George’s University of London, United Kingdom (A.J.C.)
| | - Jonathan P. Piccini
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (J.P.P.)
| | - Marco Alings
- Department of Cardiology, Amphie Hospital, Breda, the Netherlands (M.A.)
| | - Paul Dorian
- Division of Cardiology, Unity Health Toronto, Ontario, Canada (P.D.)
| | - Gilbert Gosselin
- Department of Medicine, Montreal Heart Institute, Québec, Canada (G.G., M.-C.G., B.M., D.R.)
| | - Marie-Claude Guertin
- Department of Medicine, Montreal Heart Institute, Québec, Canada (G.G., M.-C.G., B.M., D.R.)
| | - James E. Ip
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital (J.E.I.)
| | - Peter R. Kowey
- Cardiology Division and Lankenau Institute for Medical Research, Lankenau Medical Center, Wynnewood, PA (P.R.K.)
| | - Blandine Mondésert
- Department of Medicine, Montreal Heart Institute, Québec, Canada (G.G., M.-C.G., B.M., D.R.)
| | | | - Jean-Francois Roux
- Centre Hospitalier de l’Université de Sherbrooke, Québec, Canada (J.-F.R.)
| | | | - JWM van Eck
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands (J.W.M.v.E.)
| | | | | | | | | | - Denis Roy
- Department of Medicine, Montreal Heart Institute, Québec, Canada (G.G., M.-C.G., B.M., D.R.)
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Verheugt FWA, Fox KAA, Virdone S, Ambrosio G, Gersh BJ, Haas S, Pieper KS, Kayani G, Camm AJ, Parkhomenko A, Misselwitz F, Ragy H, Ten Cate H, Keltai M, Kakkar AK. Outcomes of Oral Anticoagulation in Atrial Fibrillation Patients With or Without Comorbid Vascular Disease: Insights From the GARFIELD-AF Registry. Am J Med 2023; 136:1187-1195.e15. [PMID: 37704071 DOI: 10.1016/j.amjmed.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Many patients with atrial fibrillation suffer from comorbid vascular disease. The comparative efficacy and safety of different types of oral anticoagulation (OAC) in this patient group have not been widely studied. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed for 24 months. Associations of vascular disease with clinical outcomes were analyzed using adjusted hazard ratios (HR) obtained via Cox proportional-hazard modeling. Outcomes of OAC vs no OAC, and of non-vitamin K antagonist OAC (NOAC) vs vitamin K antagonist (VKA) treatment, were compared by overlap propensity-weighted Cox proportional-hazard models. RESULTS Of 51,574 atrial fibrillation patients, 25.9% had vascular disease. Among eligible atrial fibrillation patients, those with vascular disease received OAC less frequently than those without (63% vs 73%). Over 2-year follow-up, patients with vascular disease showed a higher risk of all-cause mortality (HR 1.30; 95% confidence interval [CI], 1.16-1.47) and cardiovascular mortality (HR 1.59; 95% CI, 1.28-1.97). OAC was associated with a significant decrease in all-cause mortality and non-hemorrhagic stroke, and increased risk of major bleeding in non-vascular disease. In vascular disease, similar but non-significant trends existed for stroke and major bleeding. A significantly lower risk of all-cause mortality (HR 0.74; 95% CI, 0.61-0.90) and major bleeding (HR 0.45; 95% CI, 0.29-0.70) was observed in vascular disease patients treated with NOACs, compared with VKAs. CONCLUSIONS Atrial fibrillation patients with a history of vascular disease have worse long-term outcomes than those without. The association of NOACs vs VKA with clinical outcomes was more evident in atrial fibrillation patients with vascular disease.
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Affiliation(s)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine Cardiology, Italy
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn, USA
| | - Sylvia Haas
- [Formerly] Department of Medicine, Technical University of Munich, Germany
| | | | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, UK
| | - Alexandr Parkhomenko
- National Scientific Centre "MD Strazhesko Institute of Cardiology", Kyiv, Ukraine
| | | | - Hany Ragy
- Department of Cardiology, National Heart Institute, Cairo, Egypt
| | - Hugo Ten Cate
- Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute (CARIM), Maastricht University, Netherlands; Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany
| | - Matyas Keltai
- Semmelweis University, Hungarian Cardiovascular Institute, Budapest, Hungary
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14
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Knudsen Pope M, Hall TS, Virdone S, Atar D, John Camm A, Pieper KS, Jansky P, Haas S, Goto S, Panchenko E, Baron-Esquivias G, Angchaisuksiri P, Kakkar AK. Rhythm versus rate control in patients with newly diagnosed atrial fibrillation - Observations from the GARFIELD-AF registry. Int J Cardiol Heart Vasc 2023; 49:101302. [PMID: 38020059 PMCID: PMC10656718 DOI: 10.1016/j.ijcha.2023.101302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
Background Investigate real-world outcomes of early rhythm versus rate control in patients with recent onset atrial fibrillation. Methods The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is an international multi-centre, non-interventional prospective registry of newly diagnosed (≤6 weeks' duration) atrial fibrillation patients at risk for stroke. Patients were stratified according to treatment initiated at baseline (≤48 days post enrolment), and outcome risks evaluated by overlap propensity weighted Cox proportional-hazards models. Results Of 45,382 non-permanent atrial fibrillation patients, 23,858 (52.6 %) received rhythm control and 21,524 (47.4 %) rate control. Rhythm-controlled patients had lower median age (68.0 [Q1;Q3: 60.0;76.0] versus 73.0 [65.0;79.0]), fewer histories of stroke/transient ischemic attack/systemic embolism (9.4 % versus 13.0 %), and lower expected probabilities of death (median GARFIELD-AF death score 4.0 [2.3;7.5] versus 5.1 [2.8;9.2]). The two groups had the same median CHA2DS2-VASc scores (3.0 [2.0;4.0]) and similar proportions of anticoagulated patients (rhythm control: 66.0 %, rate control: 65.5 %). The propensity-score-weighted hazard ratios of rhythm vs rate control (reference) were 0.85 (95 % CI: 0.79-0.92, p-value < 0.0001) for all-cause mortality, 0.84 (0.72-0.97, p-value 0.020) for non-haemorrhagic stroke/systemic embolism and 0.90 (0.78-1.04, p-value 0.164) for major bleeding. Conclusion Rhythm control strategy was initiated in about half of the patients with newly diagnosed non-valvular non-permanent atrial fibrillation. After balancing confounders, significantly lower risks of all-cause mortality and non-haemorrhagic stroke were observed in patients who received early rhythm control.
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Affiliation(s)
| | - Trygve S. Hall
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Saverio Virdone
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - A. John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, the United Kingdom of Great Britain and Northern Ireland
| | - Karen S Pieper
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
| | - Petr Jansky
- Department of Cardiovascular Surgery, Motol University Hospital, Prague, Czech Republic
| | - Sylvia Haas
- Sylvia Haas: Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Gonzalo Baron-Esquivias
- Servicio de Cardiología y Cirugía Cardíaca, Hospital Universitario Virgen del Rocío., Universidad de Sevilla., Sevilla. Departamento Cardiovascular, Instituto de Biotecnología de Sevilla (IBIS), Spain
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, the United Kingdom of Great Britain and Northern Ireland
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Wu J, Nadarajah R, Nakao YM, Nakao K, Wilkinson C, Cowan JC, Camm AJ, Gale CP. Temporal trends of cause-specific mortality after diagnosis of atrial fibrillation. Eur Heart J 2023; 44:4422-4431. [PMID: 37624589 PMCID: PMC10635669 DOI: 10.1093/eurheartj/ehad571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND AND AIMS Reports of outcomes after atrial fibrillation (AF) diagnosis are conflicting. The aim of this study was to investigate mortality and hospitalization rates following AF diagnosis over time, by cause and by patient features. METHODS Individuals aged ≥16 years with a first diagnosis of AF were identified from the UK Clinical Practice Research Datalink-GOLD dataset from 1 January 2001, to 31 December 2017. The primary outcomes were all-cause and cause-specific mortality and hospitalization at 1 year following diagnosis. Poisson regression was used to calculate rate ratios (RRs) for mortality and incidence RRs (IRRs) for hospitalization and 95% confidence intervals (CIs) comparing 2001/02 and 2016/17, adjusted for age, sex, region, socio-economic status, and 18 major comorbidities. RESULTS Of 72 412 participants, mean (standard deviation) age was 75.6 (12.4) years, and 44 762 (61.8%) had ≥3 comorbidities. All-cause mortality declined (RR 2016/17 vs. 2001/02 0.72; 95% CI 0.65-0.80), with large declines for cardiovascular (RR 0.46; 95% CI 0.37-0.58) and cerebrovascular mortality (RR 0.41; 95% CI 0.29-0.60) but not for non-cardio/cerebrovascular causes of death (RR 0.91; 95% CI 0.80-1.04). In 2016/17, deaths caused from dementia (67, 8.0%), outstripped deaths from acute myocardial infarction, heart failure, and acute stroke combined (56, 6.7%, P < .001). Overall hospitalization rates increased (IRR 2016/17 vs. 2001/02 1.17; 95% CI, 1.13-1.22), especially for non-cardio/cerebrovascular causes (IRR 1.42; 95% CI 1.39-1.45). Older, more deprived, and hospital-diagnosed AF patients experienced higher event rates. CONCLUSIONS After AF diagnosis, cardio/cerebrovascular mortality and hospitalization has declined, whilst hospitalization for non-cardio/cerebrovascular disease has increased.
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Affiliation(s)
- Jianhua Wu
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, UK
| | - Ramesh Nadarajah
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Yoko M Nakao
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Kazuhiro Nakao
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Chris Wilkinson
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, UK
- Hull York Medical School, University of York, York, UK
| | - J Campbell Cowan
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A John Camm
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - Chris P Gale
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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16
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Spears J, Liskov S, Camm AJ, Kowey PR. How Antiarrhythmic Drugs Are Being Used in Patients With Heart Failure: Results of a Global Survey of Cardiologists. Am J Cardiol 2023; 206:60-62. [PMID: 37683578 DOI: 10.1016/j.amjcard.2023.08.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023]
Affiliation(s)
- Jenna Spears
- Cardiology Division, Lankenau Heart Institute, Wynnewood, Pennsylvania
| | - Steven Liskov
- Cardiology Division, Lankenau Heart Institute, Wynnewood, Pennsylvania
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George's University of London, London, United Kingdom
| | - Peter R Kowey
- Cardiology Division, Lankenau Heart Institute, Wynnewood, Pennsylvania; Department of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania.
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17
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Ip JE, Coutu B, Bennett MT, Pandey AS, Stambler BS, Sager P, Chen M, Shardonofsky S, Plat F, Camm AJ. Etripamil Nasal Spray for Conversion of Repeated Spontaneous Episodes of Paroxysmal Supraventricular Tachycardia During Long-Term Follow-Up: Results From the NODE-302 Study. J Am Heart Assoc 2023; 12:e028227. [PMID: 37753718 PMCID: PMC10727262 DOI: 10.1161/jaha.122.028227] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 07/07/2023] [Indexed: 09/28/2023]
Abstract
Background Self-administration of investigational intranasal L-type calcium channel blocker etripamil during paroxysmal supraventricular tachycardia (PSVT) appeared safe and well-tolerated in the phase 3 NODE-301 (Multi-Centre, Randomized, Double-Blind, Placebo-Controlled, Efficacy, and Safety Study of Etripamil Nasal Spray for the Termination of Spontaneous Episodes of Paroxysmal Supraventricular Tachycardia) trial of adults with sustained atrioventricular nodal-dependent PSVT. The NODE-302 open-label extension further characterized etripamil safety and efficacy. Methods and Results Eligible patients were monitored via self-applied cardiac monitoring system for 5 hours after etripamil self-administration. The primary end point was time-to-conversion of positively adjudicated PSVT to sinus rhythm after etripamil treatment. Probability of conversion to sinus rhythm was reported via Kaplan-Meier plot. Adverse events were based on self-reported symptoms and clinical evaluations. Among 169 patients enrolled, 105 self-administered etripamil ≥1 time for perceived PSVT (median [range], 232 [8-584] days' follow-up). Probability of conversion within 30 minutes of etripamil was 60.2% (median time to conversion, 15.5 minutes) among 188 PSVT episodes (92 patients) positively adjudicated as atrioventricular nodal dependent by independent ECG analysis. Among 40 patients who self-treated 2 episodes, 75% had a significantly consistent response by 30 minutes; 9 did not convert on either episode, and 21 converted on both episodes (χ2=8.09; P=0.0045). Forty-five of 105 patients (42.9%) had ≥1 treatment-emergent adverse event, generally transient and mild-to-moderate, including nasal congestion (14.3%), nasal discomfort (14.3%), or rhinorrhea (12.4%). No serious cardiac safety events were observed within 24 hours of etripamil. Conclusions In this extension study, investigational etripamil nasal spray was well tolerated for self-treating recurrent episodes of PSVT without medical supervision. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03635996.
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Affiliation(s)
- James E. Ip
- Weill Cornell Medicine, New York‐Presbyterian HospitalNew YorkNYUSA
| | - Benoit Coutu
- Centre Hospitalier de l’Université de MontréalMontrealQuebecCanada
| | - Matthew T. Bennett
- Centre for Cardiovascular Innovation Division of CardiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | | | - Philip Sager
- Cardiovascular Research Institute and Department of MedicineStanford UniversityPalo AltoCAUSA
| | | | | | | | - A. John Camm
- St. George’s University of LondonLondonUnited Kingdom
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18
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Bassand JP, Virdone S, Camm AJ, Fox KAA, Goldhaber SZ, Goto S, Haas S, Hacke W, Kayani G, Keltai M, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Kakkar AK. Oral anticoagulation across diabetic subtypes in patients with newly diagnosed atrial fibrillation: A report from the GARFIELD-AF registry. Diabetes Obes Metab 2023; 25:3040-3053. [PMID: 37435777 DOI: 10.1111/dom.15202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
AIMS This study aims to describe both management and prognosis of patients with diabetes mellitus (DM) and newly diagnosed atrial fibrillation (AF), overall as well as by antidiabetic treatment, and to assess the influence of oral anticoagulation (OAC) on outcomes by DM status. METHODS The study population comprised 52 010 newly diagnosed patients with AF, 11 542 DM and 40 468 non-DM, enrolled in the GARFIELD-AF registry. Follow-up was truncated at 2 years after enrolment. Comparative effectiveness of OAC versus no OAC was assessed by DM status using a propensity score overlap weighting scheme and weights were applied to Cox models. RESULTS Patients with DM [39.3% oral antidiabetic drug (OAD), 13.4% insulin ± OAD, 47.2% on no antidiabetic drug] had higher risk profile, OAC use, and rates of clinical outcomes compared with patients without DM. OAC use was associated in patients without DM and patients with DM with lower risk of all-cause mortality [hazard ratio 0.75 (0.69-0.83), 0.74 (0.64-0.86), respectively] and stroke/systemic embolism (SE) [0.69 (0.58-0.83), 0.70 (0.53-0.93), respectively]. The risk of major bleeding with OAC was similarly increased in patients without DM and those with DM [1.40 (1.14-1.71), 1.37 (0.99-1.89), respectively]. Patients with insulin-requiring DM had a higher risk of all-cause mortality and stroke/SE [1.91 (1.63-2.24)], [1.57 (1.06-2.35), respectively] compared with patients without DM, and experienced significant risk reductions of all-cause mortality and stroke/SE with OAC [0.73 (0.53-0.99); 0.50 (0.26-0.97), respectively]. CONCLUSIONS In both patients with DM and patients without DM with AF, OAC was associated with lower risk of all-cause mortality and stroke/SE. Patients with insulin-requiring DM derived significant benefit from OAC.
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Affiliation(s)
- Jean-Pierre Bassand
- University of Besançon Franche-Comté, Besançon, France
- Thrombosis Research Institute, London, UK
| | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Matyas Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
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19
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Kar S, Doshi SK, Alkhouli M, Camm AJ, Coylewright M, Gibson MC, Granger CB, Gurol ME, Huber K, Mansour M, Nair DG, Natale A, Pocock SJ, Reddy VR, Saliba W, Christen T, Allocco DJ, Ellenbogen KA, Leon MB. Rationale and design of a randomized study comparing the Watchman FLX device to DOACs in patients with atrial fibrillation. Am Heart J 2023; 264:123-132. [PMID: 37279840 DOI: 10.1016/j.ahj.2023.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Percutaneous left atrial appendage (LAA) closure (LAAC) was developed as a nonpharmacologic alternative to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who are at an increased risk for stroke or systemic embolism. The Watchman device permanently seals off the LAA to prevent thrombi from escaping into the circulation. Previous randomized trials have established the safety and efficacy of LAAC compared to warfarin. However, direct OACs (DOACs) have become the preferred pharmacologic strategy for stroke prevention in patients with AF, and there is limited data comparing Watchman FLX to DOACs in a broad AF patient population. CHAMPION-AF is designed to prospectively determine whether LAAC with Watchman FLX is a reasonable first-line alternative to DOACs in patients with AF who are indicated for OAC therapy. STUDY DESIGN A total of 3,000 patients with a CHA2DS2-VASc score ≥2 (men) or ≥3 (women) were randomized to Watchman FLX or DOAC in a 1:1 allocation at 142 global clinical sites. Patients in the device arm were to be treated with DOAC and aspirin, DOAC alone, or DAPT for at least 3 months postimplant followed by aspirin or P2Y12 inhibitor for 1-year. Control patients were required to take an approved DOAC for the duration of the trial. Clinical follow-up visits are scheduled at 3- and 12-months, and then annually through 5 years; LAA imaging is required at 4 months in the device group. Two primary end points will be evaluated at 3 years: (1) composite of stroke (ischemic/hemorrhagic), cardiovascular death, and systemic embolism compared for noninferiority, and (2) nonprocedural bleeding (International Society on Thrombosis and Haemostasis [ISTH] major and clinically relevant nonmajor bleeding) tested for superiority in the device arm against DOACs. The third primary noninferiority end point is the composite of ischemic stroke and systemic embolism at 5 years. Secondary end points include 3- and 5-year rates of (1) ISTH-defined major bleeding and (2) the composite of cardiovascular death, all stroke, systemic embolism, and nonprocedural ISTH bleeding. CONCLUSIONS This study will prospectively evaluate whether LAAC with the Watchman FLX device is a reasonable alternative to DOACs in patients with AF. CLINICAL TRIAL REGISTRATION NCT04394546.
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Affiliation(s)
- Saibal Kar
- Los Robles Medical Center, Thousand Oaks, CA.
| | | | | | - A John Camm
- St. Georges University of London, London, United Kingdom
| | | | - Michael C Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Mahmut E Gurol
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kenneth Huber
- St Luke's Mid America Heart Institute, Kansas City, MO
| | | | - Devi G Nair
- St Bernard's Medical Center & Arrhythmia Research Group, Jonesboro, AR
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX
| | - Stuart J Pocock
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vivek R Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Martin B Leon
- Columbia University Medical Center/NewYork Presbyterian Hospital, New York, NY
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20
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Kirchhof P, Toennis T, Goette A, Camm AJ, Diener HC, Becher N, Bertaglia E, Blomstrom Lundqvist C, Borlich M, Brandes A, Cabanelas N, Calvert M, Chlouverakis G, Dan GA, de Groot JR, Dichtl W, Kravchuk B, Lubiński A, Marijon E, Merkely B, Mont L, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Sznajder R, Velchev V, Wichterle D, Sehner S, Simantirakis E, Lip GYH, Vardas P, Schotten U, Zapf A. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes. N Engl J Med 2023; 389:1167-1179. [PMID: 37622677 DOI: 10.1056/nejmoa2303062] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Device-detected atrial high-rate episodes (AHREs) are atrial arrhythmias detected by implanted cardiac devices. AHREs resemble atrial fibrillation but are rare and brief. Whether the occurrence of AHREs in patients without atrial fibrillation (as documented on a conventional electrocardiogram [ECG]) justifies the initiation of anticoagulants is not known. METHODS We conducted an event-driven, double-blind, double-dummy, randomized trial involving patients 65 years of age or older who had AHREs lasting for at least 6 minutes and who had at least one additional risk factor for stroke. Patients were randomly assigned in a 1:1 ratio to receive edoxaban or placebo. The primary efficacy outcome was a composite of cardiovascular death, stroke, or systemic embolism, evaluated in a time-to-event analysis. The safety outcome was a composite of death from any cause or major bleeding. RESULTS The analysis population consisted of 2536 patients (1270 in the edoxaban group and 1266 in the placebo group). The mean age was 78 years, 37.4% were women, and the median duration of AHREs was 2.8 hours. The trial was terminated early, at a median follow-up of 21 months, on the basis of safety concerns and the results of an independent, informal assessment of futility for the efficacy of edoxaban; at termination, the planned enrollment had been completed. A primary efficacy outcome event occurred in 83 patients (3.2% per patient-year) in the edoxaban group and in 101 patients (4.0% per patient-year) in the placebo group (hazard ratio, 0.81; 95% confidence interval [CI], 0.60 to 1.08; P = 0.15). The incidence of stroke was approximately 1% per patient-year in both groups. A safety outcome event occurred in 149 patients (5.9% per patient-year) in the edoxaban group and in 114 patients (4.5% per patient-year) in the placebo group (hazard ratio, 1.31; 95% CI, 1.02 to 1.67; P = 0.03). ECG-diagnosed atrial fibrillation developed in 462 of 2536 patients (18.2% total, 8.7% per patient-year). CONCLUSIONS Among patients with AHREs detected by implantable devices, anticoagulation with edoxaban did not significantly reduce the incidence of a composite of cardiovascular death, stroke, or systemic embolism as compared with placebo, but it led to a higher incidence of a composite of death or major bleeding. The incidence of stroke was low in both groups. (Funded by the German Center for Cardiovascular Research and others; NOAH-AFNET 6 ClinicalTrials.gov number, NCT02618577; ISRCTN number, ISRCTN17309850.).
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Affiliation(s)
- Paulus Kirchhof
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Tobias Toennis
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Andreas Goette
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - A John Camm
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Hans Christoph Diener
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Nina Becher
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Emanuele Bertaglia
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Carina Blomstrom Lundqvist
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Martin Borlich
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Axel Brandes
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Nuno Cabanelas
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Melanie Calvert
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Gregory Chlouverakis
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Gheorghe-Andrei Dan
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Joris R de Groot
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Wolfgang Dichtl
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Borys Kravchuk
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Andrzej Lubiński
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Eloi Marijon
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Béla Merkely
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Lluís Mont
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Ann-Kathrin Ozga
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Kim Rajappan
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Andrea Sarkozy
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Daniel Scherr
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Rafał Sznajder
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Vasil Velchev
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Dan Wichterle
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Susanne Sehner
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Emmanuel Simantirakis
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Gregory Y H Lip
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Panos Vardas
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Ulrich Schotten
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Antonia Zapf
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
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21
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Camm AJ. Should the risk of atrial fibrillation deter PFO closure for cryptogenic ischaemic stroke? Eur Heart J 2023; 44:3478-3480. [PMID: 37477208 DOI: 10.1093/eurheartj/ehad425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Affiliation(s)
- A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. Georges University of London, Cranmer Terrace, London SW17 0RE, UK
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22
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Batra G, Aktaa S, Camm AJ, Costa F, Di Biase L, Duncker D, Fauchier L, Fragakis N, Frost L, Hijazi Z, Juhlin T, Merino JL, Mont L, Nielsen JC, Oldgren J, Polewczyk A, Potpara T, Sacher F, Sommer P, Tilz R, Maggioni AP, Wallentin L, Casadei B, Gale CP. Data standards for atrial fibrillation/flutter and catheter ablation: the European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart). Eur Heart J Qual Care Clin Outcomes 2023; 9:609-620. [PMID: 36243903 PMCID: PMC10495697 DOI: 10.1093/ehjqcco/qcac068] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/02/2022] [Accepted: 10/12/2022] [Indexed: 09/13/2023]
Abstract
AIMS Standardized data definitions are essential for monitoring and assessment of care and outcomes in observational studies and randomized controlled trials (RCTs). The European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart) project of the European Society of Cardiology aimed to develop contemporary data standards for atrial fibrillation/flutter (AF/AFL) and catheter ablation. METHODS AND RESULTS We used the EuroHeart methodology for the development of data standards and formed a Working Group comprising 23 experts in AF/AFL and catheter ablation registries, as well as representatives from the European Heart Rhythm Association and EuroHeart. We conducted a systematic literature review of AF/AFL and catheter ablation registries and data standard documents to generate candidate variables. We used a modified Delphi method to reach a consensus on a final variable set. For each variable, the Working Group developed permissible values and definitions, and agreed as to whether the variable was mandatory (Level 1) or additional (Level 2). In total, 70 Level 1 and 92 Level 2 variables were selected and reviewed by a wider Reference Group of 42 experts from 24 countries. The Level 1 variables were implemented into the EuroHeart IT platform as the basis for continuous registration of individual patient data. CONCLUSION By means of a structured process and working with international stakeholders, harmonized data standards for AF/AFL and catheter ablation for AF/AFL were developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based RCTs, and post-marketing surveillance of devices and pharmacotherapies.
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Affiliation(s)
- Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Suleman Aktaa
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Institute for Data Analytics, University of Leeds and Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | | | - Francisco Costa
- Cardiology Department, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Santa Cruz, 1449-005 Lisboa, Portugal
| | - Luigi Di Biase
- Division of Cardiology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, New York City, NY 10467, USA
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Laurent Fauchier
- Service de Cardiologie, Center Hospitalier Universitaire Trousseau et Faculté de Médecine, Université de Tours, 37044 Tours, France
| | - Nikolaos Fragakis
- 3rd Cardiology Department, Hippokration General Hospital, Aristotle University Medical School, 54124 Thessaloniki, Greece
| | - Lars Frost
- Department of Cardiology, Regional Hospital Central Jutland, Silkeborg, and Department of Clinical Medicine, Aarhus University, 8200 AarhusDenmark
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Tord Juhlin
- Department of Cardiology, Skåne University Hospital, 221 85 Lund, Sweden
| | - José L Merino
- Arrhythmia and Robotic Electrophysiology Unit, Hospital Universitario La Paz, IdiPaz, Universidad Autonoma, 28046 Madrid, Spain
| | - Lluis Mont
- Hospital Clinic, Universitat de Barcelona, Institut de Recerca Biomèdica August Pi Sunyer (IDIBAPS), 08036 Barcelona, Spain; CIBER cardiovascular, 28029 Madrid, Spain
| | - Jens C Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Anna Polewczyk
- Department of Physiology, Patophysiology and Clinical Immunology, Collegium Medicum of The Jan Kochanowski University, 25-369 Kielce, Poland; Department of Cardiac Surgery, Department of Cardiac Surgery Świętokrzyskie Center of Cardiology, Kielce, Poland
| | - Tatjana Potpara
- School of Medicine, University of Belgrade and Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Frederic Sacher
- Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), LIRYC Institute, 33600 Bordeaux, France
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, 32545 Bad Oeynhausen, Germany
| | - Roland Tilz
- Department of Rhythmology, University Heart Center Luebeck, 23538 Lübeck, Germany
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, 50121 Florence, Italy
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Barbara Casadei
- Division of Cardiovascular Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX4 2PG, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Institute for Data Analytics, University of Leeds and Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
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23
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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24
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Pundi K, Fan J, Kabadi S, Din N, Blomström-Lundqvist C, Camm AJ, Kowey P, Singh JP, Rashkin J, Wieloch M, Turakhia MP, Sandhu AT. Dronedarone Versus Sotalol in Antiarrhythmic Drug-Naive Veterans With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2023; 16:456-467. [PMID: 37485722 DOI: 10.1161/circep.123.011893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Sotalol and dronedarone are both used for maintenance of sinus rhythm for patients with atrial fibrillation. However, while sotalol requires initial monitoring for QT prolongation and proarrhythmia, dronedarone does not. These treatments can be used in comparable patients, but their safety and effectiveness have not been compared head to head. Therefore, we retrospectively evaluated the effectiveness and safety using data from a large health care system. METHODS Using Veterans Health Administration data, we identified 11 296 antiarrhythmic drug-naive patients with atrial fibrillation prescribed dronedarone or sotalol in 2012 or later. We excluded patients with prior conduction disease, pacemakers or implantable cardioverter-defibrillators, ventricular arrhythmia, cancer, renal failure, liver disease, or heart failure. We used natural language processing to identify and compare baseline left ventricular ejection fraction between treatment arms. We used 1:1 propensity score matching, based on patient demographics, comorbidities, and medications, and Cox regression to compare strategies. To evaluate residual confounding, we performed falsification analysis with nonplausible outcomes. RESULTS The matched cohort comprised 6212 patients (3106 dronedarone and 3106 sotalol; mean [±SD] age, 71±10 years; 2.5% female; mean [±SD] CHA2DS2-VASC, 2±1.3). The mean (±SD) left ventricular ejection fraction was 55±11 and 58±10 for dronedarone and sotalol users, correspondingly. Dronedarone, compared with sotalol, did not demonstrate a significant association with risk of cardiovascular hospitalization (hazard ratio, 1.03 [95% CI, 0.88-1.21]) or all-cause mortality (hazard ratio, 0.89 [95% CI, 0.68-1.16]). However, dronedarone was associated with significantly lower risk of ventricular proarrhythmic events (hazard ratio, 0.53 [95% CI, 0.38-0.74]) and symptomatic bradycardia (hazard ratio, 0.56 [95% CI, 0.37-0.87]). The primary findings were stable across sensitivity analyses. Falsification analyses were not significant. CONCLUSIONS Dronedarone, compared with sotalol, was associated with a lower risk of ventricular proarrhythmic events and conduction disorders while having no difference in risk of incident cardiovascular hospitalization and mortality. These observational data provide the basis for prospective efficacy and safety trials.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | | | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden (C.B.-L.)
| | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | - Peter Kowey
- Lankenau Heart Institute, Wynnewood, PA (P.K.)
| | | | | | - Mattias Wieloch
- Department of Coagulation Disorders, Skåne University Hospital, Lund University, Malmö, Sweden (M.W.)
- Sanofi, Stockholm, Sweden (M.W.)
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
| | - Alexander T Sandhu
- Department of Medicine, Stanford University School of Medicine, CA (K.P., M.P.T., A.T.S.)
- Veterans Affairs Palo Alto Health Care System, CA (J.F., N.D., M.P.T., A.T.S.)
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25
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Stambler BS, Camm AJ, Alings M, Dorian P, Heidbuchel H, Houtgraaf J, Kowey PR, Merino JL, Mondésert B, Piccini JP, Pokorney SD, Sager PT, Verma A, Wharton JM, Bharucha DB, Plat F, Shardonofsky S, Chen M, Ip JE. Self-administered intranasal etripamil using a symptom-prompted, repeat-dose regimen for atrioventricular-nodal-dependent supraventricular tachycardia (RAPID): a multicentre, randomised trial. Lancet 2023; 402:118-128. [PMID: 37331368 DOI: 10.1016/s0140-6736(23)00776-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Etripamil is a fast-acting, intranasally administered calcium-channel blocker in development for on-demand therapy outside a health-care setting for paroxysmal supraventricular tachycardia. We aimed to evaluate the efficacy and safety of etripamil 70 mg nasal spray using a symptom-prompted, repeat-dose regimen for acute conversion of atrioventricular-nodal-dependent paroxysmal supraventricular tachycardia to sinus rhythm within 30 min. METHODS RAPID was a multicentre, randomised, placebo-controlled, event-driven trial, conducted at 160 sites in North America and Europe as part 2 of the NODE-301 study. Eligible patients were aged at least 18 years and had a history of paroxysmal supraventricular tachycardia with sustained, symptomatic episodes (≥20 min) as documented by electrocardiogram. Patients were administered two test doses of intranasal etripamil (each 70 mg, 10 min apart) during sinus rhythm; those who tolerated the test doses were randomly assigned (1:1) using an interactive response technology system to receive either etripamil or placebo. Prompted by symptoms of paroxysmal supraventricular tachycardia, patients self-administered a first dose of intranasal 70 mg etripamil or placebo and, if symptoms persisted beyond 10 min, a repeat dose. Continuously recorded electrocardiographic data were adjudicated, by individuals masked to patient assignment, for the primary endpoint of time to conversion of paroxysmal supraventricular tachycardia to sinus rhythm for at least 30 s within 30 min after the first dose, which was measured in all patients who administered blinded study drug for a confirmed atrioventricular-nodal-dependent event. Safety outcomes were assessed in all patients who self-administered blinded study drug for an episode of perceived paroxysmal supraventricular tachycardia. This trial is registered at ClinicalTrials.gov, NCT03464019, and is complete. FINDINGS Between Oct 13, 2020, and July 20, 2022, among 692 patients randomly assigned, 184 (99 from the etripamil group and 85 from the placebo group) self-administered study drug for atrioventricular-nodal-dependent paroxysmal supraventricular tachycardia, with diagnosis and timing confirmed. Kaplan-Meier estimates of conversion rates by 30 min were 64% (63/99) with etripamil and 31% (26/85) with placebo (hazard ratio 2·62; 95% CI 1·66-4·15; p<0·0001). Median time to conversion was 17·2 min (95% CI 13·4-26·5) with the etripamil regimen versus 53·5 min (38·7-87·3) with placebo. Prespecified sensitivity analyses of the primary assessment were conducted to test robustness, yielding supporting results. Treatment-emergent adverse events occurred in 68 (50%) of 99 patients treated with etripamil and 12 (11%) of 85 patients in the placebo group, most of which were located at the administration site and were mild or moderate, and all of which were transient and resolved without intervention. Adverse events occurring in at least 5% of patients treated with etripamil were nasal discomfort (23%), nasal congestion (13%), and rhinorrhea (9%). No serious etripamil-related adverse events or deaths were reported. INTERPRETATION Using a symptom-prompted, self-administered, initial and optional-repeat-dosing regimen, intranasal etripamil was well tolerated, safe, and superior to placebo for the rapid conversion of atrioventricular-nodal-dependent paroxysmal supraventricular tachycardia to sinus rhythm. This approach could empower patients to treat paroxysmal supraventricular tachycardia themselves outside of a health-care setting, and has the potential to reduce the need for additional medical interventions, such as intravenous medications given in an acute-care setting. FUNDING Milestone Pharmaceuticals.
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Affiliation(s)
- Bruce S Stambler
- Cardiac Arrhythmia Research and Education, Piedmont Heart Institute, Atlanta, GA, USA
| | - A John Camm
- Clinical Cardiology, St George's University of London, London, UK.
| | - Marco Alings
- Department of Surgery, Amphia Ziekenhuis, Breda, Netherlands
| | - Paul Dorian
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hein Heidbuchel
- Cardiology, University Hospital Antwerp, Antwerp, Belgium; Cardiovascular Research, Antwerp University, Antwerp, Belgium
| | - Jaco Houtgraaf
- Cardiology, Diakonessenhuis Hospital, Utrecht, Netherlands
| | - Peter R Kowey
- Medicine and Clinical Pharmacology, Jefferson Medical College, Philadelphia, PA, USA; Lankenau Heart Institute and Medical Research Center, Wynnewood, PA, USA
| | - Jose L Merino
- Arrhythmia-Electrophysiology Research Unit, La Paz University Hospital, IdiPAZ, Universidad Autonoma, Madrid, Spain
| | - Blandine Mondésert
- Electrophysiology Service, Montreal Heart Institute, University de Montréal, Montréal, QC, Canada
| | - Jonathan P Piccini
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Sean D Pokorney
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Philip T Sager
- Stanford Cardiovascular Service, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Atul Verma
- Institute of Medical Science, University of Toronto, Newmarket, ON, Canada
| | - J Marcus Wharton
- Frank P Tourville Sr Arrhythmia Center, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | - James E Ip
- Clinical Medicine, Weill Cornell Medical Center, New York, NY, USA
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Reiffel JA, Blomström-Lundqvist C, Boriani G, Goette A, Kowey PR, Merino JL, Piccini JP, Saksena S, Camm AJ. Real-world utilization of the pill-in-the-pocket method for terminating episodes of atrial fibrillation: data from the multinational Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey. Europace 2023; 25:euad162. [PMID: 37354453 PMCID: PMC10290490 DOI: 10.1093/europace/euad162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/02/2023] [Indexed: 06/26/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. Episodes may stop spontaneously (paroxysmal AF); may terminate only via intervention (persistent AF); or may persist indefinitely (permanent AF) (see European and American guidelines, referenced below, for more precise definitions). Recently, there has been renewed interest in an approach to terminate AF acutely referred to as 'pill-in-the-pocket' (PITP). The PITP is recognized in both the US and European guidelines as an effective option using an oral antiarrhythmic drug for acute conversion of acute/recent-onset AF. However, how PITP is currently used has not been systematically evaluated. METHODS AND RESULTS The recently published Antiarrhythmic Interventions for Managing Atrial Fibrillation (AIM-AF) survey included questions regarding current PITP usage, stratified by US vs. European countries surveyed, by representative countries within Europe, and by cardiologists vs. electrophysiologists. This manuscript presents the data from this planned sub-study. Our survey revealed that clinicians in both the USA and Europe consider PITP in about a quarter of their patients, mostly for recent-onset AF with minimal or no structural heart disease (guideline appropriate). However, significant deviations exist. See the Graphical abstract for a summary of the data. CONCLUSION Our findings highlight the frequent use of PITP and the need for further physician education about appropriate and optimal use of this strategy.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians & Surgeons, c/o 202 Birkdale Lane, New York, NY 33458, USA
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Medical Science, Uppsala University, akademiska sjukhuset, ingang 35, 2tr 751 85 Uppsala, Sweden
| | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio Emilia, Via Del Pozzo71, 41124 Moderna, Italy
| | - Andreas Goette
- St. Vincenz Hospital, Am Busdorf 2 33098, Paderborn, Germany
| | - Peter R Kowey
- Sidney Kimmel Medical College at Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA
- Lankenau Heart Institute, 100 East Lancaster, Ave, Wynnewood, PA 19096, USA
| | - Jose L Merino
- Chief, Arrhythmia & Robotic EP Unit, La Paz University Hospital, and Professor of Cardiology, Universidad Autonoma, IDIPAZ, Madrid, Spain
- La Paz University Hospital, Castellana Avenue, 261, 28046 Madrid, Spain
| | - Jonathan P Piccini
- Duke University, Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Sanjeev Saksena
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
- Medical Director and Trustee, Electrophysiologiy Research Foundation, 161 Washington Valley Road, Warren, NJ 07059, USA
| | - A John Camm
- St George’s University Hospitals, Blackshaw Road, Tooting London SW17 0QT, UK
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Kanagaratnam P, Francis DP, Chamie D, Coyle C, Marynina A, Katritsis G, Paiva P, Szigeti M, Cole G, de Andrade Nunes D, Howard J, Esper R, Khan M, More R, Barreto G, Meneguz-Moreno R, Arnold A, Nowbar A, Kaura A, Mariveles M, March K, Shah J, Nijjer S, Lip GY, Mills N, Camm AJ, Cooke GS, Corbett SJ, Llewelyn MJ, Ghanima W, Toshner M, Peters N, Petraco R, Al-Lamee R, Boshoff ASM, Durkina M, Malik I, Ruparelia N, Cornelius V, Shun-Shin M. A RANDOMISED CONTROLLED TRIAL TO INVESTIGATE THE USE OF ACUTE CORONARY SYNDROME THERAPY IN PATIENTS HOSPITALISED WITH COVID-19: THE C19-ACS TRIAL. J Thromb Haemost 2023:S1538-7836(23)00428-2. [PMID: 37230416 DOI: 10.1016/j.jtha.2023.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/11/2023] [Accepted: 04/29/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Patients hospitalised with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. OBJECTIVES To investigate efficacy of an acute coronary syndrome regimen in patients hospitalised with COVID-19 and coronary disease risk factors. PATIENTS/METHODS A randomised controlled open-label trial across acute hospitals (UK and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28-days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, death). RESULTS 320 patients from 9 centres were randomised. The trial terminated early due to low recruitment. At 30 days there was no significant difference in mortality (intervention: 11.5% vs control: 15%, unadjusted OR 0.73, 95%CI 0.38 to 1.41, p=0.355). Significant bleeds were infrequent and not significantly different between the arms (intervention: 1.9% vs control 1.9%, p>0.999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR 1.46, 95% CrI 0.88 to 2.37, Pr(Beta>0)=93%; adjusted OR 1.50, 95% CrI 0.91 to 2.45, Pr(Beta>0)=95%) and median time to discharge home was two days shorter (95% CrI -4 to 0, 2% probability that it was worse). CONCLUSIONS Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.
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Affiliation(s)
- Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK.
| | - Darrel P Francis
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Daniel Chamie
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Clare Coyle
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Patricia Paiva
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Matyas Szigeti
- Imperial College, London, UK; Physiological Controls Research Centre, Obuda University, Budapest, Hungary
| | - Graham Cole
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - James Howard
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Ranjit More
- Blackpool Teaching Hospitals NHS Foundation Trust, UK
| | | | - Rafael Meneguz-Moreno
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; Centro de Ensino e Pesquisa da Rede Primavera, Aracaju, Brazil; Universidade Federal de Sergipe, Lagarto, Brazil
| | - Ahran Arnold
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Amit Kaura
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | | | - Jaymin Shah
- London North West University Healthcare NHS Trust, UK
| | | | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nicholas Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK
| | - A John Camm
- St George's University of London, London, UK
| | - Graham S Cooke
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Martin J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - Waleed Ghanima
- Østfold Hospital: Kalnes, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Mark Toshner
- Heart and Lung Research Institute, Dept of Medicine, University of Cambridge
| | - Nicholas Peters
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Ricardo Petraco
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Rasha Al-Lamee
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | | | - Margarita Durkina
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London
| | - Iqbal Malik
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
| | - Neil Ruparelia
- Imperial College Healthcare NHS Trust, London, UK; Royal Berkshire Hospital NHS Trust, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London
| | - Matthew Shun-Shin
- Imperial College Healthcare NHS Trust, London, UK; Imperial College, London, UK
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Camm AJ. Leap or lag: left atrial appendage closure and guidelines. Europace 2023; 25:euad067. [PMID: 37012659 PMCID: PMC10227666 DOI: 10.1093/europace/euad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/28/2023] [Indexed: 04/05/2023] Open
Abstract
Atrial fibrillation (AF) is associated with life-threatening thromboembolism. Most emboli stem from thrombosis in the left atrial appendage (LAA). The current treatment of choice is oral anticoagulants (OACs), but a small proportion of patients cannot take OACs predominantly because of the so-called unacceptable bleeding risks. However, many who initially accept OACs subsequently stop therapy or reduce the OAC treatment to a potentially non-effective dose leaving them exposed to thromboembolic risk. A relatively simple alternative therapy involves the catheter-based insertion of a LAA closure (LAAC) device to prevent thromboembolism from the LAA. There is a considerable evidence base for this therapy consisting of clinical trials and observational data which suggests comparable therapeutic efficacy with a possible small excess of ischaemic strokes. Although LAAC has been very closely examined by regulators and approved for market release, guidelines from most professional societies give only weak recommendations for use of this device which may be the only known effective therapy available to some at-risk AF patients. Guidance materials from the same societies more enthusiastically endorse LAAC. Clinical practice is running well ahead of the guidelines because equipoise has been lost by physicians faced with patients for whom they have no other effective therapy. Guideline writers are correct in providing recommendations which are less strong for LAAC than for OACs, for those who are able and willing to take OAC treatment, but for those who are not, a stronger recommendation is needed. But, should the guidelines lag behind or leap ahead of the available evidence?
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Affiliation(s)
- A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace, London SW17 0RE, UK
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Gottschalk S, Kany S, König HH, Crijns HJGM, Vardas P, Camm AJ, Wegscheider K, Metzner A, Rillig A, Kirchhof P, Dams J. Cost-effectiveness of early rhythm control vs. usual care in atrial fibrillation care: an analysis based on data from the EAST-AFNET 4 trial. Europace 2023; 25:euad051. [PMID: 36966734 PMCID: PMC10227663 DOI: 10.1093/europace/euad051] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 03/29/2023] Open
Abstract
AIMS The randomized, controlled EAST-AFNET 4 trial showed that early rhythm control (ERC) reduces the rate of a composite primary outcome (cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome) by ∼20%. The current study examined the cost-effectiveness of ERC compared to usual care. METHODS AND RESULTS This within-trial cost-effectiveness analysis was based on data from the German subsample of the EAST-AFNET 4 trial (n = 1664/2789 patients). Over a 6-year time horizon and from a healthcare payer's perspective, ERC was compared to usual care regarding costs (hospitalization and medication) and effects (time to primary outcome; years survived). Incremental cost-effectiveness ratios (ICERs) were calculated. Cost-effectiveness acceptability curves were constructed to visualize uncertainty. Early rhythm control was associated with higher costs [+€1924, 95% CI (-€399, €4246)], resulting in ICERs of €10 638 per additional year without a primary outcome and €22 536 per life year gained. The probability of ERC being cost-effective compared to usual care was ≥95% or ≥80% at a willingness-to-pay value of ≥€55 000 per additional year without a primary outcome or life year gained, respectively. CONCLUSION From a German healthcare payer's perspective, health benefits of ERC may come at reasonable costs as indicated by the ICER point estimates. Taking statistical uncertainty into account, cost-effectiveness of ERC is highly probable at a willingness-to-pay value of ≥€55 000 per additional life year or year without a primary outcome. Future studies examining the cost-effectiveness of ERC in other countries, subgroups with higher benefit from rhythm control therapy, or cost-effectiveness of different modes of ERC are warranted.
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Affiliation(s)
- Sophie Gottschalk
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistraße 52 Building W37, 20246 Hamburg, Germany
| | - Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistraße 52 Building W37, 20246 Hamburg, Germany
| | - Harry JGM Crijns
- Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Universiteitssingel 50, 6200 MD, Maastricht, The Netherlands
| | - Panos Vardas
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, 29 square de Meeus, B-1000 Brussels, BELGIUM
| | - A John Camm
- Molecular & Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Christoph-Probst-Weg 1, 20246 Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
| | - Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Judith Dams
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistraße 52 Building W37, 20246 Hamburg, Germany
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Camm CF, Camm AJ. Farewell from the founding editors of the European Heart Journal - Case Reports. Eur Heart J Case Rep 2023; 7:ytad202. [PMID: 37153818 PMCID: PMC10155224 DOI: 10.1093/ehjcr/ytad202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- C Fielder Camm
- Keble College, University of Oxford, Parks Road, Oxford OX1 3PG, UK
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Singh JP, Blomström-Lundqvist C, Turakhia MP, Camm AJ, Fazeli MS, Kreidieh B, Crotty C, Kowey PR. Dronedarone versus sotalol in patients with atrial fibrillation: A systematic literature review and network meta-analysis. Clin Cardiol 2023. [PMID: 37025083 DOI: 10.1002/clc.24011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/23/2022] [Accepted: 02/17/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND There are limited comparative data on safety and efficacy within commonly used Vaughan-Williams (VW) class III antiarrhythmic drugs (AADs) for maintenance of sinus rhythm in adults with atrial fibrillation (AF). HYPOTHESIS We hypothesized that dronedarone and sotalol, two commonly prescribed VW class III AADs with class II properties, have different safety and efficacy effects in patients with nonpermanent AF. METHODS A systematic literature review was conducted searching MEDLINE®, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to June 15, 2021 (NCT05279833). Clinical trials and observational studies that evaluated safety and efficacy of dronedarone or sotalol in adults with AF were included. Bayesian random-effects network meta-analysis (NMA) was used to quantify comparative safety and efficacy. Where feasible, we performed sensitivity analyses by including only randomized controlled trials (RCTs). RESULTS Of 3581 records identified through database searches, 37 unique studies (23 RCTs, 13 observational studies, and 1 nonrandomized trial) were included in the NMA. Dronedarone was associated with a statistically significantly lower risk of all-cause death versus sotalol (hazard ratio [HR] = 0.38 [95% credible interval, CrI: 0.19, 0.74]). The association was numerically similar in the sensitivity analysis (HR = 0.46 [95% CrI: 0.21, 1.02]). AF recurrence and cardiovascular death results were not significantly different between dronedarone and sotalol in all-studies and sensitivity analyses. CONCLUSION The NMA findings indicate that, across all clinical trials and observational studies included, dronedarone compared with sotalol was associated with a lower risk of all-cause death, but with no difference in AF recurrence.
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Affiliation(s)
- Jagmeet P Singh
- Cardiology Division, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Medical Science, Uppsala University, Uppsala, Sweden
| | - Mintu P Turakhia
- Department of Medicine (Cardiovascular Medicine), Center for Digital Health, Stanford University, Stanford, California, USA
| | - A John Camm
- Cardiac Academic Group, St. George's University of London, London, UK
| | | | - Bahij Kreidieh
- The Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
| | | | - Peter R Kowey
- The Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Boriani G, Camm AJ. In memory of Francesco Furlanello: a great advocate for dedicated commitment to effective, up-to-date, and expert management of cardiac arrhythmias and sports cardiology. Europace 2023; 25:1517-1519. [PMID: 36857529 PMCID: PMC10105842 DOI: 10.1093/europace/euad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, Cranmer Terrace London SW17 0RE, UK
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Nakao YM, Nakao K, Wu J, Nadarajah R, Camm AJ, Gale CP. Risks and benefits of oral anticoagulants for stroke prophylaxis in atrial fibrillation according to body mass index: Nationwide cohort study of primary care records in England. EClinicalMedicine 2022; 54:101709. [PMID: 36353266 PMCID: PMC9637568 DOI: 10.1016/j.eclinm.2022.101709] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are effective and safe alternatives to warfarin for stroke prophylaxis for atrial fibrillation (AF). Whether this extends to patients at the extremes of body mass index (BMI) is unclear. METHODS Using linked primary and secondary data, Jan 1, 2010 to Nov 30, 2018, we included CHA2DS2-VASC score ≥3 in women and ≥2 in men with AF treated with oral anticoagulants (OACs). Outcomes were ischaemic stroke, major bleeding and all-cause mortality by World Health Organisation BMI classification. Patients who received warfarin were propensity score matched (1:1 ratio) with those who received DOACs and the association of time-varying OAC exposure on outcomes quantified using Cox proportional hazards models. FINDINGS We included 29,135 (22,818 warfarin, 6317 DOAC); 585 (2.0%) underweight, 8427 (28.9%) normal weight, 10,705 (36.7%) overweight, 5910 (20.3%) class I obesity and 3508 (12.0%) class II/III obesity. Patients treated with DOACs were older and more comorbid. After 3.7 (SD 2.5) years follow up, there was no difference in risk of ischaemic stroke and major bleeding by BMI category between DOACs and warfarin. Normal weight, overweight and obese class I patients had higher risk of all-cause mortality when treated with DOACs compared with warfarin (HR: 1.45 [95% CI 1.24-1.69], p < 0.001; 1.41 [95% CI 1.19-1.66], p < 0.001; and 1.90 [95% CI 1.50-2.39], p < 0.001), an effect not observed after DOACs became the most common OAC prescription. Amongst underweight patients OAC exposure was associated with greater harm from bleeding than benefit from stroke prevention (benefit to harm ratio, 0.35 [95% CI 0.26-0.44]). INTERPRETATION In patients with AF in each BMI classification we found no difference in ischaemic stroke and bleeding risk for DOACs compared with warfarin. Underweight patients experienced divergent risk-benefit patterns from oral anticoagulation compared with other BMI categories. FUNDING None.
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Affiliation(s)
- Yoko M. Nakao
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Corresponding author. @YokoMNakao
| | - Kazuhiro Nakao
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Jianhua Wu
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- School of Dentistry, University of Leeds, Leeds, UK
| | - Ramesh Nadarajah
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A. John Camm
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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34
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Stambler BS, Plat F, Sager PT, Shardonofsky S, Wight D, Potvin D, Pandey AS, Ip JE, Coutu B, Mondésert B, Sterns LD, Bennett M, Anderson JL, Damle R, Haberman R, Camm AJ. First Randomized, Multicenter, Placebo-Controlled Study of Self-Administered Intranasal Etripamil for Acute Conversion of Spontaneous Paroxysmal Supraventricular Tachycardia (NODE-301). Circ Arrhythm Electrophysiol 2022; 15:e010915. [DOI: 10.1161/circep.122.010915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background:
Pharmacologic termination of paroxysmal supraventricular tachycardia (PSVT) often requires medically supervised intervention. Intranasal etripamil, is an investigational fast-acting, nondihydropyridine, L-type calcium channel blocker, designed for unsupervised self-administration to terminate atrioventricular nodal–dependent PSVT. Phase 2 results showed potential safety and efficacy of etripamil in 104 patients with PSVT.
Methods:
NODE-301, a phase 3, multicenter, double-blind, placebo-controlled study evaluated the efficacy and safety of etripamil nasal spray administered, unsupervised in patients with symptomatic sustained PSVT. After a medically supervised etripamil test dose while in sinus rhythm, patients were randomized 2:1 to receive etripamil 70 mg or placebo. When PSVT symptoms developed, patients applied a cardiac monitor and attempted a vagal maneuver; if symptoms persisted, they self-administered blinded treatment. An independent Adjudication Committee reviewed continuous electrocardiogram recordings. The primary efficacy endpoint was termination of adjudicated PSVT within 5 hours after study drug administration.
Results:
NODE-301 accrued 156 positively adjudicated PSVT events treated with etripamil (n=107) or placebo (n=49). The hazard ratio for the primary endpoint, time-to-conversion to sinus rhythm during the 5-hour observation period, was 1.086 (95% CI, 0.726–1.623;
P
=0.12). In predefined sensitivity analyses, etripamil effects (compared with placebo) occurred at 3, 5, 10, 20, and 30 minutes (
P
<0.05). For example, at 30 minutes, there was a 53.7% of SVT conversion in the treatment arm compared to 34.7% in the placebo arm (hazard ratio, 1.87 [95% CI, 1.09–3.22];
P
=0.02). Etripamil was well tolerated; adverse events were mainly related to transient nasal discomfort and congestion (19.6% and 8.0%, respectively, of randomized treatment-emergent adverse events.
Conclusions:
Although the primary 5-hour efficacy endpoint was not met, analyses at earlier time points indicated an etripamil treatment effect in terminating PSVT. Etripamil self-administration during PSVT was safe and well tolerated. These results support continued clinical development of etripamil nasal spray for self-administration during PSVT in a medically unsupervised setting.
REGISTRATION:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT03464019.
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Affiliation(s)
| | - Francis Plat
- Milestone Pharmaceuticals, Montreal, Quebec, Canada (F.P., S.S., D.W.)
| | - Philip T. Sager
- Cardiovascular Research Institute & Department of Medicine, Stanford University, Palo Alto, CA (P.T.S.)
| | | | - Douglas Wight
- Milestone Pharmaceuticals, Montreal, Quebec, Canada (F.P., S.S., D.W.)
| | | | | | - James E. Ip
- Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, NY (J.E.I.)
| | - Benoit Coutu
- Centre Hospitalier de l’ Université de Montréal (B.C.)
| | | | - Laurence D. Sterns
- Victoria Cardiac Arrhythmia Trials, Inc, Victoria, British Columbia (L.D.S.)
| | - Matthew Bennett
- Centre for Cardiovascular Innovation. Division of Cardiology, University of British Columbia, Vancouver, Canada (M.B.)
| | | | - Roger Damle
- South Denver Cardiology Associates, PC, Littleton, CO (R.D.)
| | | | - A. John Camm
- St. George’s University of London, London, England (A.J.C.)
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35
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Pasupula DK, Siddappa Malleshappa SK, Munir MB, Bhat AG, Anandaraj A, Jakkoju A, Spooner M, Koranne K, Hsu JC, Olshansky B, Camm AJ. Combined atrial fibrillation ablation and left atrial appendage occlusion procedure in the United States: a propensity score matched analysis from 2016-2019 national readmission database. Europace 2022; 25:390-399. [PMID: 36350997 PMCID: PMC9935040 DOI: 10.1093/europace/euac181] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/16/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS The safety and feasibility of combining percutaneous catheter ablation (CA) for atrial fibrillation with left atrial appendage occlusion (LAAO) as a single procedure in the USA have not been investigated. We analyzed the US National Readmission Database (NRD) to investigate the incidence of combined LAAO + CA and compare major adverse cardiovascular events (MACEs) with matched LAAO-only and CA-only patients. METHODS AND RESULTS In this retrospective study from NRD data, we identified patients undergoing combined LAAO and CA procedures on the same day in the USA from 2016 to 2019. A 1:1 propensity score match was performed to identify patients undergoing LAAO-only and CA-only procedures. The number of LAAO + CA procedures increased from 28 (2016) to 119 (2019). LAAO + CA patients (n = 375, mean age 74 ± 9.2 years, 53.4% were males) had non-significant higher MACE (8.1%) when compared with LAAO-only (n = 407, 5.3%) or CA-only patients (n = 406, 7.4%), which was primarily driven by higher rate of pericardial effusion (4.3%). All-cause 30-day readmission rates among LAAO + CA patients (10.7%) were similar when compared with LAAO-only (12.7%) or CA-only (17.5%) patients. The most frequent primary reason for readmissions among LAAO + CA and LAAO-only cohorts was heart failure (24.6 and 31.5%, respectively), while among the CA-only cohort, it was paroxysmal atrial fibrillation (25.7%). CONCLUSION We report an 63% annual growth (from 28 procedures) in combined LAAO and CA procedures in the USA. There were no significant difference in MACE and all-cause 30-day readmission rates among LAAO + CA patients compared with matched LAAO-only or CA-only patients.
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Affiliation(s)
| | - Sudeep K Siddappa Malleshappa
- Division of Haematology-Oncology, Department of Internal Medicine, UMass Chan-Baystate, 759 Chestnut St, Springfield, MA 01199, USA
| | - Muhammad B Munir
- Division of Cardiology, Department of Internal Medicine, University of California Davis, 4150 V Street, Suite 3100, Sacramento, CA 95817, USA
| | - Anusha Ganapati Bhat
- Department of Cardiology, Department of Internal Medicine, University of Maryland, 620 W Lexington St, Baltimore, MD 21201, USA
| | - Antony Anandaraj
- Division of Cardiovascular Disease, Department of Internal Medicine, MercyOne North Iowa Medical Center, 1000 4th St SW, Mason City, IA 50401, USA
| | - Avaneesh Jakkoju
- Division of Cardiology, Cardiovascular Institute of South, 441 Heymann Blvd, Lafayette, LA 70503, USA
| | - Michael Spooner
- Division of Cardiovascular Disease, Department of Internal Medicine, MercyOne North Iowa Medical Center, 1000 4th St SW, Mason City, IA 50401, USA
| | - Ketan Koranne
- Division of Cardiovascular Disease, Department of Internal Medicine, MercyOne North Iowa Medical Center, 1000 4th St SW, Mason City, IA 50401, USA
| | - Jonathan C Hsu
- Division of Cardiology, Department of Internal Medicine, University of California San Diego, 9500 Gilman Dr. La Jolla, CA 92093, USA
| | - Brian Olshansky
- Department of Cardiology, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - A John Camm
- Division of Cardiology, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
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36
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Brandes A, Stavrakis S, Freedman B, Antoniou S, Boriani G, Camm AJ, Chow CK, Ding E, Engdahl J, Gibson MM, Golovchiner G, Glotzer T, Guo Y, Healey JS, Hills MT, Johnson L, Lip GYH, Lobban T, Macfarlane PW, Marcus GM, McManus DD, Neubeck L, Orchard J, Perez MV, Schnabel RB, Smyth B, Steinhubl S, Turakhia MP. Consumer-Led Screening for Atrial Fibrillation: Frontier Review of the AF-SCREEN International Collaboration. Circulation 2022; 146:1461-1474. [PMID: 36343103 PMCID: PMC9673231 DOI: 10.1161/circulationaha.121.058911] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/22/2022] [Indexed: 11/09/2022]
Abstract
The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.
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Affiliation(s)
| | - Stavros Stavrakis
- Cardiovascular Section, University of Oklahoma Health Science Center
| | - Ben Freedman
- Heart Research Institute, University of Sydney, Sydney, Australia
| | | | - Giuseppe Boriani
- Department of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Clara K. Chow
- Cardiovascular Division, University of Sydney, Sydney, Australia
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Johan Engdahl
- Department of Cardiology, Karolinska Institute, Stockholm, Sweeden
| | - Michael M. Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Taya Glotzer
- Hackensack University Medical Center, Hackensack, NJ
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, China
| | | | | | | | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | | | | | - Gregory M. Marcus
- Department of Cardiology, University of California, San Francisco, San Franscisco, CA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Lis Neubeck
- Centre for Cardiovascular Health, Edinburgh Napier University
| | - Jessica Orchard
- Charles Perkins Centre, University of Sydney, Sydney, Australia
| | | | | | - Breda Smyth
- Department of Public Health, Health Service Executive West, Galway, Ireland
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37
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Stambler BS, Plat F, Sager PT, Lubkov V, Shardonofsky S, Wight D, Chen M, Camm AJ. Rationale for and design of a multicenter, placebo-controlled, phase 3 study to assess efficacy and safety of intranasal etripamil for the conversion of paroxysmal supraventricular tachycardia. Am Heart J 2022; 253:20-29. [PMID: 35728658 DOI: 10.1016/j.ahj.2022.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 06/15/2023]
Abstract
Presently, acute pharmacological termination of paroxysmal supraventricular tachycardia (PSVT) unresponsive to patient-initiated vagal maneuvers requires in-hospital intervention. Etripamil, a fast-acting, nondihydropyridine, L-type calcium channel blocker, is formulated as an intranasal spray to rapidly terminate atrioventricular (AV) nodal-dependent PSVT in a medically unsupervised setting. The NODE-301 study did not meet its prespecified primary end point of PSVT conversion over 5 hours following a single dose of etripamil 70 mg. However, analysis at earlier time points demonstrated etripamil treatment effect during the first 30 minutes, consistent with its expected rapid onset and short duration of action. This led to the design of the RAPID study, which includes a new dosing regimen (up to 2 etripamil 70 mg doses separated by 10 minutes) to increase the exposure and pharmacodynamic effect of etripamil. The primary objective of RAPID (NCT03464019) is to determine if etripamil self-administered by patients is superior to placebo in terminating PSVT in an at-home setting. The secondary objective is to evaluate the safety of etripamil when self-administered by patients without medical supervision. Additional efficacy end points include the proportion of patients requiring additional medical intervention in an emergency department to terminate PSVT and patient-reported outcomes. After successfully completing a test dose to assess the safety of 2 70 mg doses of etripamil during sinus rhythm, approximately 500 patients will be randomized 1:1 to etripamil or placebo to accrue 180 positively adjudicated AV nodal-dependent PSVT events for treatment with the study drug. Etripamil may offer a new alternative to the current in-hospital treatment modality, providing for safe and effective at-home termination of PSVT.
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Affiliation(s)
| | - Francis Plat
- Milestone Pharmaceuticals, Montreal, Quebec, Canada.
| | | | | | | | | | | | - A John Camm
- St. George's University of London, London, United Kingdom
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38
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Kirchhof P, Camm AJ, Crijns HJGM, Piccini JP, Torp-Pedersen C, McKindley D, Stewart J, Wieloch M, Hohnloser SH. Dronedarone as early rhythm control: post-hoc analysis of the ATHENA trial using EAST-AFNET4 criteria. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The EAST-AFNET4 study found that early, systematic rhythm control reduced cardiovascular (CV) outcomes in patients with early atrial fibrillation/atrial flutter (AF) of ≤12 months compared to guideline-recommended usual care.
Purpose
This post-hoc analysis aimed to assess whether antiarrhythmic drug therapy alone (i.e. dronedarone 400 mg BID) improved CV outcomes compared to placebo in patients with early AF in the ATHENA trial (NCT00174785; Ref 2) applying the EAST-AFNET4 criteria.
Methods
All patients in the randomised, placebo-controlled ATHENA trial with ≥2 CV conditions as defined in the EAST-AFNET 4 inclusion criteria and known AF duration at baseline were identified. Patients were split into early AF (≤12 months duration) and late AF (>12 months duration) subgroups. Outcomes were collected over a mean follow-up of 21 months and included a composite of CV death, stroke, or hospitalisation with worsening of heart failure or acute coronary syndrome; nights spent in hospital per year; and a safety composite endpoint comprising death, stroke, or pre-specified serious adverse events. All analyses were conducted in the intention-to-treat population.
Results
Dronedarone treatment was associated with significantly (p=0.014) fewer CV events vs placebo in patients with early AF (Fig 1). There was no interaction with AF duration (p=0.64). Patients on dronedarone spent numerically fewer nights in hospital vs placebo in early (13.4 vs 14.0) and late AF (13.9 vs 16.3), with no treatment interaction between subgroups (p=NS). Dronedarone was associated with more sinus rhythm (SR) at 12 months vs placebo (early AF: 79.9% vs 70.3%; late AF: 60.6% vs 54.0%), and similar rates of SR at 24 months (early AF: 65.8% vs 65.7%; late AF: 54.7% vs 54.1%). For the safety composite endpoint, estimated events/patients were as follows for the early AF group (dronedarone: 153/135; placebo: 182/165) and the late AF group (dronedarone: 86/81; placebo: 95/89).
Conclusions
The clinical benefit of early rhythm control found in the EAST-AFNET4 trial can be replicated in this analysis of patients with early AF treated in the ATHENA trial comparing dronedarone to placebo. These data support the use of dronedarone as part of early rhythm control.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Sanofi
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Affiliation(s)
- P Kirchhof
- University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Cardiology , Hamburg , Germany
| | - A J Camm
- St George's University of London , London , United Kingdom
| | - H J G M Crijns
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - J P Piccini
- Duke Clinical Research Institute , Durham , United States of America
| | | | - D McKindley
- Sanofi , Bridgewater , United States of America
| | | | | | - S H Hohnloser
- Johann Wolfgang Goethe University , Frankfurt , Germany
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39
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Pope MK, Hall TS, Atar D, Virdone S, Pieper K, Jansky P, Steffel J, Haas S, Gersh BJ, Goto S, Panchenko E, Baron-Esquivias G, Angchaisuksiri P, Camm AJ, Kakkar AK. Rhythm versus rate control in patients with newly diagnosed atrial fibrillation: observations from the GARFIELD-AF registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Atrial fibrillation is associated with considerable morbidity and mortality. Real-world reports on the effect of early rhythm control on patient outcomes in patient with recent onset atrial fibrillation are limited.
Purpose
To assess the effect of early rhythm versus rate control on clinical outcomes in patients with newly diagnosed non-valvular atrial fibrillation.
Method
The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is a non-interventional registry of adult (≥18 years) patients with newly diagnosed atrial fibrillation (≤ six weeks' duration) and at least one investigator determined risk factor for stroke. Patients were enrolled in 1317 participating sites in 35 countries between March 2010 and August 2016. Patients with permanent atrial fibrillation were excluded. Stratification to rhythm or rate control was based on treatment strategy initiated at baseline (≤48 days post enrolment). Rhythm control was defined as investigator reported initiation of rhythm control (antiarrhythmic drug(s), cardioversion, or ablation – alone or in combination with rate modifiers). Rate control was defined as investigator reported initiation of rate control and absence of rhythm control therapy. Overlap propensity weighting and Cox proportional-hazards models were used to evaluate effect on outcomes.
Results
Of 45,382 included patients, 23,858 (52.6%) received rhythm control and 21,524 (47.4%) rate control. Rates of rhythm control were similar throughout the study time period (52.7% in 2010/2011, 54.2% in 2015/2016). Patients in the rhythm control group were younger (median age (Q1; Q3) 68.0 (60.0; 76.0) versus 73.0 (65.0; 79.0)), had lower rates of prior stroke/transitory ischemic attack/systemic embolism (9.4% vs 13.0%), and a lower median GARFIELD death score (4.0 (2.3; 7.5) versus 5.1 (2.8; 9.2)). Median CHA2DS2-VASc Scores were 3.0 (2.0; 4.0) in both groups. Rate of anticoagulation treatment was similar in the rhythm and rate control group (66.0% versus 65.5%). After propensity score overlap weighting, patients of the two groups were well balanced on all observed characteristics.
Event rates per 100 person-years (95% confidence interval [CI]) over two years follow-up in the rhythm and rate control group were 2.94 (2.78–3.10) versus 4.43 (4.22–4.64) for mortality, 0.84 (0.75–0.92) versus 1.16 (1.05–1.27) for non-haemorrhagic stroke/systemic embolism and 0.84 (0.76–0.93) versus 1.16 (1.06–1.27) for major bleeding. Adjusted hazard ratios (95% CI) for the same time period were 0.85 (0.79–0.92), 0.84 (0.72–0.97) and 0.9 (0.78–1.04).
Conclusion
In this large, internation registry, a rhythm control strategy was initiated at baseline in about half of the patients with newly diagnosed non-valvular atrial fibrillation. After adjustment for confounding factors, a significantly lower risk of all-cause mortality and non-haemorrhagic stroke/systemic embolism were observed for patients that received an early rhythm control strategy.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK).
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Affiliation(s)
- M K Pope
- University of Oslo, Institute of Clinical Medicine , Oslo , Norway
| | - T S Hall
- Oslo University Hospital Ulleval, Department of Cardiology , Oslo , Norway
| | - D Atar
- Oslo University Hospital Ulleval, Department of Cardiology , Oslo , Norway
| | - S Virdone
- Thrombosis Research Institute , London , United Kingdom
| | - K Pieper
- Thrombosis Research Institute , London , United Kingdom
| | - P Jansky
- Motol University Hospital, Department of Cardiovascular Surgery , Prague , Czechia
| | - J Steffel
- University of Zurich , Zurich , Switzerland
| | - S Haas
- Technical University of Munich, Formerly Department of Medicine , Munich , Germany
| | - B J Gersh
- Mayo Clinic College of Medicine and Science, Department of Cardiovascular Medicine , Rochester , United States of America
| | - S Goto
- Tokai University School of Medicine , Kanagawa , Japan
| | - E Panchenko
- National Medical Research Center of Cardiology , Moscow , Russian Federation
| | | | - P Angchaisuksiri
- Ramathibodi Hospital, Department of Medicine , Mahidol University , Thailand
| | - A J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular and Clinical Sciences Research Institute , London , United Kingdom
| | - A K Kakkar
- Thrombosis Research Institute , London , United Kingdom
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40
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Escobar Cervantes C, Camm AJ, Virdone S, Fox KAA, Bassand JP, Pieper K, Kayani G, Kakkar AK. Stroke and bleed related deaths in newly diagnosed atrial fibrillation patients: insights from the GARFIELD-AF registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Atrial fibrillation (AF) is associated with a significant increase in stroke risk. Anticoagulation (AC) guidelines recommend stratification of stroke risk to aid AC choice. However, despite evidence supporting AC, the associated bleeding risk often leads to underdosing or omission of AC. Transition from stratification of stroke and bleeding risk to stratification of mortality associated with stroke and bleeding may overcome this therapeutic inertia.
Purpose
To quantify the risk of stroke- and bleed-related mortality in newly diagnosed AF patients according to different AC strategies.
Methods
GARFIELD-AF is the largest multinational, prospective AF registry worldwide. Stroke- and bleed-related deaths were defined as a death occurring within 30 days after each event. Predictors of stroke- and bleed-related deaths were identified through least absolute shrinkage and selection operator and were selected from a comprehensive list of demographic, clinical and lifestyle factors. Expected probabilities of stroke- and bleed-related death by AC strategy were extracted from the developed Cox proportional-hazards models.
Results
Among the 52,018 GARFIELD-AF patients, 195 stroke-related deaths and 172 bleed-related deaths occurred. Patients who suffered stroke- or bleed-related deaths were older (median [Q1; Q3]: 78.0 [72.0; 84.0] and 77.0 [70.5; 83.0]) than those who did not (71.0 [63.0; 78.0]) and had a higher prevalence of comorbidities including heart failure, vascular disease, and prior stroke.
Patients who suffered a stroke-related death less frequently received vitamin K antagonists (VKAs) and non-vitamin K Antagonist Oral anticoagulants (NOACs) compared to those who were alive at two years or died of a non-stroke-related death. In contrast, patients who suffered a bleed-related death more often received VKAs compared to those who did not. NOACs and AP monotherapy treatment were less common in patients who had bleed-related death (Figure 1).
Predictors for stroke-related death included age, ethnicity, heart failure, prior stroke, AC treatment, pulse, and dementia. Bleed-related mortality predictors were age, ethnicity, chronic kidney disease, AC treatment, vascular disease, and smoking status. VKAs and NOACs were associated with a lower risk of stroke-related death, reducing 2-year risk from 0.73% without AC to 0.41% and 0.36%, respectively. In contrast, bleed-related deaths increased with VKA treatment, but not with NOACs (Figure 2). The overall net benefit versus no AC treatment was greater with NOACs than VKAs.
Conclusion
Among AF patients at high stroke risk, NOACs and VKAs were associated with a reduced risk of stroke-related death compared to no AC, but the risk of bleed-related death was higher with VKA. This suggests that a new approach to risk stratification based on the net mortality benefits of NOAC use in newly diagnosed AF patients at high risk of stroke should be considered.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK)
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Affiliation(s)
| | - A J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular and Clinical Sciences Research Institute , London , United Kingdom
| | - S Virdone
- Thrombosis Research Institute , London , United Kingdom
| | - K A A Fox
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | | | - K Pieper
- Thrombosis Research Institute , London , United Kingdom
| | - G Kayani
- Thrombosis Research Institute , London , United Kingdom
| | - A K Kakkar
- Thrombosis Research Institute , London , United Kingdom
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Verheugt FWA, Fox KAA, Virdone S, Gersh BJ, Haas S, Pieper K, Kayani G, Camm AJ, Parkhomenko A, Kakkar AK. Differential efficacy and safety of oral anticoagulation in atrial fibrillation patients with or without comorbid vascular disease: insights from the GARFIELD-AF registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Many patients with atrial fibrillation (AF) have comorbid vascular disease. The effects of oral anticoagulation (OAC) in AF patients with vascular disease, however, have not been widely studied.
Purpose
To investigate the impact of OAC in AF patients with (Vasc) or without (nVasc) concomitant vascular disease.
Methods
GARFIELD-AF is the largest multinational, prospective AF registry. The study comprised 51,574 GARFIELD-AF patients with newly diagnosed AF, 13,365 Vasc and 38,209 nVasc patients. All patients who reported coronary artery disease, aortic or peripheral artery disease, acute coronary syndromes, myocardial infarction, stenting, or coronary artery bypass graft were classified as having vascular disease. Adjusted hazard ratios were obtained via Cox proportional-hazards models to quantify the association of vascular disease with selected endpoints. Comparative effectiveness analyses were restricted to patients enrolled from April 2013-September 2016 (when NOACs became widely available) and who were eligible for anticoagulation (CHA2DS2-VASc ≥2 excl. gender). To evaluate the safety and efficacy of different anticoagulation strategies in Vasc and nVasc patients, propensity score using an overlap weighting scheme was applied. Weights were applied to Cox proportional-hazards models to estimate the effects of OAC vs No OAC and NOAC vs VKA.
Results
Vasc patients were older (median (Q1; Q3): 72.0 (65.0; 79.0) vs 70.0 (62.0; 78.0) and more often male (62.0 vs 53.6%). Vasc patients had a higher rate of comorbidities including heart failure, hypertension, and diabetes. Vasc patients received less OAC (62.8 vs 68.3%). NOACs were less common compared with nVasc patients (23.8% vs 28.7%) but a similar proportion of VKAs was observed in both (39.0% vs 39.6%). Antiplatelet monotherapy was more common in Vasc (31%) than nVasc (18%) patients.
At 2-years, Vasc was associated with a higher risk of all-cause (HR [95% CI]: 1.30 [1.16–1.47]) and cardiovascular mortality (1.59 [1.28–1.97]). OACs significantly lowered the risk of all-cause mortality and stroke in nVasc patients (0.72 [0.63–0.82] and 0.64 [0.49–0.84], respectively), but not in nVasc patients. OACs led to a numerical increase in major bleeding in Vasc patients (1.32 [0.90–1.93]) and a significant increase in major bleeding in nVasc patients (1.40 [1.03–1.90]) (Figure 1). Compared with VKAs, NOACs did not significantly improve the risk of outcomes in nVasc patients. In Vasc patients however, NOACs significantly lowered the risk of all-cause mortality (0.74 [0.61–0.90]) and major bleeding (0.45 [0.29–0.70]) compared with VKAs (Figure 2).
Conclusion
AF patients with vascular disease have worse long-term outcomes than those without. They receive less often OAC, specifically NOAC, and more antiplatelet agents. The beneficial effects of NOAC over VKA are much more pronounced in patients with than in those without vascular disease.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK).
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Affiliation(s)
- F W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG) , Amsterdam , The Netherlands
| | - K A A Fox
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - S Virdone
- Thrombosis Research Institute , London , United Kingdom
| | - B J Gersh
- Mayo Clinic College of Medicine and Science , Rochester , United States of America
| | - S Haas
- Vascular Centre Munich , Munich , Germany
| | - K Pieper
- Thrombosis Research Institute , London , United Kingdom
| | - G Kayani
- Thrombosis Research Institute , London , United Kingdom
| | - A J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular and Clinical Sciences Research Institute , London , United Kingdom
| | - A Parkhomenko
- National Scientific Center of Ukraine, MD Strazhesko Institute of Cardiology , Kiev , Ukraine
| | - A K Kakkar
- Thrombosis Research Institute , London , United Kingdom
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Camm AJ, Crijns HJGM, Elvan A, Tuininga Y, Badings E, Kuijper AFM, De Jong JSSG, Lee M, Schellings D, Van Gelder IC, Ruskin J, Kowey P, Dufton C, Maupas J, Belardinelli L. Alleviation of AF related symptoms following acute conversion of recent-onset, symptomatic atrial fibrillation to sinus rhythm with flecainide acetate oral inhalation solution. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Pharmacological restoration of sinus rhythm (SR) in patients with symptomatic atrial fibrillation (AF) is expected to be accompanied by prompt alleviation of symptoms to avoid the need for electrical cardioversion (ECV) and/or hospitalization. The feasibility and safety of acute cardioversion of recent-onset (≤48 hours) symptomatic AF to SR with flecainide acetate oral inhalation (FlecIH) solution was shown in the Phase 2, open-label INSTANT trial. We examined symptoms, heart rate, time to discharge and need for ECV reported among patients in the INSTANT trial whose AF was successfully converted to SR (“conversion group”; N=25) versus those whose AF did not convert to SR (“no conversion group”; N=29).
Methods
Conversion success was determined using 12-lead Holter monitoring during a 90-minute observation period. Patients in the no conversion group were offered alternative treatment per the investigator discretion. Symptoms, vital signs, time to discharge, and the need for ECV were evaluated through Day 5.
Results
Data from 54 patients (33.3% female) with a mean age of 62.1 years and a mean BMI of 26.8 kg/m2 were analyzed. All patients reported at least one AF-related symptoms at baseline (palpitations=85%; dizziness=35%; shortness of breath=37%; chest discomfort=39%) and 83.3% presented with AF symptoms ≤24 hours in duration. At 90 minutes, 80.0% of the conversion group were asymptomatic compared to 37.9% of the no conversion group (p<0.001). Mean (SD) ventricular rate at 90 minutes was 70.6 (12.5) bpm in the conversion group compared to 100.4 (29.4) bpm in the no conversion group (p<0.001). Median time to discharge was 2.3 (IQR: 0.75) hours for the conversion group compared to 3.6 (IQR: 1.02) hours for the no conversion group (p=0.001). By Day 5, 23 (79.3%) patients in the no conversion group had undergone ECV; no patients in the conversion group experienced AF recurrence by Day 5 (0% required ECV; p<0.001).
Conclusions
Conversion of recent onset AF to SR with inhaled flecainide was associated with a reduction in symptoms, normalization of heart rate, rapid hospital discharge and avoidance of ECV during a 5-day follow-up period.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): InCarda Therapeutics
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Affiliation(s)
- A J Camm
- St George's University of London, Cardiac and Vascular Sciences , London , United Kingdom
| | - H J G M Crijns
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - A Elvan
- Isala Clinics , Zwolle , The Netherlands
| | - Y Tuininga
- University of Edinburgh , Edinburgh , United Kingdom
| | - E Badings
- Deventer Hospital , Deventer , The Netherlands
| | | | - J S S G De Jong
- Hospital Onze Lieve Vrouwe Gasthuis , Amsterdam , The Netherlands
| | - M Lee
- Memorial Care Long Beach Medical Center , Long Beach , United States of America
| | - D Schellings
- Slingeland Hospital , Doetinchem , The Netherlands
| | - I C Van Gelder
- University Medical Centre Groningen , Groningen , The Netherlands
| | - J Ruskin
- Massachusetts General Hospital , Boston , United States of America
| | - P Kowey
- Lankenau Institute for Medical Research , Philadelphia , United States of America
| | - C Dufton
- InCarda Therapeutics , Newark , United States of America
| | - J Maupas
- InCarda Therapeutics , Newark , United States of America
| | - L Belardinelli
- InCarda Therapeutics , Newark , United States of America
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Ruskin J, Dufton C, Maupas J, Crijns H, Elvan A, De Jong J, Oosterhof T, Tuininga Y, Badings E, Aksoy I, Nuyens D, Van Dijk V, Camm AJ, Kowey P, Belardinelli L. Predictors of successful cardioversion of recent-onset atrial fibrillation to sinus rhythm with orally inhaled flecainide. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Height, weight, and body mass index (BMI) are well established risk factors for atrial fibrillation (AF) but whether they are also predictors of successful pharmacological cardioversion of AF is unknown. Data from the open-label INSTANT study of flecainide acetate oral inhalation solution (FlecIH) for acute cardioversion of recent-onset symptomatic AF were examined to determine if these anthropometric measures are predictors of successful cardioversion of AF to sinus rhythm (SR) with FlecIH.
Methods
Logistic regression was performed on a broad array of patient and disease characteristics to identify predictors of cardioversion success at 90 minutes post-dose, and potential interactions were examined by boundary restriction analysis. Data are presented for patients receiving 120 mg FlecIH.
Results
Data from 81 patients (32.1% female) with a mean age of 59.8 years (range: 26.0, 84.0) were included in the analysis. This cohort had a mean weight of 87 kg (range: 57, 150), a mean height of 180 cm (range: 156, 199), and a mean BMI of 26.8 kg/m2 (range: 17.2, 37.9). A logistic regression model identified height, weight, and BMI as significant predictors of cardioversion success (p<0.01) and a boundary restriction analysis revealed a negative correlation between BMI and conversion rate across the entire dataset (see Figure 1). Clinically significant conversion rates were observed for patients with BMI values that were considered normal (BMI <25 kg/m2 = 53%; 95% CI: 36, 70), overweight (BMI ≥25 and <30 kg/m2 = 47%; 95% CI: 29, 64), and obese (BMI ≥30 and <35 kg/m2 = 43%; 95% CI: 17, 69); however, none of the severely obese patients (BMI ≥35 mg/m2) had their AF successfully converted to sinus rhythm (see Figure 2).
Conclusions
Successful cardioversion of recent onset AF with 120 mg FlecIH was observed in normal, overweight, and obese patients with BMI values <35 kg/m2; however, conversion rate decreases with increasing BMI. Further evaluation of FlecIH dosing in severely obese patients is warranted.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): InCarda Therapeutics
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Affiliation(s)
- J Ruskin
- Mass General Hopital (MGH) , Boston , United States of America
| | - C Dufton
- InCarda Therapeutics , Newark , United States of America
| | - J Maupas
- InCarda Therapeutics , Newark , United States of America
| | - H Crijns
- Maastricht University Medical Centre (MUMC) , Maastricht , The Netherlands
| | - A Elvan
- Isala Clinics , Zwolle , The Netherlands
| | - J De Jong
- Hospital Onze Lieve Vrouwe Gasthuis , Amsterdam , The Netherlands
| | - T Oosterhof
- Gelderse Vallei Hospital , Ede , The Netherlands
| | - Y Tuininga
- Deventer Hospital , Deventer , The Netherlands
| | - E Badings
- Deventer Hospital , Deventer , The Netherlands
| | - I Aksoy
- Admiraal de Ruijter Hospital , Goes , The Netherlands
| | - D Nuyens
- Hospital Oost-Limburg (ZOL) , Genk , Belgium
| | - V Van Dijk
- St Antonius Hospital , Nieuwegein , The Netherlands
| | - A J Camm
- St George's University of London , London , United Kingdom
| | - P Kowey
- Lankenau Heart Institute , Wynnewood , United States of America
| | - L Belardinelli
- InCarda Therapeutics , Newark , United States of America
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Kreidieh B, Singh JP, Blomstrom-Lundqvist C, Turakhia MP, Camm AJ, Fazeli MS, Crotty C, Kowey PR. Dronedarone versus sotalol in patients with atrial fibrillation: a systematic literature review and network meta-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
There are limited comparative data on safety and efficacy within Vaughn Williams class III anti-arrhythmic drugs (AADs) for maintenance of sinus rhythm in adults with atrial fibrillation (AF).
Purpose
We sought to compare the safety and efficacy of dronedarone and sotalol, two commonly prescribed Vaughn Williams class III AADs with class II rate-controlling properties in patients with non-permanent AF.
Methods
A systematic literature review was conducted by searching MEDLINE®, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to June 15, 2021. Clinical trials and observational studies that evaluated safety and efficacy of dronedarone or sotalol in adults with AF were included. Where feasible, Bayesian random-effects network meta-analysis (NMA) was conducted to estimate comparative safety and efficacy. Where possible, sensitivity analyses were conducted by including only randomized controlled trials (RCTs).
Results
Of 3,581 records identified through database searches, 37 unique studies (23 RCTs, 13 observational studies, and 1 non-randomized trial) were included in the NMA. Dronedarone was associated with a statistically significantly lower risk of all-cause death versus sotalol in the all-studies NMA (hazard ratio [HR]: 0.38; 95% credible interval [CrI]: 0.19, 0.74; 22 studies); sensitivity analysis followed the same trend numerically (HR: 0.46; 95% CrI: 0.21, 1.02; 16 RCTs). Risk ratios of AF recurrence were not significantly different between dronedarone and sotalol in both all-studies and sensitivity analyses.
Conclusion
Dronedarone, compared with sotalol, was associated with significantly lowered risk of all-cause death in the analysis combining RCTs and observational studies, with no differences in AF recurrence observed between the two therapies. This meta-analysis provides a comprehensive assessment of safety and efficacy evidence useful in evaluating treatment options in AF.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Sanofi
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Affiliation(s)
- B Kreidieh
- The Lankenau Institute for Medical Research , Wynnewood , United States of America
| | - J P Singh
- Massachusetts General Hospital, Harvard Medical School, Cardiology Division , Boston , United States of America
| | | | - M P Turakhia
- Center for Digital Health, Stanford University, Department of Medicine (Cardiovascular Medicine) , Stanford , United States of America
| | - A J Camm
- Cardiac Academic Group, St. George's University of London , London , United Kingdom
| | - M S Fazeli
- Evidinno Outcomes Research Inc. , Vancouver , Canada
| | - C Crotty
- Evidinno Outcomes Research Inc. , Vancouver , Canada
| | - P R Kowey
- The Lankenau Institute for Medical Research , Wynnewood , United States of America
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Wu J, Nadarajah R, Nakao Y, Nakao K, Wilkinson C, Raveendra K, Mamas MA, Camm AJ, Gale CP. Temporal trends and patterns in atrial fibrillation incidence: a population-based study of 3.4 million individuals. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide; confers an increased risk of adverse outcomes and once diagnosed most patients will require lifelong-treatment. Population-based studies of AF incidence are needed to inform health-service planning. However, few reports refer to a standard population and estimates of incidence in high income countries vary by over 12-fold.
Purpose
We aimed to assess trends in the crude and standardised atrial fibrillation incidence by sex, age, socioeconomic status and region in a large general population cohort from England. We also investigated the comorbidity profile of patients over almost two decades.
Methods
We used linked primary and secondary electronic health records of 3.4 million individuals from the Clinical Practice Research Datalink (CPRD). The CPRD database contains anonymised patient data from approximately 7% of the UK population and is broadly representative in terms of age, sex, and ethnicity. Eligible patients aged 16 years and older contributed data between Jan 1 1998 and Dec 31 2017. We defined incident AF diagnosis as the first record of AF in primary care or hospital admission records from any diagnostic position. For incidence calculations, we excluded all individuals who had a diagnosis of AF before the study start date, or within the first 12 months of registration with their general practice. For patients with incident AF, we extracted baseline characteristics, comorbidities, socioeconomic status and geographic region. We calculated standardised rates by applying direct age and sex standardisation to the 2013 European Standard Population. We inferred crude rates by applying year-specific, age-specific and sex-specific incidence to UK census mid-year population estimates.
Results
From 1998 to 2017 AF incidence (standardised by age and sex) increased by 30% (from 247 to 322 per 100,000 person-years; adjusted incidence ratio [IRR] 1.30, 95% CI 1.27–1.33) (Figure 1). Absolute number of incident AF increased by 72% (from 117,880 in 1998 to 202,333 in 2017), due to an increasing number of older people. Comorbidity burden at diagnosis of AF increased (2.58 [SD 1.83] vs 3.74 [2.29] conditions; adjusted difference 1.26, 95% CI 1.14–1.39). Age-standardised incidence was higher in men than women (IRR 1.49; 95% CI 1.46–1.52), and men were younger at diagnosis (adjusted difference 5.53 years; 95% CI 5.36–5.69). Socioeconomically deprived individuals had more comorbidities and were more likely to develop AF than the most affluent individuals (IRR 1.20; 95% CI 1.15–1.24). Over time, the age of AF diagnosis declined disproportionately in the most deprived individuals (Figure 2).
Conclusion
In England AF incidence has increased, and the socioeconomic gradient in age at diagnosis and comorbidity burden widened. This changing burden of AF requires policy-based interventions to prevent associated morbidity and mortality.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): British Heart Foundation, National Institute of Health Research
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Affiliation(s)
- J Wu
- University of Leeds, Leeds Institute of Data Analytics , Leeds , United Kingdom
| | - R Nadarajah
- Leeds General Infirmary , Leeds , United Kingdom
| | - Y Nakao
- University of Leeds, Leeds Institute of Data Analytics , Leeds , United Kingdom
| | - K Nakao
- University of Leeds, Leeds Institute of Data Analytics , Leeds , United Kingdom
| | - C Wilkinson
- Newcastle University , Newcastle-Upon-Tyne , United Kingdom
| | - K Raveendra
- University of Leeds, Faculty of Medicine , Leeds , United Kingdom
| | - M A Mamas
- Keele University , Keele , United Kingdom
| | - A J Camm
- St George's University of London , London , United Kingdom
| | - C P Gale
- Leeds General Infirmary , Leeds , United Kingdom
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Wang X, Mobley AR, Tica O, Okoth K, Ghosh RE, Myles P, Williams T, Haynes S, Nirantharakumar K, Shukla D, Kotecha D, Mehta S, Breeze S, Lancaster K, Fordyce S, Allen N, Calvert M, Denniston A, Gkoutos G, Jayawardana S, Ball S, Baigent C, Brocklehurst P, Lester W, McManus R, Seri S, Valentine J, Camm AJ, Haynes S, Moore DJ, Rogers A, Stanbury M, Flather M, Walker S, Wang D. Systematic approach to outcome assessment from coded electronic healthcare records in the DaRe2THINK NHS-embedded randomized trial . Eur Heart J Digit Health 2022; 3:426-436. [PMID: 36712153 PMCID: PMC9708037 DOI: 10.1093/ehjdh/ztac046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/15/2022] [Indexed: 02/01/2023]
Abstract
Aims Improving the efficiency of clinical trials is key to their continued importance in directing evidence-based patient care. Digital innovations, in particular the use of electronic healthcare records (EHRs), allow for large-scale screening and follow up of participants. However, it is critical these developments are accompanied by robust and transparent methods that can support high-quality and high clinical value research. Methods and results The DaRe2THINK trial includes a series of novel processes, including nationwide pseudonymized pre screening of the primary-care EHR across England, digital enrolment, remote e-consent, and 'no-visit' follow up by linking all primary- and secondary-care health data with patient-reported outcomes. DaRe2THINK is a pragmatic, healthcare-embedded randomized trial testing whether earlier use of direct oral anticoagulants in patients with prior or current atrial fibrillation can prevent thromboembolic events and cognitive decline (www.birmingham.ac.uk/dare2think). This study outlines the systematic approach and methodology employed to define patient information and outcome events. This includes transparency on all medical code lists and phenotypes used in the trial across a variety of national data sources, including Clinical Practice Research Datalink Aurum (primary care), Hospital Episode Statistics (secondary care), and the Office for National Statistics (mortality). Conclusion Co-designed by a patient and public involvement team, DaRe2THINK presents an opportunity to transform the approach to randomized trials in the setting of routine healthcare, providing high-quality evidence generation in populations representative of the community at risk.
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Affiliation(s)
- Xiaoxia Wang
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,Health Data Research UK Midlands, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alastair R Mobley
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,Health Data Research UK Midlands, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Otilia Tica
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kelvin Okoth
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Rebecca E Ghosh
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Puja Myles
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Tim Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | | | - David Shukla
- Institute of Applied Health Sciences, University of Birmingham, Birmingham, UK,Primary Care Clinical Research, NIHR Clinical Research Network West Midlands, Birmingham, UK
| | - Dipak Kotecha
- Corresponding author. Heritage Building, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2GW, UK. Tel: +44 121 3718122,
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Rillig A, Borof K, Breithardt G, Camm AJ, Crijns HJGM, Goette A, Kuck KH, Metzner A, Vardas P, Vettorazzi E, Wegscheider K, Zapf A, Kirchhof P. Early Rhythm Control in Patients With Atrial Fibrillation and High Comorbidity Burden. Circulation 2022; 146:836-847. [PMID: 35968706 DOI: 10.1161/circulationaha.122.060274] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The randomized EAST-AFNET4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial-Atrial Fibrillation Network) demonstrated that early rhythm control (ERC) reduces adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. The effectiveness and safety of ERC in patients with multiple cardiovascular comorbidities is not known. METHODS These prespecified subanalyses of EAST-AFNET4 compared the effectiveness and safety of ERC with usual care (UC) stratified into patients with higher (CHA2DS2-VASc score ≥4) and lower comorbidity burden. Sensitivity analyses ignored sex (CHA2DS2-VA score). RESULTS EAST-AFNET4 randomized 1093 patients with CHA2DS2-VASc score ≥4 (74.8±6.8 years, 61% female) and 1696 with CHA2DS2-VASc score <4 (67.4±8.0 years, 37% female). ERC reduced the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome in patients with CHA2DS2-VASc score ≥4 (ERC, 127/549 patients with events; UC, 183/544 patients with events; hazard ratio [HR], 0.64 [0.51-0.81]; P < 0.001) but not in patients with CHA2DS2-VASc score <4 (ERC, 122/846 patients with events; UC, 133/850 patients with events; HR, 0.93 [0.73-1.19]; P=0.56, Pinteraction=0.037). The primary safety outcome (death, stroke, or serious adverse events of rhythm control therapy) was not different between study groups in patients with CHA2DS2-VASc score ≥4 (ERC, 112/549 patients with events; UC, 132/544 patients with events; HR, 0.84 [0.65, 1.08]; P=0.175), but occurred more often in patients with CHA2DS2-VASc scores <4 randomized to ERC (ERC, 119/846 patients with events; UC, 91/850 patients with events; HR, 1.39 [1.05-1.82]; P=0.019, Pinteraction=0.008). Life-threatening events or death were not different between groups (CHA2DS2-VASc score ≥4, ERC, 84/549 patients with event, UC, 96/544 patients with event; CHA2DS2-VASc scores <4, ERC, 75/846 patients with event, UC, 73/850 patients with event). When female sex was ignored for the creation of higher and lower risk groups (CHA2DS2-VA score), the Pinteraction was not significant for the primary efficacy outcome (P=0.25), but remained significant (P=0.044) for the primary safety outcome. CONCLUSIONS Patients with recently diagnosed atrial fibrillation and CHA2DS2-VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01288352. URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2010-021258-20. URL: https://www.isrctn.com/; Unique identifier: ISRCTN04708680.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
| | - Günter Breithardt
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany (G.B.)
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, UK (A.J.C.)
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, The Netherlands (H.J.G.M.C.)
| | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- St Vincenz Hospital, Paderborn, Germany (A.G.)
- Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Germany (A.G.)
| | - Karl-Heinz Kuck
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- LANS Cardio, Hamburg, Germany (K.-H.K.)
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece (P.V.)
| | - Eik Vettorazzi
- Institute of Medical Biometry and Epidemiology (E.V., K.W., A.Z.), University Medical Center Hamburg-Eppendorf, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology (E.V., K.W., A.Z.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology (E.V., K.W., A.Z.), University Medical Center Hamburg-Eppendorf, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center (A.R., K.B., A.M., P.K.), University Medical Center Hamburg-Eppendorf, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/Kiel, Germany (A.R., K.-H.K., A.M., K.W., P.K.)
- Atrial Fibrillation Network (AFNET), Münster, Germany (G.B., A.G., K.-H.K., K.W., P.K.)
- Institute of Cardiovascular Sciences, University of Birmingham, UK (P.K.)
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Eckardt L, Sehner S, Suling A, Borof K, Breithardt G, Crijns HJGM, Goette A, Wegscheider K, Zapf A, Camm AJ, Metzner A, Kirchhof P. Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: the EAST - AFNET 4 trial. Eur Heart J 2022; 43:4127-4144. [PMID: 36036648 PMCID: PMC9584752 DOI: 10.1093/eurheartj/ehac471] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/22/2022] Open
Abstract
Aims A strategy of systematic, early rhythm control (ERC) improves cardiovascular outcomes in patients with atrial fibrillation (AF). It is not known how this outcome-reducing effect is mediated. Methods and results Using the Early treatment of Atrial Fibrillation for Stroke prevention Trial (EAST—AFNET 4) data set, potential mediators of the effect of ERC were identified in the total study population at 12-month follow up and further interrogated by use of a four-way decomposition of the treatment effect in an exponential model predicting future primary outcome events. Fourteen potential mediators of ERC were identified at the 12-month visit. Of these, sinus rhythm at 12 months explained 81% of the treatment effect of ERC compared with usual care during the remainder of follow up (4.1 years). In patients not in sinus rhythm at 12 months, ERC did not reduce future cardiovascular outcomes (hazard ratio 0.94, 95% confidence interval 0.65–1.67). Inclusion of AF recurrence in the model only explained 31% of the treatment effect, and inclusion of systolic blood pressure at 12 months only 10%. There was no difference in outcomes in patients who underwent AF ablation compared with those who did not undergo AF ablation. Conclusion The effectiveness of early rhythm control is mediated by the presence of sinus rhythm at 12 months in the EAST-AFNET 4 trial. Clinicians implementing ERC should aim for rapid and sustained restoration of sinus rhythm in patients with recently diagnosed AF and cardiovascular comorbidities.
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Affiliation(s)
- L Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany.,2Atrial Fibrillation Network (AFNET), Münster, Germany
| | - S Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - A Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - K Borof
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany
| | - G Breithardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Germany.,2Atrial Fibrillation Network (AFNET), Münster, Germany
| | - H J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Netherlands
| | - A Goette
- 2Atrial Fibrillation Network (AFNET), Münster, Germany.,Department of Cardiology, Vincenz-Krankenhaus Paderborn, Germany
| | - K Wegscheider
- 2Atrial Fibrillation Network (AFNET), Münster, Germany.,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - A Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - A J Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London, UK
| | - A Metzner
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany
| | - P Kirchhof
- 2Atrial Fibrillation Network (AFNET), Münster, Germany.,Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Berlin, Germany.,Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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49
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Abstract
It is well known that diabetes is a prominent risk factor for cardiovascular (CV) events. The level of CV risk depends on the type and duration of diabetes, age and additional co-morbidities. Diabetes is an independent risk factor for atrial fibrillation (AF) and is frequently observed in patients with AF, which further increases their risk of stroke associated with this cardiac arrhythmia. Nearly one third of patients with diabetes globally have CV disease (CVD). Additionally, co-morbid AF and coronary artery disease are more frequently observed in patients with diabetes than the general population, further increasing the already high CV risk of these patients. To protect against thromboembolic events in patients with diabetes and AF or established CVD, guidelines recommend optimal CV risk factor control, including oral anticoagulation treatment. However, patients with diabetes exist in a prothrombotic and inflammatory state. Greater clinical benefit may therefore be seen with the use of stronger antithrombotic agents or innovative drug combinations in high-risk patients with diabetes, such as those who have concomitant AF or established CVD. In this review, we discuss CV risk management strategies in patients with diabetes and concomitant vascular disease, stroke prevention regimens in patients with diabetes and AF and how worsening renal function in these patients may complicate these approaches. Accumulating evidence from clinical trials and real-world evidence show a benefit to the administration of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with diabetes and AF.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, Cranmer Terrace, SW17 0RE, UK.
| | - Hani Sabbour
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Warren Alpert School of Medicine, Brown University, Rhode Island, USA
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Neuherberg, Munich, Germany
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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50
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Schnabel RB, Marinelli EA, Arbelo E, Boriani G, Boveda S, Buckley CM, Camm AJ, Casadei B, Chua W, Dagres N, de Melis M, Desteghe L, Diederichsen SZ, Duncker D, Eckardt L, Eisert C, Engler D, Fabritz L, Freedman B, Gillet L, Goette A, Guasch E, Svendsen JH, Hatem SN, Haeusler KG, Healey JS, Heidbuchel H, Hindricks G, Hobbs FDR, Hübner T, Kotecha D, Krekler M, Leclercq C, Lewalter T, Lin H, Linz D, Lip GYH, Løchen ML, Lucassen W, Malaczynska-Rajpold K, Massberg S, Merino JL, Meyer R, Mont L, Myers MC, Neubeck L, Niiranen T, Oeff M, Oldgren J, Potpara TS, Psaroudakis G, Pürerfellner H, Ravens U, Rienstra M, Rivard L, Scherr D, Schotten U, Shah D, Sinner MF, Smolnik R, Steinbeck G, Steven D, Svennberg E, Thomas D, True Hills M, van Gelder IC, Vardar B, Palà E, Wakili R, Wegscheider K, Wieloch M, Willems S, Witt H, Ziegler A, Daniel Zink M, Kirchhof P. Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference. Europace 2022; 25:6-27. [PMID: 35894842 PMCID: PMC9907557 DOI: 10.1093/europace/euac062] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.
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Affiliation(s)
- Renate B Schnabel
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Serge Boveda
- Cardiology—Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France,Universiteit Ziekenhuis, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Barbara Casadei
- RDM, Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mirko de Melis
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Lien Desteghe
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Division of Electrophysiology, Department of Cardiology and Angiology, Münster, Germany
| | | | - Daniel Engler
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Larissa Fabritz
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,University Center of Cardiovascular Science Hamburg, Hamburg, Germany
| | - Ben Freedman
- Heart Research Institute, The University of Sydney, Sydney, Australia
| | | | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Muenster, Germany,St Vincenz Hospital, Paderborn, Germany
| | - Eduard Guasch
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl Georg Haeusler
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Jeff S Healey
- Population Health Research Institute, McMaster University Hamilton, ON, Canada
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Gerhard Hindricks
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - Dipak Kotecha
- University of Birmingham & University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Hospital Munich South, Department of Cardiology, Munich, Germany,Department of Cardiology, University of Bonn, Bonn, Germany
| | - Honghuang Lin
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maja Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Wim Lucassen
- Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands
| | | | - Steffen Massberg
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | | | - Lluıs Mont
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Lis Neubeck
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | - Teemu Niiranen
- Medtronic, Dublin, Ireland,Centre for Cardiovascular Health Edinburgh Napier University, Edinburgh, UK
| | - Michael Oeff
- Atrial Fibrillation Network (AFNET), Muenster, Germany
| | - Jonas Oldgren
- University of Turku and Turku University Hospital, Turku, Finland
| | | | - George Psaroudakis
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Helmut Pürerfellner
- School of Medicine, Belgrade University, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ursula Ravens
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Bayer AG, Leverkusen, Germany
| | - Michiel Rienstra
- Ordensklinikum Linz, Elisabethinen, Cardiological Department, Linz, Austria
| | - Lena Rivard
- Institute of Experimental Cardiovascular Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Daniel Scherr
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ulrich Schotten
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Dipen Shah
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Moritz F Sinner
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands,Royal Brompton Hospital, London, UK
| | | | - Gerhard Steinbeck
- Atrial Fibrillation Network (AFNET), Muenster, Germany,MUMC+, Maastricht, The Netherlands
| | - Daniel Steven
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital of Geneva, Cardiac Electrophysiology Unit, Geneva, Switzerland
| | - Emma Svennberg
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Dierk Thomas
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital Cologne, Heart Center, Department of Electrophysiology, Cologne, Germany,Karolinska Institutet, Department of Medicine Huddinge, Karolinska University Hospital, Stockholm, Sweden,Department of Cardiology, Medical University Hospital, Heidelberg, Germany
| | - Mellanie True Hills
- HCR (Heidelberg Center for Heart Rhythm Disorders), Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Isabelle C van Gelder
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Burcu Vardar
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elena Palà
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX, USA
| | - Reza Wakili
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Karl Wegscheider
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Mattias Wieloch
- Department of Cardiology and Vascular Medicine, Westgerman Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Department of Coagulation Disorders, Skane University Hospital, Lund University, Malmö, Sweden
| | | | | | - Matthias Daniel Zink
- Asklepios Hospital St Georg, Department of Cardiology and Internal Intensive Care Medicine, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Corresponding author. Tel: +49 40 7410 52438; Fax: +49 40 7410 55862. E-mail address:
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