Evaluating subclinical left ventricular and left atrial dysfunction in idiopathic atrial fibrillation: A speckle-tracking based strain-analysis

OBJECTIVE

A subset of patients with atrial fibrillation (AF) presents without established AF risk factors and normal left ventricular (LV) systolic function, called idiopathic AF (IAF). Traditionally, echocardiography derived LV dimensions and ejection fraction (EF) are used to exclude LV dysfunction in IAF, but their sensitivity is limited. Our objective is to evaluate the presence of subtle alterations in LV function despite normal LVEF in patients with IAF compared to healthy controls, using speckle-tracking echocardiography (STE) based global longitudinal strain (GLS).

METHODS

Standard transthoracic echocardiography was performed in 80 patients with IAF and 129 healthy controls. Patients with overt cardiac disease as well as known established AF risk factors were excluded. STE analysis was performed to assess GLS of the LV, and left atrial strain (LAS).

RESULTS

LVEF was normal and comparable between patients with IAF and healthy controls (63 ± 4% for both groups; p = 0.801). Mean GLS was within normal limits for both groups but statistically significantly more negative in patients with IAF (-20.6 ± 2.5% vs. -19.7 ± 2.5%; p = 0.016), however not when indexed for ventricular cycle length (p = 0.784). No differences in LA volume or non-indexed LAS were seen in patients with IAF compared to healthy controls.

CONCLUSIONS

In this selected group of IAF patients, STE did not detect any overt LV or LA dysfunction compared to healthy controls. Thus, IAF occurred in these patients not only in the absence of established AF risk factors but also without evidence of ventricular dysfunction.

360° Virtual reality to improve patient education and reduce anxiety towards atrial fibrillation ablation

AIMS

Evaluation of (i) the effects of a virtual reality (VR) preprocedural patient education video on information provision, procedure-related knowledge, satisfaction, and the level of worries in patients planned for atrial fibrillation (AF) ablation and (ii) the feasibility of a disposable cardboard VR viewer for home use in this setting.

METHODS AND RESULTS

In this prospective observational cohort study, patients were alternatively assigned in a 1:1 ratio to the control or VR group. Controls received standard preprocedural information. VR group received standard information and a VR video (via in-hospital VR headset and disposable cardboard). The Amsterdam Preoperative Anxiety and Information Scale (APAIS) together with additional questions concerning procedural experience and satisfaction was completed pre- and post-ablation. Of 134 patients [38.1% female, aged 66 (58-72) years] included, 49.2% were assigned to the control and 50.7% to the VR group. The number of patients that worried about the ablation procedure was lower in VR than in control patients (19.1% vs. 40.9%, P = 0.006). More VR females than males had worries about the procedure (34.8% vs. 11.1%, P = 0.026). The number of VR patients that were satisfied with the preprocedural information provision was higher post-ablation than pre-ablation (83.3% vs. 60.4%, P = 0.007). In total, 59.4% reported that the disposable cardboard was easy to use and led to a discussion with relatives in 68.8%.

CONCLUSION

In patients scheduled for AF ablation, a VR preprocedural educational video led to better information provision and procedure-related knowledge, higher satisfaction, and less worries regarding the procedure. The disposable cardboard was feasible for home use.

A new efficient and integrated pathway for patient evaluation prior to atrial fibrillation ablation

AIM

In this quality improvement project, a care pathway for patients considered for atrial fibrillation (AF) ablation was optimized with the goals to improve the patient journey and simultaneously integrate prospective data collection into the clinical process.

METHODS AND RESULTS

The Lean Six Sigma approach was used to map the pre-existing process, identify constraints and formulate countermeasures. The percentage of patients going through the full pre-ablation preparation that eventually underwent AF ablation, number of hospital visits and consultations, pathway compliance, and completeness of scientific data were measured before and after pathway optimisation. Constraints in the process were (1) lack of standardized processes, (2) inefficient use of resources, (3) lack of multidisciplinary integration, (4) lack of research integration, and (5) suboptimal communication. The impact of the corresponding countermeasures (defining a uniform process, incorporating 'go/no-go' moment, introducing a 'one-stop-shop', integrating prospective data collection, and improving communication) was studied for 33 patients before and 26 patients after pathway optimisation. After optimisation, the percentage of patients receiving a full pre-ablation preparation that eventually underwent AF ablation increased from 59% to 94% (p < 0.01). Fewer hospital visits (3.2 ± 1.2 versus 2.3 ± 0.8, p = 0.01) and electrophysiologist consultations (1.8 ± 0.7 versus 1.0 ± 0.3, p < 0.01) were required after pathway optimisation. Pathway compliance and complete collection of scientific data increased significantly (3% versus 73%, p < 0.01 and 15% versus 73%, p < 0.01, respectively).

CONCLUSION

The optimisation project resulted in a more efficient evaluation of patients considered for AF ablation. The new more efficient process includes prospective data collection and facilitates easy conduct of research studies focused on improvements of patient outcomes.

Optimization of a care pathway before atrial fibrillation ablation with the integration of translational research into routine clinical care

Funding Acknowledgements

Type of funding sources: None.

Background

The diagnostic work-up for atrial fibrillation (AF) catheter ablation is often complex and expensive. Improving the organization of this work-up may help to streamline patient journeys and to reduce administrative burden and costs. Additionally, reorganizing the existing work-up provides the opportunity to integrate (translational) research into routine clinical care, hereby contributing to improved patient selection and improved care for future patients.

Purpose

The aim of this project was to optimize a care pathway for patients considered for AF ablation, with the goals to improve the patient journey and simultaneously integrate research into the clinical process.

Methods

The Lean Six Sigma approach was used to map the pre-existing process, identify constraints in the process and formulate countermeasures. The impact of this pathway optimization was evaluated using four outcome measures: (1) efficient use of medical resources, defined as the percentage of patients receiving the pre-ablation work-up and eventually undergoing AF ablation, (2) number of hospital visits and consultations with a cardiologist, (3) pathway compliance, defined as the percentage of patients that completed the work-up with a maximum of 2 outpatient hospital visits, a maximum of 1 cardiologist consultation, laboratory results available, and a complete echocardiogram available, and (4) completeness of scientific data, defined as the availability of a predefined set of relevant variables (clinical indicators, medication, laboratory results and echocardiography derived data).

Results

Five root causes for constraints in the pre-existing work-up were identified and corresponding countermeasures were formulated (Figure 1). The impact of the countermeasures was studied for 33 patients before and 26 patients after pathway optimization. After optimization, efficient use of resources increased from 44% to 95% (p&lt;0.01). The project resulted in fewer hospital visits per patient (3.2 ±1.2 versus 2.3 ±0.8, p=0.01) and fewer cardiologist consultations (1.8 ±0.7 versus 1.0 ±0.3, p&lt;0.01). Pathway compliance increased significantly (3% versus 73%, p&lt;0.01), an increase that was reflected in all separate components of overall pathway compliance (Figure 2, panel A). The percentage of available data for scientific research increased from 80% to 94% (p&lt;0.01), resulting in a complete dataset in 73% of patients after, compared to only 15% of patients prior to the optimization project (p&lt;0.01, Figure 2, panel B).

Conclusions

This optimization project resulted in a more efficient care pathway for patients considered for AF ablation. The structural integration of research into the care pathway may lay the foundations for further improvements of AF care in the future.

Concealed Coronary Atherosclerosis In Idiopathic Paroxysmal Atrial Fibrillation is Associated with Imminent Cardiovascular Diseases

Background

Previous research showed a significant difference in the presence of subclinical coronary artery disease (CAD) on cardiac CT angiography (CTA) between patients with idiopathic paroxysmal atrial fibrillation (iAF) versus a matched sinus rhythm population (iSR). Here we present 5-year follow-up data and the consequences of subclinical CAD on baseline CTA on the development of cardiovascular disease in iAF.

Methods

In 99 iAF patients (who underwent CTA as part of work-up for pulmonary vein isolation) and 221 matched iSR controls (who underwent CTA for CAD assessment), the incidence of hypertension, diabetes and major cardiovascular events (MACCE) during follow-up was obtained. Multivariable Cox regression analysis was used to reveal predictors of incident cardiovascular disease in the iAF group.

Results

During a follow-up of 68±11 months, over one third of patients developed cardiovascular disease, with no difference between iAF and iSR (log-rank p=0.56), and comparable low rates of MACCE (4.0% vs 5.0%,p=0.71). Within the iAF group, age (HR1.12(1.03-1.20);p=0.006), left atrial diameter (HR1.16(1.03-1.31);p=0.01), Segment Involvement Score (total number of coronary segments with atherosclerotic plaque; HR1.43(1.09-1.89);p=0.01) and the number of calcified plaques on CTA (HR0.53(0.30-0.92);p=0.01) were independent predictors of incident cardiovascular disease.

Conclusions

Subclinical coronary disease on CTA may be useful to identify the subset of patients with iAF that harbour concealed cardiovascular risk factors and need intensive clinical follow-up to ensure timely initiation of appropriate therapy once CV disease develops, including anticoagulation and vascular prophylactic therapy.

Long-term outcome of targeted therapy of underlying conditions in patients with early persistent atrial fibrillation and heart failure: data of the RACE 3 trial

AIMS

The Routine vs. Aggressive risk factor driven upstream rhythm Control for prevention of Early persistent atrial fibrillation (AF) in heart failure (HF) (RACE 3) trial demonstrated that targeted therapy of underlying conditions improved sinus rhythm maintenance at 1 year. We now explored the effects of targeted therapy on the additional co-primary endpoints; sinus rhythm maintenance and cardiovascular outcome at 5 years.

METHODS AND RESULTS

Patients with early persistent AF and mild-to-moderate stable HF were randomized to targeted or conventional therapy. Both groups received rhythm control therapy according to guidelines. The targeted group additionally received four therapies: angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (ARBs), statins, mineralocorticoid receptor antagonists (MRAs), and cardiac rehabilitation. The presence of sinus rhythm and cardiovascular morbidity and mortality at 5-year follow-up were assessed. Two hundred and sixteen patients consented for long-term follow-up, 107 were randomized to targeted and 109 to conventional therapy. At 5 years, MRAs [76 (74%) vs. 10 (9%) patients, P < 0.001] and statins [81 (79%) vs. 59 (55%), P < 0.001] were used more in the targeted than conventional group. Angiotensin-converting enzyme inhibitors/ARBs and physical activity were not different between groups. Sinus rhythm was present in 49 (46%) targeted vs. 43 (39%) conventional group patients at 5 years (odds ratio 1.297, lower limit of 95% confidence interval 0.756, P = 0.346). Cardiovascular mortality and morbidity occurred in 20 (19%) in the targeted and 15 (14%) conventional group patients, P = 0.353.

CONCLUSION

In patients with early persistent AF and HF superiority of targeted therapy in sinus rhythm maintenance could not be preserved at 5-year follow-up. Cardiovascular outcome was not different between groups.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov NCT00877643.

Prospective evaluation of the learning curve and electrical characteristics of left bundle branch area pacing

Background

Left bundle branch area pacing (LBBAP) has recently been introduced as a physiological pacing technique with a synchronous ventricular activation.

Objective

To prospectively evaluate the feasibility and learning curve, as well as the electrical characteristics of LBBAP.

Methods

In 80 consecutive LBBAP pacemaker patients, ECG characteristics during intrinsic rhythm, RV septum pacing (RVSP) and LBBAP were evaluated. From the ECG's QRS duration and LVAT (stimulus to V6 R-wave peak time, RWPT) were measured. Also, the left bundle branch potential (LBBpot) to V6 RWPT interval was measured and compared to the LVAT. After conversion of the ECG into VCG (Kors conversion matrix), QRS area, as measurement for electrical dyssynchrony, was calculated.

Results

Permanent lead implantation was successful in 77/80 patients (96%) undergoing an attempt at LBBAP. LBBAP lead implantation time as well as fluoroscopy time were significantly shorter during last 25% of implantation compared to first 25% of implantations (17±5 min vs. 33±16 min and 12±7 min vs. 21±13 min, respectively, panel A and B). LBB capture was obtained in 54/80 patients (68%). In 36/45 patients (80%) with intact AV conduction and narrow QRS an LBBpot was present. The mean interval between the LBBpot and the onset of QRS was 22±6 ms.

In the patients with narrow QRS (n=45), QRS duration increased significantly during both RVSP (139±24 ms) and LBBAP (123±21 ms), compared to intrinsic rhythm (95±13 ms).

QRS area on the other hand, increased during both RVSP (73±20 μVs) but decreased during LBBAP (41±15 μVs), to values close to intrinsic rhythm (32±16 μVs, panel C). For all patients, QRS area was significantly lower in patients with LBB capture compared to patients without capture (43±18 μVs vs 54±21 μVs, respectively).

In patients with LBB capture (n=54), LVAT was significantly shorter compared to patients without LBB capture (75±14 vs. 88±9 ms, respectively). In the patients with LBB capture, there was a significant correlation between the LBBpot – V6 RWPT and S – V6 RWPT intervals (Pearson correlation 0.739, P&lt;0.001).

Conclusion

LBBAP is a safe and feasible technique, with a clear learning curve that seems obtained after ± 40–60 implantations. LBB capture is obtained in two-thirds of patients. Although QRS duration remains prolonged, LBBAP largely restores ventricular electrical synchrony to values close to intrinsic (narrow QRS) rhythm.

Funding Acknowledgement

Type of funding sources: None.

Virtual reality to improve patient information and reduce anxiety towards atrial fibrillation ablation in times of remote patient care (and after)

Funding Acknowledgements

Type of funding sources: None.

Background. Nowadays frequently deployed invasive catheter ablation therapy in patients with symptomatic atrial fibrillation (AF) is unfortunately associated with distress such as preoperative anxiety. Improving preoperative patient information may lower anxiety towards AF ablation procedures.

Purpose. To evaluate whether a lifelike 360˚ virtual reality (VR) patient information video decreases anxiety levels and improves patient preparation towards AF ablation as compared to standard preoperative patient information.

Methods. Consecutive patients planned for AF ablation were recruited from the outpatient AF clinic and were randomized into two groups: the control group and the intervention group (VR group). The control group received standard preoperative information through oral counselling and information leaflets, the VR group received the standard information as well as a short dedicated 360˚ VR video (via in-hospital VR headset and disposable cardboard VR glasses for home use). Online questionnaires (aimed at information provision, anxiety and procedural experience) were administered both pre- and post-ablation.

Results. A total of 103 patients (39.8% female, age 64 [58-71] years) were included in the analysis. The VR group (n = 58) reported to be clearly better informed about catheterization laboratory environment (78% vs. 73%) and the course of the procedure (82% vs. 78%), indicated fewer concerns about the procedure (47% vs. 55%) and were eager to learn even more (82% vs. 74%) as compared to controls (n = 45). However, there was no significant difference in the anxiety scores between the VR group and controls (10 [8-12] vs. 10 [8-14], p = 0.548). Home use of the video was satisfactory and resulted in discussion with relatives. Patient overall satisfaction was higher in VR group as compared to controls (84% vs. 81%).

Conclusions. This study shows that a dedicated 360˚ VR video reduces concerns but does not reduce anxiety scores. Though, it easily improves procedural knowledge, patient information and patient satisfaction. Especially in times of remote patient care, this new way of informing patients may be of added value.

The relation between the atrial blood supply and the complexity of acute atrial fibrillation

Background

Patients with a history of myocardial infarction and coronary artery disease (CAD) have a higher risk of developing AF. Conversely, patients with atrial fibrillation (AF) have a higher risk of developing myocardial infarction, suggesting a link in underlying pathophysiology. The aim of this study was to assess whether coronary angiographic parameters are associated with a substrate for AF in patients without a history of AF.

Methods

During cardiac surgery in 62 patients (coronary artery bypass grafting (CABG;n = 47), aortic valve replacement (AVR;n = 9) or CABG + AVR (n = 6)) without a history of clinical AF (age 65.4 ± 8.5 years, 26.2% female), AF was induced by burst pacing. The preoperative coronary angiogram (CAG) was assessed for the severity of CAD, and the adequacy of atrial coronary blood supply as quantified by a novel scoring system including the location and severity of right coronary artery disease in relation to the right atrial branches. Epicardial mapping of the right atrium (256 unipolar electrodes) was used to assess the complexity of induced AF.

Results

There was no association between the adequacy of right atrial coronary blood supply on preoperative CAG and AF complexity parameters. Multivariable analysis revealed that only increasing age (B0.232 (0.030;0.433),p = 0.03) and the presence of 3VD (B3.602 (0.187;7.018),p = 0.04) were independently associated with an increased maximal activation time difference.

Conclusions

The adequacy of epicardial right atrial blood supply is not associated with increased complexity of induced atrial fibrillation in patients without a history of clinical AF, while age and the extent of ventricular coronary artery disease are.

Antiarrhythmic drugs in patients with early persistent atrial fibrillation and heart failure: results of the RACE 3 study

AIMS

Maintaining sinus rhythm in patients with persistent atrial fibrillation (AF) is challenging. We explored the efficacy of class I and III antiarrhythmic drugs (AADs) in patients with persistent AF and mild to moderate heart failure (HF).

METHODS AND RESULTS

In the RACE 3 trial, patients with early persistent symptomatic AF and short history of mild to moderate HF with preserved or reduced left ventricular ejection fraction (LVEF) were randomized to targeted or conventional therapy. Both groups received AF and HF guideline-driven treatment. Additionally, the targeted-group received mineralocorticoid receptor antagonists, statins, angiotensin-converting enzyme inhibitors and/or receptor blockers, and cardiac rehabilitation. Class I and III AADs could be instituted in case of symptomatic recurrent AF. Eventually, pulmonary vein isolation could be performed. Primary endpoint was sinus rhythm on 7-day Holter after 1-year. Included were 245 patients, age 65 ± 9 years, 193 (79%) men, AF history was 3 (2-6) months, HF history 2 (1-4) months, 72 (29.4%) had HF with reduced LVEF. After baseline electrical cardioversion (ECV), 190 (77.6%) had AF recurrences; 108 (56.8%) received class I/III AADs; 19 (17.6%) flecainide, 36 (33.3%) sotalol, 3 (2.8%) dronedarone, 50 (46.3%) amiodarone. At 1-year 73 of 108 (68.0%) patients were in sinus rhythm, 44 (40.7%) without new AF recurrences. Maintenance of sinus rhythm was significantly better with amiodarone [n = 29/50 (58%)] compared with flecainide [n = 6/19 (32%)] and sotalol/dronedarone [n = 9/39 (23%)], P = 0.0064. Adverse events occurred in 27 (25.0%) patients, were all minor and reversible.

CONCLUSION

In stable HF patients with early persistent AF, AAD treatment was effective in nearly half of patients, with no serious adverse effects reported.

Frequency and Determinants of Spontaneous Conversion to Sinus Rhythm in Patients Presenting to the Emergency Department with Recent-onset Atrial Fibrillation: A Systematic Review

The exact frequency and clinical determinants of spontaneous conversion (SCV) in patients with symptomatic recent-onset AF are unclear. The aim of this systematic review is to provide an overview of the frequency and determinants of SCV of AF in patients presenting at the emergency department. A comprehensive literature search for studies about SCV in patients presenting to the emergency department with AF resulted in 25 articles - 12 randomised controlled trials and 13 observational studies. SCV rates range between 9-83% and determinants of SCV also varied between studies. The most important determinants of SCV included short duration of AF (<24 or <48 hours), low number of episodes, normal atrial dimensions and absence of previous heart disease. The large variation in SCV rate and determinants of SCV was related to differences in duration of the observation period, inclusion and exclusion criteria and in variables used in the prediction models.

Clinical determinants of early spontaneous conversion to sinus rhythm in patients with atrial fibrillation

Background

The current standard of care for acute atrial fibrillation (AF) focuses primarily on immediate restoration of sinus rhythm by cardioversion, although AF often terminates spontaneously.

Objective

To identify determinants of early spontaneous conversion (SCV) in patients presenting at the emergency department (ED) because of AF.

Methods

An observational study was performed of patients who visited the ED with documented AF between July 2014 and December 2016. The clinical characteristics and demographics of patients with and without SCV were compared.

Results

We enrolled 943 patients (age 69 ± 12 years, 47% female). SCV occurred within 3 h of presentation in 158 patients (16.8%). Logistic regression analysis showed that duration of AF <24 h [odds ratio (OR) 7.7, 95% confidence interval (CI) 3.5–17.2, p < 0.001], left atrial volume index <42 ml/m² (OR 1.8, 95% CI 1.2–2.8, p = 0.010), symptoms of near-collapse at presentation (OR 2.4, 95% CI 1.2–5.1, p = 0.018), a lower body mass index (BMI) (OR 0.9, 95% CI 0.91–0.99, p = 0.028), a longer QTc time during AF (OR 1.01, 95% CI 1.0–1.02, p = 0.002) and first-detected AF (OR 2.5, 95% CI 1.6–3.9, p < 0.001) were independent determinants of early SCV.

Conclusion

Early spontaneous conversion of acute AF occurs in almost one-sixth of admitted patients during a short initial observation in the ED. Spontaneous conversion is most likely to occur in patients with first-onset, short-duration AF episodes, lower BMI, and normal left atrial size.

Long-term intermittent versus short continuous heart rhythm monitoring for the detection of atrial fibrillation recurrences after catheter ablation

BACKGROUND

The utility of long-term intermittent heart rhythm monitoring after atrial fibrillation (AF) ablation remains unclear. Therefore, we compared the efficacy and usability of long-term intermittent (AliveCor Kardia® (ACK)) versus short continuous (Holter) heart rhythm monitoring for the detection of AF recurrences after AF ablation and evaluated ACK accuracy to detect AF.

METHODS

Patients were provided with Holter (for ≥24 h) simultaneously with an ACK (4 weeks) used three times a day and in case of symptoms. The primary endpoint was the difference in proportion of patients diagnosed with recurrent AF by ACK as compared to Holter monitoring. Secondary endpoints were the usability (System Usability Scale and a four-item questionnaire) of ACK and Holter monitoring; and the accuracy of the ACK algorithm for AF detection.

RESULTS

Out of 126 post-ablation patients, 115 (91.3%; 35 females, median age 64.0 [58.0-68.0] years) transmitted overall 7838 ACK ECG recordings. ACK and Holter monitoring detected 29 (25.2%) and 17 (14.8%) patients with AF recurrences, respectively (p < 0.001). More than 2 weeks of ACK monitoring did not have additional diagnostic yield for detection of AF recurrences. Patients graded ACK higher than Holter monitoring and found ACK more convenient in daily usage than Holter (p < 0.001). Sensitivity and specificity of ACK for AF detection were 95.3% and 97.5%, respectively.

CONCLUSIONS

Long-term intermittent monitoring by ACK more effectively detects AF recurrences after AF ablation and has a higher patients' usability than short continuous Holter monitoring. ACK showed a high accuracy to detect AF.

Detection of atrial fibrillation recurrences after ablation: long-term intermittent versus short continuous heart rhythm monitoring

Background

Catheter based ablation therapy is an established treatment in patients with symptomatic atrial fibrillation (AF). Currently, the detection of AF recurrences after AF ablation is most frequently performed by short continuous heart rhythm monitoring, such as Holter monitoring. Our aim is to evaluate the effectiveness and accurateness of long-term intermittent rhythm monitoring using a single-lead ECG (AliveCor Kardia®) compared to short continuous monitoring with Holter for the detection of AF recurrences after ablation.

Methods

We conducted a prospective study of patients after AF ablation between May 2017 and October 2019. As standard of care, patients underwent Holter monitoring (minimum 24 hours) at 3, 6 and 12 months after ablation. At the same time patients were instructed to use an AliveCor Kardia (ACK) monitor to record a 30-second ECG three times a day and in case of symptoms for a period of four weeks. The primary endpoint was the difference in proportion of AF recurrences detected by ACK compared to Holter. Secondary endpoint was the sensitivity and specificity of ACK algorithm. Further, patients were asked to complete a questionnaire on the System Usability Scale to evaluate the usability for both ACK and Holter.

Results

Out of 126 post-ablation patients, 115 (91%) patients (35 female, age 63±8 years) transmitted their ACK recordings and were included in this analysis. A total of 7838 ECGs were assessed. The mean AKC usage time was 27+11 days, mean number of recordings 68+28 per patient. Our primary endpoint, the proportion of detection of recurrent AF, was almost twice as high in ACK (24%) than in Holter (14%, p&lt;0.05). The ACK algorithm categorized 80% as normal sinus rhythm, 10% as possible AF, 10% as unclassified and 0.6% as unreadable. According to the interpretation of the researchers' team, 38 (0.5%) ECGs were uninterpretable and in 98% of the unclassified ECGs by ACK, the researchers' team was able to establish a diagnosis. The ACK diagnostic algorithm displayed a sensitivity of 95% and specificity of 98% for AF detection. The ACK diagnostic algorithm had a high likelihood of misclassifying premature atrial contractions and sinus rhythm accompanied by artifacts as AF (6.8% and 11% of all recordings assessed by AKC as AF, respectively). Based on the System Usability Scale, patients rated ACK as more acceptable in daily usage than Holter (75.0% versus 58.6% had an overall score above 70%, respectively).

Conclusions

ACK effectively and accurately detects AF recurrences in patients who underwent AF ablation and has a high patients' acceptability compared to Holter monitoring. Long-term intermittent rhythm monitoring may provide a promising tool for rhythm follow-up after AF ablation procedures.

Interpretation of ACK recordings

Funding Acknowledgement

Type of funding source: None

Electrical characteristics of deep septal vs. left bundle branch (area) pacing

Background/Introduction

Recent studies have described transvenous left bundle branch (LBB) pacing as a new conduction system pacing strategy. However, information on effect of pacing depth within the septum and the additional effect of LBB capture is unknown.

Purpose

To investigate the relation of electrocardographic characteristics with transseptal LV lead implantation depth and LBB capture.

Methods

20 consecutive patients referred for pacemaker implantation were enrolled. The right atrial (RA) lead was positioned according to routine practice. The LV septal pacing lead (Medtronic 3830) was transvenously positioned against the right side of the interventricular septum and advanced in small steps of 1–2mm towards the left side of the septum. At each depth in the septum 12-lead ECG's were recorded during pacing, from which vectorcardiograms (VCG) were calculated. QRS duration and QRS area were measured, the latter being the integral of the QRSarea in X, Y and Z directions. Successful LBB capture was defined as paced right bundle branch block (RBBB) morphology, stable and short stimulus to LV activation time (LVAT; R in V5) and recorded LBB potential.

Differences were compared among pacing conditions using repeated measures ANOVA with Bonferroni multiple comparisons procedure applied to pairwise comparisons. Statistical significance was assumed at p&lt;0.05.

Results

LV septal lead implantation was successful in all patients. Left bundle branch capture was achieved in 10/20 patients (50%). Post-procedural LV pacing threshold, impedance and sensing was 0.7±0.1 V at 0.5 ms pulse width, 658±5 Ω and 13±10 mV, respectively. Compared to intrinsic rhythm, QRS duration was significantly increased by both RV septum (RVS; 124±5 vs. 161±3 ms) and LV septum pacing (LVS; 142±3 ms).

QRS area increased significantly during RVS pacing as compared to intrinsic rhythm but decreased when moving from RVS to LVS to values close to intrinsic rhythm (panel A & B). LVS-pacing derived QRS area was significantly lower in patients with LBB capture (36±6 mV*ms) compared to patients without LBB capture (deep septal pacing; 46±12 mV*ms).

The reduction in QRS area between RVS and LVS pacing coincided with normalization of the QRS vector in the transverse plane (panel C), which is characterized electrocardiographically by predominantly negative-to-positive inversion of the QRS complex in the precordial leads (V1-V3).

Conclusions

Compared to RV septal pacing, LV septal pacing restores ventricular electrical synchrony, as determined by QRS area, and normalizes the activation vector in the transverse plane to a level comparable to intrinsic rhythm. Differences in resynchronization between left bundle branch pacing and deep septal pacing are small.

LBBAP restores ventricular synchrony

Funding Acknowledgement

Type of funding source: None

Short-Term Hemodynamic and Electrophysiological Effects of Cardiac Resynchronization by Left Ventricular Septal Pacing

BACKGROUND

Cardiac resynchronization therapy (CRT) is usually performed by biventricular (BiV) pacing. Previously, feasibility of transvenous implantation of a lead at the left ventricular (LV) endocardial side of the interventricular septum, referred to as LV septal (LVs) pacing, was demonstrated.

OBJECTIVES

The authors sought to compare the acute electrophysiological and hemodynamic effects of LVs with BiV and His bundle (HB) pacing in CRT patients.

METHODS

Temporary LVs pacing (transaortic approach) alone or in combination with right ventricular (RV) (LVs+RV), BiV, and HB pacing was performed in 27 patients undergoing CRT implantation. Electrophysiological changes were assessed using electrocardiography (QRS duration), vectorcardiography (QRS area), and multielectrode body surface mapping (standard deviation of activation times [SDAT]). Hemodynamic changes were assessed as the first derivative of LV pressure (LVdP/dtmax).

RESULTS

As compared with baseline, LVs pacing resulted in a larger reduction in QRS area (to 73 ± 22 μVs) and SDAT (to 26 ± 7 ms) than BiV (to 93 ± 26 μVs and 31 ± 7 ms; both p < 0.05) and LVs+RV pacing (to 108 ± 37 μVs; p < 0.05; and 29 ± 8 ms; p = 0.05). The increase in LVdP/dtmax was similar during LVs and BiV pacing (17 ± 10% vs. 17 ± 9%, respectively) and larger than during LVs+RV pacing (11 ± 9%; p < 0.05). There were no significant differences between basal, mid-, or apical LVs levels in LVdP/dtmax and SDAT. In a subgroup of 16 patients, changes in QRS area, SDAT, and LVdP/dtmax were comparable between LVs and HB pacing.

CONCLUSIONS

LVs pacing provides short-term hemodynamic improvement and electrical resynchronization that is at least as good as during BiV and possibly HB pacing. These results indicate that LVs pacing may serve as a valuable alternative for CRT.

Biomarkers Associated With Aortic Valve Calcification: Should We Focus on Sex Specific Processes?

Objective

Circulating biomarkers are useful in detection and monitoring of cardiovascular diseases. However, their role in aortic valve disease is unclear. Mechanisms are rapidly elucidated and sex differences are suggested to be involved. Therefore, we sought to identify biomarkers involved in aortic valve calcification (AVC) stratified by sex.

Methods

Blood samples of 34 patients with AVC (without further overt cardiovascular disease, including absence of hemodynamic consequences of valvular calcification) were compared with 136 patients without AVC. AVC was determined using computed tomography calcium scoring. Circulating biomarkers were quantified using a novel antibody-based method (Olink Proseek Multiplex Cardiovascular Panel I) and 92 biomarkers were compared between patients with and without AVC.

Results

In the overall population, Interleukin-1 Receptor Antagonist and pappalysin-1 were associated with increased and decreased odds of having AVC. These differences were driven by the male population [IL1RA: OR 2.79 (1.16-6.70), p = 0.022; PAPPA: OR 0.30 (0.11-0.84), p = 0.021]. Furthermore, TNF-related activation-induced cytokine (TRANCE) and fibroblast growth factor-23 were associated decreased odds of having AVC, and monocyte chemotactic protein-1 was associated with increased odds of having AVC [TRANCE: OR 0.32 (0.12-0.80), p = 0.015; FGF23: OR 0.41 (0.170-0.991), p = 0.048; MCP1: OR 2.64 (1.02-6.81), p = 0.045]. In contrast, galanin peptides and ST2 were associated with increased odds of having AVC in females [GAL: OR 12.38 (1.31-116.7), p = 0.028; ST2: OR13.64 (1.21-153.33), p = 0.034].

Conclusion

In this exploratory study, we identified biomarkers involved in inflammation, fibrosis and calcification which may be associated with having AVC. Biomarkers involved in fibrosis may show higher expression in females, whilst biomarkers involved in inflammation and calcification could associate with AVC in males.

Variation in the Association between Antineoplastic Therapies and Venous Thromboembolism in Patients with Active Cancer

Background Venous thromboembolism (VTE) is a major cause of death in cancer patients. Although patients with cancer have numerous risk factors for VTE, the relative contribution of cancer treatments is unclear.

Objective The objective of this study is to evaluate the association between cancer therapies and the risk of VTE.

Methods From UK Clinical Practice Research Datalink, data on patients with first cancer diagnosis between 2008 and 2016 were extracted along with information on hospitalization, treatments, and cause of death. Primary outcome was active cancer-associated VTE. To establish the independent effects of risk factors, adjusted subhazard ratios (adj-SHR) were calculated using Fine and Gray regression analysis accounting for death as competing risk.

Results Among 67,801 patients with a first cancer diagnosis, active cancer-associated VTE occurred in 1,473 (2.2%). During a median observation time of 1.2 years, chemotherapy, surgery, hormonal therapy, radiation therapy, and immunotherapy were given to 71.1, 37.2, 17.2, 17.5, and 1.4% of patients with VTE, respectively. The active cancers associated with the highest risk of VTE—as assessed by incidence rates—included pancreatic cancer, brain cancer, and metastatic cancer. Chemotherapy was associated with an increased risk of VTE (adj-SHR: 3.17, 95% confidence interval [CI]: 2.76–3.65) while immunotherapy with a not significant reduced risk (adj-SHR: 0.67, 95% CI: 0.30–1.52). There was no association between VTE and radiation therapy (adj-SHR: 0.91, 95% CI: 0.65–1.27) and hormonal therapies.

Conclusion VTE risk varies with cancer type. Chemotherapy was associated with an increased VTE risk, whereas with radiation and immunotherapy therapy, an association was not confirmed.

Vascular Calcification and not Arrhythmia in Idiopathic Atrial Fibrillation Associates with Sex Differences in Diabetic Microvascular Injury miRNA Profiles

BACKGROUND

Atrial Fibrillation (AF) in patients without concomitant cardiovascular pathophysiological disease, is called idiopathic Atrial Fibrillation (iAF). Nonetheless, iAF patients have often times subclinical coronary (micro) vascular dysfunction and, particularly in women, a higher prevalence of subsequent cardiovascular comorbidities. Previously, we identified a plasma miRNA association with diabetes and microvascular injury in Diabetic Nephropathy (DN) patients. Therefore, in this study we assessed whether plasma levels of these diabetic, microvascular injury associated miRNAs reflect microvascular integrity in iAF patients, associated with the presence of paroxysmal arrhythmia or instead are determined by concealed coronary artery disease.

METHODS

Circulating levels of a pre-selected set of diabetic, (micro) vascular injury associated miRNAs, were measured in 59 iAF patients compared to 176 Sinus Rhythm (SR) controls. Furthermore, the presence of coronary artery and aortic calcification in each patient was assessed using Cardiac Computed Tomography Angiography (CCTA).

RESULTS

Paroxysmal arrhythmia in iAF patients did not result in significant miRNA expression profile differences in iAF patients compared to SR controls. Nonetheless, coronary artery calcification (CAC) was associated with higher levels of miRNAs-103, -125a-5p, -221 and -223 in men. In women, CAC was associated with higher plasma levels of miRNA-27a and miRNA-126 and correlated with Agatston scores. Within the total population, ascending Aortic Calcification (AsAC) patients displayed increased plasma levels of miRNA-221, while women, in particular, demonstrated a Descending Aorta Calcification (DAC) associated increase in miRNA-212 levels.

CONCLUSIONS

Diabetic microvascular injury associated miRNAs in iAF are associated with subclinical coronary artery disease in a sex-specific way and confirm the notion that biological sex identifies iAF subgroups that may require dedicated clinical care.

Incident Atrial Fibrillation, Dementia and the Role of Anticoagulation: A Population-Based Cohort Study

INTRODUCTION

 Atrial fibrillation (AF) is associated with dementia. Anticoagulation may modify this relationship, but it is unclear if this is due to stroke reduction alone.

METHODS

 Age- and sex-matched individuals from the U.K. Clinical Practice Research Datalink (2008-2016) with and without an incident diagnosis of AF were followed for a new dementia diagnosis. We estimated adjusted hazard ratios (aHRs) for incident dementia diagnosis in the AF cohort, overall and stratified by anticoagulation status, using the matched non-AF cohorts as reference. We performed a sensitivity analysis excluding individuals with stroke/transient ischaemic attack (TIA) before the observation period.

RESULTS

 Over 193,082 person-years (mean follow-up 25.7 ± 0.1 months), 347/15,276 AF (2.3%) and 1,085/76,096 non-AF (1.4%) were newly diagnosed with dementia (aHR, 1.31, 95% confidence interval, 1.15-1.49). The AF group had more co-morbidity and higher rates of dementia, both with and without anticoagulation, than non-AF. When those with history of stroke/ TIA before the observation period were excluded and those with incident stroke/TIA during the observation period were censored, AF individuals not on anticoagulation had significantly higher rates of dementia compared with non-AF, aHR 1.30 (1.06-1.58).

CONCLUSION

 Our findings support the hypothesis that AF is a distinct risk factor for dementia, independent of stroke/TIA and other vascular risk factors. In those without stroke/TIA, risk of dementia is increased only in those who are not on anticoagulation, suggesting anticoagulation is protective presumably through reduction of sub-clinical embolic events. Further prospective research is needed to better ascertain the role of anticoagulation amongst targeted therapeutic strategies to reduce cognitive decline in AF.

The Biomarkers NT-proBNP and CA-125 are Elevated in Patients with Idiopathic Atrial Fibrillation

BACKGROUND

Blood biomarkers related to AF could be useful to detect silent AF and to develop stratified strategies for AF prevention. Previous studies identified markers that predict incident AF. However, it is difficult to differentiate whether biomarkers relate to underlying cardiovascular diseases, are generated by the atria in response to an AF episode, or both. We therefore measured a panel of blood biomarkers in patients without overt CVD with and without AF to investigate the association between biomarkers and atrial fibrillation (AF) in patients without overt cardiovascular disease (CVD).

METHODS

Blood samples - drawn remote from an AF episode - of 60 patients with AF but without overt forms of CVD (idiopathic AF; iAF) were compared to 120 matched patients with sinus rhythm only. A novel antibody-based method for quantification of blood biomarkers (OlinkProseek Multiplex Cardiovascular) was used to compare 92 biomarkers between the two groups.

RESULTS

N-terminal pro-B-type natriuretic peptide (NT-proBNP), Cathepsin L1, Endothelial cell-specific molecule 1, Cancer Antigen-125 (CA-125), Heat shock 27kDa protein, Galanin peptides, Proteinase-activated receptor 1, Stem cell factor, and CD40-ligand were all higher in iAF patients than in SR controls. Both NT-proBNP (OR1.55(1.07-2.25);p=0.022) and CA-125 (OR1.68(1.07-2.64);p=0.026) were independently associated with iAF.

CONCLUSIONS

This exploratory study, investigating over 90 cardiovascular blood biomarkers in patients without known CVD, identified one established biomarker for paroxysmal AF, NT-proBNP, and a novel marker, CA-125. CA-125 - previously unrelated to paroxysmal AF in an otherwise healthy population - may thus be a potential indicator of remote paroxysms of AF.

Agatston score of the descending aorta is independently associated with coronary events in a low-risk population

Objectives

A standard coronary artery calcium scan includes part of the aorta. This additional information is often not included in routine analyses. We aimed to determine the feasibility of assessing the Agatston score of the descending aorta calcification (DAC) on standard coronary calcium scans and the association of this score with coronary events in a low-risk study population.

Methods

Between January 2008 and March 2011, 390 consecutive patients who were referred for cardiac CT as part of work-up for pulmonary vein isolation (n=115) or assessment of presence of coronary artery disease (n=275) were included. At baseline, all patients were free of a history of cardiovascular disease. Two independent observers determined the Agatston score of the ascending aorta and descending aorta.

Results

A total of 16 patients (4.1%) developed coronary events (acute coronary syndrome (n=6) and symptomatic significant coronary artery disease requiring treatment (n=10)) during a follow-up of 67±12 months, with more events in patients with calcifications in the descending aorta than in those without (8.4% vs 3.7 %; p=0.08). Multivariable Cox regression, corrected for Framingham Risk Score (FRS) and coronary Agatston score (CAC), revealed that DAC was independently associated with coronary events (per 100 units; HR: 1.06, 95% CI 1.02 to 1.09; p=0.001). DAC furthermore increased the identification of patients that will experience a coronary event (area under the curve: 0.68 for FRS only, 0.75 for FRS+CAC and 0.78 for FRS+CAC+DAC).

Conclusions

The Agatston score of the descending aorta could be included in the standard analysis of cardiac CT scans of low-risk patients since it holds valuable information for the prediction of coronary events.

Vitamin K Antagonists, Non-Vitamin K Antagonist Oral Anticoagulants, and Vascular Calcification in Patients with Atrial Fibrillation

Background  Vitamin K antagonists (VKAs) are associated with coronary artery calcification in low-risk populations, but their effect on calcification of large arteries remains uncertain. The effect of non-vitamin K antagonist oral anticoagulants (NOACs) on vascular calcification is unknown. We investigated the influence of use of VKA and NOAC on calcification of the aorta and aortic valve. Methods  In patients with atrial fibrillation without a history of major adverse cardiac or cerebrovascular events who underwent computed tomographic angiography, the presence of ascending aorta calcification (AsAC), descending aorta calcification (DAC), and aortic valve calcification (AVC) was determined. Confounders for VKA/NOAC treatment were identified and propensity score adjusted logistic regression explored the association between treatment and calcification (Agatston score > 0). AsAC, DAC, and AVC differences were assessed in propensity score-matched groups. Results  Of 236 patients (33% female, age: 58 ± 9 years), 71 (30%) used VKA (median duration: 122 weeks) and 79 (34%) used NOAC (median duration: 16 weeks). Propensity score-adjusted logistic regression revealed that use of VKA was significantly associated with AsAC (odds ratio [OR]: 2.31; 95% confidence interval [CI]: 1.16-4.59; p  = 0.017) and DAC (OR: 2.38; 95% CI: 1.22-4.67; p  = 0.012) and a trend in AVC (OR: 1.92; 95% CI: 0.98-3.80; p  = 0.059) compared with non-anticoagulation. This association was absent in NOAC versus non-anticoagulant (AsAC OR: 0.51; 95% CI: 0.21-1.21; p  = 0.127; DAC OR: 0.80; 95% CI: 0.36-1.76; p  = 0.577; AVC OR: 0.62; 95% CI: 0.27-1.40; p  = 0.248). A total of 178 patients were propensity score matched in three pairwise comparisons. Again, use of VKA was associated with DAC ( p  = 0.043) and a trend toward more AsAC ( p  = 0.059), while use of NOAC was not (AsAC p  = 0.264; DAC p  = 0.154; AVC p  = 0.280). Conclusion  This cross-sectional study shows that use of VKA seems to contribute to vascular calcification. The calcification effect was not observed in NOAC users.

Multi-ethnic genome-wide association study for atrial fibrillation

Atrial fibrillation (AF) affects more than 33 million individuals worldwide1 and has a complex heritability2. We conducted the largest meta-analysis of genome-wide association studies (GWAS) for AF to date, consisting of more than half a million individuals, including 65,446 with AF. In total, we identified 97 loci significantly associated with AF, including 67 that were novel in a combined-ancestry analysis, and 3 that were novel in a European-specific analysis. We sought to identify AF-associated genes at the GWAS loci by performing RNA-sequencing and expression quantitative trait locus analyses in 101 left atrial samples, the most relevant tissue for AF. We also performed transcriptome-wide analyses that identified 57 AF-associated genes, 42 of which overlap with GWAS loci. The identified loci implicate genes enriched within cardiac developmental, electrophysiological, contractile and structural pathways. These results extend our understanding of the biological pathways underlying AF and may facilitate the development of therapeutics for AF.

Cardioversion of persistent atrial fibrillation is associated with a 24-hour relapse gap: Observations from prolonged postcardioversion rhythm monitoring

BACKGROUND

Many recurrences occur after electrical cardioversion (ECV) of atrial fibrillation (AF). Assessment of extent of remodeling and continuous prolonged rhythm monitoring might reveal actionable recurrence mechanisms.

HYPOTHESIS

After ECV of AF specific patterns of arrhythmia recurrence can be distinguished.

METHODS

All patients who underwent successful ECV due to persistent AF were included. Tissue velocity echocardiography during AF was performed before ECV to study atrial fibrillatory cycle length and fibrillatory velocity. After ECV, the heart rhythm of all patients was monitored 3 times daily during 4 weeks, and timing of recurrence was noted.

RESULTS

In total, 50 patients (68% male) were included; mean age was 68 ± 9 years. Median duration of the current AF episode was 102 (range, 74-152) days. Twenty-one (42%) patients showed recurrence of persistent AF. No recurrences occurred during the first 24 hours. There were no differences in clinical characteristics between patients with or without recurrence of AF. However, patients with early recurrence of AF had significantly higher precardioversion wall-motion velocity compared with patients who remained in sinus rhythm (2.8 [1.6-3.6] vs 1.4 [0.9-3.3] cm/s; P = 0.017), whereas atrial fibrillatory cycle length did not differ.

CONCLUSIONS

In this study on 50 patients successfully cardioverted for persistent AF, there was a relapse gap of ≥24 hours. This phenomenon has not been well appreciated before and offers an AF-free window of opportunity for electrocardiographically triggered cardiac imaging or complex electrophysiological procedures. Echocardiographic tissue velocity imaging may visualize atrial remodeling relevant to AF recurrence.

Late complications of an atrial septal occluder provoked by anticoagulant therapy

Late complications of an atrial septal occluder device (ASO) are rare but may be serious. We report a case with extensive hemopericardium five years after ASO implantation most likely triggered by anticoagulant therapy. Although not surgically confirmed, indirect clues for erosion of the atrial wall by the device were the exclusion of other etiologies, lack of recurrence after pericardial drainage and withdrawal of anticoagulants. In addition, multimodality imaging using echocardiography, computed tomography, and cardiac magnetic resonance imaging were helpful to elucidate this unusual cause. Initiation of anticoagulant treatment in patients with an ASO should be carefully balanced and may warrant more frequent echocardiographic follow-up. .

Presence and extent of cardiac computed tomography angiography defined coronary artery disease in patients presenting with syncope

Background

In syncope patients, presence of coronary artery disease (CAD) is associated with poor prognosis. However, data concerning CAD prevalence in syncope patients without known cardiovascular disease are lacking. Therefore, the aim of this study was to investigate presence and extent of CAD in syncope patients.

Methods

We included 142 consecutive patients presenting with syncope at the outpatient cardiology clinic who underwent coronary computed tomography (CT) angiography. Syncope type was ascertained by two reviewers, blinded for coronary CT angiography results. Of the patients, 49 had cardiac syncope (arrhythmia or structural cardiopulmonary disease) and 93 had non-cardiac syncope (reflex [neurally-mediated], orthostatic or of unknown cause). Cardiac syncope patients were compared with matched stable chest pain patients regarding age, gender, smoking status, diabetes mellitus type 2 and systolic blood pressure.

Results

Distribution of CAD presence and extent in cardiac and non-cardiac syncope patients was as follows: 72% versus 48% any CAD; 31% versus 26% mild, 8% versus 14% moderate and 33% versus 7% severe CAD.

Compared with non-cardiac syncope, patients with cardiac syncope had a significantly higher CAD presence and extent (p = 0.001). Coronary calcium score, segment involvement and stenosis score were also higher in cardiac syncope patients (p-values ≤0.004). Compared to the chest pain control group, patients with cardiac syncope showed a higher, however, non-significant, prevalence of any CAD (72% versus 63%) and severe CAD (33% versus 19%).

Conclusion

Patients with cardiac syncope show a high presence and extent of CAD in contrast to non-cardiac syncope patients. These results suggest that CAD may play an important role in the occurrence of cardiac syncope.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-017-0970-7) contains supplementary material, which is available to authorized users.

Acute cardioversion vs a wait-and-see approach for recent-onset symptomatic atrial fibrillation in the emergency department: Rationale and design of the randomized ACWAS trial

BACKGROUND

Current standard of care for patients with recent-onset atrial fibrillation (AF) in the emergency department aims at urgent restoration of sinus rhythm, although paroxysmal AF is a condition that resolves spontaneously within 24 hours in more than 70% of the cases. A wait-and-see approach with rate-control medication only and when needed cardioversion within 48 hours of onset of symptoms is hypothesized to be noninferior, safe, and cost-effective as compared with current standard of care and to lead to a higher quality of life.

DESIGN

The ACWAS trial (NCT02248753) is an investigator-initiated, randomized, controlled, 2-arm noninferiority trial that compares a wait-and-see approach to the standard of care. Consenting adults with recent-onset symptomatic AF in the emergency department without urgent need for cardioversion are eligible for participation. A total of 437 patients will be randomized to either standard care (pharmacologic or electrical cardioversion) or the wait-and-see approach, consisting of symptom reduction through rate control medication until spontaneous conversion is achieved, with the possibility of cardioversion within 48 hours after onset of symptoms. Primary end point is the presence of sinus rhythm on 12-lead electrocardiogram at 4 weeks; main secondary outcomes are adverse events, total medical and societal costs, quality of life, and cost-effectiveness for 1 year.

CONCLUSIONS

The ACWAS trial aims at providing evidence for the use of a wait-and-see approach for patients with recent-onset symptomatic AF in the emergency department.

Poor anticoagulation relates to extended access times for cardioversion and is associated with long-term major cardiac and cerebrovascular events

BACKGROUND

Patients undergoing elective electrical cardioversion (ECV) for atrial fibrillation have a temporarily increased risk of thromboembolism. Current guidelines recommend adequate anticoagulation for ≥3 consecutive weeks precardioversion, i.e. consecutive INR values 2.0-3.0 in patients with vitamin K antagonists (VKA). We aimed to evaluate the occurrence and impact of subtherapeutic INRs precardioversion and to study factors associated with these unwanted fluctuations.

METHODS

We recruited 346 consecutive patients undergoing elective ECV in the Maastricht University Medical Centre between 2008 and 2013. Predictors of subtherapeutic INR values were identified and incorporated into a logistic regression model.

RESULTS

A subtherapeutic INR precardioversion occurred in 55.2% of patients. The only statistically significant predictor was VKA-naivety (Odds Ratio (OR) 4.78, 95% Confidence Interval (CI) 2.67-8.58, p<0.001). In patients with ≥1 subtherapeutic INR precardioversion, time from referral until cardioversion was 91.1±42.8days, compared to 41.7±26.6days (p<0.001) in patients without subtherapeutic INRs. No thromboembolic events occurred <30days after the ECV. Independent predictors for the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion (n=30, median follow-up of 374days) were coronary artery disease in the history (OR 3.35, 95%CI 1.54-7.25, p=0.002) and subtherapeutic INR precardioversion (OR 3.64, 95%CI 1.43-9.24, p=0.007).

CONCLUSIONS

The use of VKA often results in subtherapeutic INRs precardioversion and is associated with a significant delay until cardioversion, especially in patients with recent initiation of VKA therapy. Furthermore, subtherapeutic INR levels prior to ECV are associated with the combined endpoint of cardiovascular death, ischemic stroke and the need of blood transfusion.

Lone or idiopathic atrial fibrillation, messenger of misery in sight

This editorial refers to 'Gender-related differences in risk of cardiovascular morbidity and all-cause mortality in patients hospitalized with incident atrial fibrillation without concomitant diseases: a nationwide cohort study of 9519 patients' by T. Andersson et al. In order to adequately describe root causes and adverse consequences of apparently idiopathic AF, the requested study population has to be large and be followed for a very long time. Andersson et al. adequately deployed the excellent national Swedish health registries in order to cover the hiatus of aforementioned studies in the current idiopathic AF literature. Considering the notion that patients with idiopathic or lone AF have comparable prospects as AF patients overall but are only caught early in their 'arrhythmia and vascular career', the study by Andersson et al. should trigger physicians to give high priority to exposing predisposing factors or early stages of underlying cardiovascular disease in such a way that preventative measures can be accurately deployed in these patients.

Tissue velocity imaging of the left atrium predicts response to flecainide in patients with acute atrial fibrillation

BACKGROUND

Acute atrial fibrillation (AF) is often treated with the administration of intravenous flecainide; however, this treatment may not always be successful and is potentially hazardous. Previous studies suggest that electro-echocardiographic tissue velocity imaging (TVI) of the atrial wall may reflect atrial remodeling.

OBJECTIVE

To study whether atrial TVI can be used to identify nonresponders of flecainide administered intravenously in patients with acute AF.

METHODS

We used atrial TVI to measure atrial fibrillatory cycle length determined by using tissue velocity imaging (AFCL-TVI) and atrial fibrillatory wall motion velocity determined by using tissue velocity imaging (AFV-TVI) in the left atrium in 52 (55%) patients presenting with acute AF in the emergency department. These 2 parameters reflect electrical and structural remodeling, respectively. Standard baseline characteristics were recorded.

RESULTS

Patients were predominantly men (76%) and 64 ± 11 years old. Thirty-six (69%) patients had successful cardioversion after flecainide infusion. There were no significant differences in baseline characteristics between responders and nonresponders. Patients with a successful cardioversion had a longer mean AFCL-TVI and higher median (interquartile range) AFV-TVI compared with patients with failed cardioversion: 172 ± 29 ms vs 137 ± 35 ms (P < .001) and 4.2 (3.3-6.2) cm/s vs 2.3 (1.9-3.5) cm/s (P = .001).

CONCLUSIONS

Electro-echocardiographic atrial TVI measurement is a promising noninvasive tool for predicting outcome of pharmacological cardioversion. A short AFCL-TVI and a low AFV-TVI are related to failure of cardioversion of AF using flecainide.

The occurrence of cardiovascular disease during 5-year follow-up in patients with idiopathic atrial fibrillation

AIMS

Idiopathic atrial fibrillation (AF) may be an expression of as yet undetected underlying heart disease. We found it useful for clinical practice to study the long-term development of cardiovascular disease (CVD) in patients diagnosed with idiopathic AF.

METHODS AND RESULTS

Forty-one consecutive idiopathic AF patients (56 ± 10 years, 66% male) were compared with 45 healthy control patients in permanent sinus rhythm. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. Baseline characteristics and echocardiographic parameters were equal in AF cases and controls. During a mean follow-up of 66 ± 11 months, CVD occurred significantly more often in idiopathic AF patients compared with controls (49 vs. 20%, P= 0.006). Patients with idiopathic AF were significantly younger at the time of their first CV event compared with controls (59 ± 9 vs. 64 ± 5 years, P= 0.027), and had more severe disease. Multivariable Cox regression analysis revealed that age, a history of AF, and echocardiographic left ventricular wall width were significant predictors of CVD development.

CONCLUSION

Patients originally diagnosed with idiopathic AF develop CVD more often, at younger age, and with a more severe disease profile compared with healthy sinus rhythm control patients. The detection and treatment of CVD in an early stage could improve the prognosis of these patients. At present it seems prudent to regularly check idiopathic AF patients for the insidious development of CVD.

Idiopathic atrial fibrillation revisited in a large longitudinal clinical cohort

AIMS

An age of 60 years is often used as cut-off for the diagnosis of idiopathic atrial fibrillation (AF). We investigated the importance of age and atrial size in patients with idiopathic AF and AF patients with isolated hypertension.

METHODS AND RESULTS

Out of 3978 AF patients in the Euro Heart Survey on AF with known follow-up, 119 (3%) patients had idiopathic AF. We disregarded age and atrial size when selecting idiopathic AF patients since the atria may enlarge by AF itself. For comparison, we selected 152 patients with isolated hypertension from the database. A total of 57 (48%) of the patients were older than 60 years. Persistent or permanent AF was more prevalent in the older idiopathic AF patients (34% in the age <60 vs. 66% in the age >60 years group, P= 0.002) but mean duration of known AF did not differ between these groups [310 days (inter-quartile range, IQR) 60-1827) vs. 430 days (IQR 88-1669), P= 0.824]. Left atrial size did not differ significantly in relation to age (1.50 ± 0.29 mm/kg/m² in the age <60 vs. 1.56 ± 0.31 mm/kg/m² in the age >60 years group, P= 0.742). Only two paroxysmal AF patients progressed to permanent AF. No cardiovascular events occurred during the 1-year follow-up. In contrast, strokes occurred in five patients (6%) with isolated hypertension despite similar clinical profile and comparable atrial size as idiopathic AF patients.

CONCLUSION

Idiopathic AF may present at advanced age and is even then not associated with significant atrial enlargement, AF progression, or an adverse short-term prognosis. In contrast, elevated blood pressure even when found in the absence of significant atrial remodelling, seems of prognostic importance.