Pitfalls and tips for lumenless lead extraction inserted deep within the ventricular septum

Key Clinical Message

This case highlights the pitfalls and provides tips for the extraction of deeply implanted lumenless leads, and encourages careful lead selection in the current era of widespread left bundle branch area pacing.

Abstract

The extraction of cardiovascular implantable electronic device leads is sometimes complicated. We describe a case with difficult but successful extraction of SelectSecure, a lumenless permanent pacemaker lead, implanted deep in the ventricular septum, highlighting its pitfalls and tips in the current era of left bundle branch area pacing.

Sex Differences in the Association Between Depression and Incident Cardiovascular Disease

Background

Depression is a known risk factor for cardiovascular disease (CVD), but the potential sex differences in this association remain unclear.

Objectives

The aim of this study was to investigate the association between depression and subsequent CVD events, and to explore potential sex differences.

Methods

The authors conducted a retrospective analysis using the JMDC Claims Database between 2005 and 2022. The study population included 4,125,720 individuals aged 18 to 75 years without a history of cardiovascular disease or renal failure and missing data at baseline. Participants were followed up for a mean of 1,288 days to assess the association between depression and subsequent CVD events, such as myocardial infarction, angina pectoris, stroke, heart failure, and atrial fibrillation.

Results

Our analysis revealed a significant association between depression and subsequent composite CVD events in both men and women, with a stronger association observed in women. The HR for the composite endpoint was 1.64 (95% CI: 1.59-1.70) in women and 1.39 (95% CI: 1.35-1.42) in men after multivariable adjustment (P for interaction <0.001). Furthermore, the individual components of the composite endpoint were also associated with depression in both men and women, each of which was also observed to be more strongly associated in women.

Conclusions

Our study provides evidence of a significant association between depression and subsequent CVD events in both men and women, with a more pronounced association observed in women. These findings highlight the importance of addressing depression and tailoring prevention and management strategies according to sex-specific factors.

Sex Differences in the Relationship Between Schizophrenia and the Development of Cardiovascular Disease

BACKGROUND

There are few data on sex differences in the association between schizophrenia and the development of cardiovascular disease (CVD). We sought to clarify the relationship of schizophrenia with the risk of developing CVDs and to explore the potential modification effect of sex differences.

METHODS AND RESULTS

We conducted a retrospective analysis using the JMDC Claims Database between 2005 and 2022. The study population included 4 124 508 individuals aged 18 to 75 years without a history of CVD or renal replacement therapy. The primary end point is defined as a composite end point that includes myocardial infarction, angina pectoris, stroke, heart failure, atrial fibrillation, and pulmonary thromboembolism. During a mean follow-up of 1288±1001 days, we observed 182 158 composite end points. We found a significant relationship of schizophrenia with a greater risk of developing composite CVD events in both men and women, with a stronger association observed in women. The hazard ratio for the composite end point was 1.63 (95% CI, 1.52-1.74) in women and 1.42 (95% CI, 1.33-1.52) in men after multivariable adjustment (P for interaction=0.0049). This sex-specific difference in the association between schizophrenia and incident CVD was consistent for angina pectoris, heart failure, and atrial fibrillation.

CONCLUSIONS

Our analysis using a large-scale epidemiologic cohort demonstrated that the association between schizophrenia and subsequent CVD events was more pronounced in women than in men, suggesting the clinical importance of addressing schizophrenia and tailoring the CVD prevention strategy based on sex-specific factors.

Impact of Sleep Apnea on Nocturnal Parasympathetic Activity in Atrial Fibrillation Patients After Catheter Ablation - Implications for Heart Rate Variability Analysis

BACKGROUND

The impact of sleep apnea (SA) on heart rate variability (HRV) in atrial fibrillation (AF) patients has not been investigated.Methods and Results: Of 94 patients who underwent AF ablation between January 2021 and September 2022, 76 patients who had a nocturnal Holter electrocardiography and polysomnography conducted simultaneously were included in the analysis. A 15-min duration of HRV, as determined by an electrocardiogram during apnea and non-apnea time, were compared between patients with and without AF recurrence at 12 months' postoperatively. Patients had a mean age of 63.4±11.6 years, 14 were female, and 20 had AF recurrence at 12 months' follow-up. The root mean square of the difference between consecutive normal-to-normal intervals (RMSSD, ms) an indicator of a parasympathetic nervous system, was more highly increased in patients with AF recurrence than those without, during both apnea and non-apnea time (apnea time: 16.7±4.5 vs. 13.5±3.3, P=0.03; non-apnea time: 20.9±9.5 vs. 15.5±5.9, P<0.01). However, RMSSD during an apneic state was decreased more than that in a non-apneic state in both groups of patients with and without AF recurrence (AF recurrence group: 16.7±4.5 vs. 20.9±9.5, P<0.01; non-AF recurrence group; 13.5±3.3 vs. 15.5±5.9, P=0.03). Consequently, the effect of AF recurrence on parasympathetic activity was offset by SA. Similar trends were observed for other parasympathetic activity indices; high frequency (HF), logarithm of HF (lnHF) and the percentage of normal-to-normal intervals >50 ms (pNN50).

CONCLUSIONS

Without considering the influence of SA, the results of nocturnal HRV analysis might be misinterpreted. Caution should be taken when using nocturnal HRV as a predictor of AF recurrence.

Prediction model for the new onset of atrial fibrillation combining features of 24-hour Holter electrocardiogram with 12-lead electrocardiogram

Background

Several factors that predict new-onset atrial fibrillation (AF) have been investigated using the 24-hour Holter electrocardiogram (ECG) and 12-lead ECG; however, these have been based on each test independently. The aim of this study was to combine findings from the two tests to create a comprehensive, easy-to-use score and to examine its validity.

Methods and Results

A total of 502 patients underwent 24-hour Holter ECG and 12-lead ECG were followed up for 6.2 ± 3.5 years, and 66 patients developed new-onset AF. Multivariate Cox regression analyses revealed that total number of supraventricular extrasystoles (SVEs) ≥ 100 beats/day and SVE's longest run ≥ 3 beats on 24-hour Holter ECG and PR interval ≥ 185 ms, amplitude ratio of P wave (aVR/V1) < 1.0 and amplitude of RV5 + SV1 ≥ 2.2 mV on 12-lead ECG were significant independent predictors for developing AF (all p < 0.01). Using these cut-off points, the PAAFS (acronym for risk factors) score was constructed by adding one point for each parameter if the patient met each of the criteria. The area under the curve (AUC) of the PAAFS score was 0.80, compared to the AUCs of 24-hour Holter ECG-only factors (0.73) and 12-lead ECG-only factors (0.72), indicating an improvement in score. The annual incidence of AF for each PAAFS score were 0.0%, 0.2%, 0.7%, 1.9%, 5.6%, and 11.1%/year for scores 0 to 5, respectively.

Conclusion

The PAAFS score, which combines findings from 24-hour Holter ECG and 12-lead ECG, was superior to 24-hour Holter ECG and 12-lead ECG alone in predictive accuracy for new-onset AF.

Survey of physicians' and patients' understanding, perceptions, and attitudes toward depressive state in atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia among older people and has a significant impact on quality of life. However, it is not always perceived as a serious mental health risk. This study investigated the understanding, perceptions, and attitudes toward the risk of depressive state associated with older patients with AF.

METHODS

We conducted a quantitative survey in April-June 2021 among patients with AF aged ≥65 years (n = 156), and physicians or cardiologists attending at least 10 older patients with AF annually (n = 158).

RESULTS

In total, 45% of patients considered AF a cause of a depressive state. In contrast, 16% of physicians reported that they considered AF a cause of a depressive state. Fifty-two percent of the patients had experienced a depressive state. Of these, 98% expressed that a depressive state lowered their quality of life. Two of the three patients reported that they would consult their physicians if they felt depressed. By contrast, 30% of physicians responded that even if they perceived their patients as depressed, they prescribe anti-anxiety medication but do not refer the patient to psychiatrists. Of the physicians, 50% stated that they did not regard the association of AF and depressive state as serious, although both physicians and patients understood that negative anxiety, such as fear of AF attacks, strokes, or heart failure, was the most important contributor to a depressive state.

CONCLUSION

Establishing mental healthcare involving physicians together with psychiatrists is necessary to improve the mental and physical health outcomes for older patients with AF. Geriatr Gerontol Int 2023; ••: ••-••.

The impact of home electrocardiograph measurement rate on the detection of atrial fibrillation recurrence after ablation: A prospective multicenter observational study

Background

This multicenter prospective observational study examined the impact of additionally using a home electrocardiograph (ECG) to detect atrial fibrillation (AF) recurrence after ablation.

Methods

Between May 2019 and December 2020, 128 patients undergoing ablation were enrolled in the study. After performing ablation, they were instructed to measure their ECGs at home using Complete (ECG paired with a blood pressure monitor; Omron Healthcare, Japan) every day and to visit the hospital every 3 months until after 12 months for 24-hour Holter ECG and 12-lead ECG as usual care (UC).

Results

After ablation, 94 patients were followed up, and AF recurrence at 12 months was detected more commonly in adjudicators-interpreted Complete (31 [33 %]) than in UC (18 [9 %]) (hazard ratio 1.95, 95 % confidence interval [95 %CI] 1.35-2.81, P < 0.001). In patients with recurrent AF found via both modalities (n = 16), the time to first AF detection by Complete was 40.9 ± 73.9 days faster than that in UC (P = 0.04). Notably, when the adherence to Complete measurement was divided by 80 %, the add-on effect of Complete on the detection of recurrent AF in UC indicated the hazard ratio (HR) of 1.71 (95 %CI 0.92-3.18, P = 0.09) for the low adherence (<80 %) group, but it was significant for the high adherence (≥80 %) group, with HR of 2.19 (95 %CI 1.43-3.36, P < 0.001).

Conclusions

Despite a shorter measurement time, Complete detected recurrent AF more frequently and faster compared with UC after AF ablation. A significant adherence-dependent difference of Complete was found in detecting AF recurrence.

Comparison of maximum-sized visually guided laser balloon and cryoballoon ablation

Balloon ablation therapy has recently been used for atrial fibrillation (AF) ablation. Laser balloons possess the property in which the balloon size can be changed. Standard laser balloon ablation (Standard LBA) was followed by additional ablation using a maximally extended balloon (Extended LBA) and its lesion characteristics were compared to cryoballoon ablation (CBA), another balloon technology. From June 2020 to July 2021, patients with paroxysmal AF who underwent an initial pulmonary vein (PV) isolation were enrolled. Sixty-five patients with paroxysmal AF were included, 32 in the LBA and 33 in the CBA group. To measure the isolated surface area after the ablation procedures, left atrial voltage mapping was performed after Standard LBA, Extended LBA, and CBA. The baseline patient characteristics did not differ between LBA and CBA. Extended LBA could successfully increase the isolated area more than Standard LBA for all four PVs. Compared to CBA, the isolated area of both superior PVs was significantly greater with Extended LBA (left superior PV: 8.5 ± 2.1 vs 7.3 ± 2.4, p = 0.04, right superior PV: 11.4 ± 3.7 vs 8.7 ± 2.7, p < 0.01), and thus the non-isolated posterior wall (PW) was smaller (8.5 ± 3.4 vs 12.4 ± 3.3, p < 0.01). Nevertheless, changes in the cardiac injury markers were significantly lower with LBA than CBA. There was no significant correlation between the cardiac injury level and isolated area in both groups. In conclusion, Extended LBA exhibited a significantly greater isolation of both superior PVs and resulted in a smaller non-isolated PW, but the cardiac injury markers were significantly suppressed as compared to CBA.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Cardiogenic Shock Due to Unsuspected Tachycardia in a Child

A 10-year-old girl experienced cardiac failure due to atrial tachycardia originating from a left atrial appendage. Surgical appendectomy was done after a recurrence of the atrial tachycardia just after the first attempt at catheter ablation. A second ablation attempt was avoided because of the risk of cardiac perforation. (Level of Difficulty: Intermediate.)

Screening for untreated atrial fibrillation in the elderly population: A community-based study

Background

Strokes are common in people with atrial fibrillation (AF), and can have devastating consequences, especially in the elderly and if AF is untreated. However, community-based studies on screening for untreated AF have not been conducted in Japan, and there has been no evaluation of the effectiveness of early screening for AF in the elderly (≥65 years).

Methods

The Kyoto Prefectural University of Medicine (KPUM) Education Initiative has conducted an AF awareness campaign consisted of screening tests using a blood pressure (BP) monitor with electrocardiogram (ECG) (the Complete, Omron Healthcare Co., Ltd., Kyoto, Japan) and educational lectures for the elderly (≥65 years) from 2019 to 2020. A modeled effectiveness analysis was performed comparing the life-years and QALYs (quality-adjusted life-years) between direct-acting oral anticoagulation (DOAC)-treated AF and untreated AF in a Japanese setting. The basic description of the Markov model was used for the analysis.

Results

A total of 1648 participants were screened, and after excluding those with missing information or data (n = 41), 1607 were finally enrolled. The mean (± standard deviation) age of participants was 72.4±5.8 years, 827 (51.5%) were female, 628 (39.1%) had hypertension, and 1368 (85.1%) had CHA2DS2-VASc score ≥2. After cardiologists’ evaluation of all ECG recordings of the Complete, 15 (0.93%) AF were newly detected. For each AF treated with DOAC, 0.859 QALYs gained over the lifetime for 65 years-old men, and 0.856 QALYs for 65 years-old women compared to non-treatment.

Conclusion

A moderate number of untreated AF were identified in the community-based study. Identification of an increased number of patients with AF, if properly treated with DOAC, ultimately leads to a reduction in the number of strokes occurred over subjects’ lifetime.

Depression and quality of life in older adults with atrial fibrillation: A cross-sectional community-based study

AIM

In the older population, depression often occurs alongside physical illness. A cross-sectional community-based study examined the relationship between atrial fibrillation (AF), depression, and quality of life (QoL), and the impact of chest symptoms.

METHODS

A total of 1364 older adults (≥65 years) who attended AF awareness symposia from July 2019 to December 2020 provided consent to participate in the study and valid questionnaire responses. Depression was assessed with the Geriatric Depression Scale (GDS)-15, and QoL with the 12-item Short-Form Health Survey (SF-12).

RESULTS

AF patients (n = 130) were divided into symptomatic AF (n = 87) and asymptomatic AF (n = 43) groups. Depressive state and physical component summary (PCS) and mental component summary (MCS) in the SF-12 were compared with the control group (non-AF group without chest symptoms, n = 911), extracted from the same symposium participants. The depression rate (defined as GDS-15 ≥ 10) was 9.2% in symptomatic AF patients, 2.3% in asymptomatic AF patients, and 2.7% in controls. The mean PCS and MCS in each group were 43.4 ± 10.8 and 54.8 ± 8.6, 44.6 ± 10.7 and 57.3 ± 7.3, and 48.5 ± 7.9 and 56.7 ± 6.8, respectively. Multivariate regression analysis showed that symptomatic AF patients had a higher risk of depression (odds ratio: 3.46, 95% confidence interval (CI) 1.27-8.57, P = 0.01) and poor QoL (PCS: B -3.17, 95% CI -5.05 to -1.29, P = 0.001 and MCS: B -1.80, 95% CI -3.45 to -0.16, P = 0.03) compared with controls, but asymptomatic AF patients did not.

CONCLUSIONS

In a cross-sectional community-based study, symptomatic AF patients were vulnerable to depression and poor QoL, but asymptomatic AF patients were not. Geriatr Gerontol Int 2022; ••: ••-••.

Smartphone Application to Improve Oral Anticoagulation Adherence in Patients with Atrial Fibrillation: Prospective Observational Study

BACKGROUND

Poor adherence to oral anticoagulants (OACs) in elderly patients with atrial fibrillation (AF) has been shown to negatively impact healthcare costs, morbidity, and mortality. Although various methods such as automated reminders, counseling, telephone support, and patient education have been effective in improving medication adherence, the burden on healthcare providers has been considerable. Recently, an attempt has been made to improve medication adherence without burdening healthcare providers by using smartphone applications (i.e., app), but the use of the app for elderly patients with AF is still limited.

OBJECTIVE

The purpose of this study was to determine whether the new-developed smartphone application for AF patients (The Smart AF app) that integrates education, automatic reminder and patient engagement strategies with a simple user interface (UI) can improve medication adherence in elderly patients with AF.

METHODS

Patient enrollment was done by obtaining informed consent from AF patients attending Kyoto Prefectural University of Medicine hospitals between May 2019 and September 2020. Follow-up was planned at 1, 3, and 6 months after enrollment, and questionnaire reminders were automatically sent to patient applications at designated follow-up time points. A questionnaire-based survey of medication adherence was performed electronically using the self-reported 8-item Morisky Medication Adherence Scale (MMAS-8) as the survey tool.

RESULTS

A total of 136 patients with AF were enrolled in this study. During the follow-up period, 112 patients underwent follow-up at 1 month, 107 at 3 months, and 96 at 6 months. The mean age of the enrolled patients was 64.3 years, and males accounted for 79.4% (108/136) of the study population. The mean CHADS2 score was 1.2, with hypertension being the most common comorbidity. At the time of enrollment, 126 and 10 patients were taking direct oral anticoagulants (DOACs) and warfarin, respectively. For medication adherence as measured according to the MMAS-8, MMAS scores at 1 month, 3 months, and 6 months were significantly improved compared with baseline MMAS scores. (all p values<0.01). The overall improvement in medication adherence achieved by the 6-month intervention was as follows. 77.8% (14/18) of patients in the high adherence group (score=8) at baseline remained, 45.3% (24/53) of patients in the medium adherence group (score=6 to <8) at baseline moved to the high adherence group, and 72% (18/25) of patients in the low adherence group (score<6) moved to either the medium or high adherence group.

CONCLUSIONS

The Smart AF app improved medication adherence among elderly patients with AF. In the realm of medication management, an approach using mobile health technology that emphasizes education, automatic reminder and patient engagement, may be helpful.

Geriatric depression and quality of life in atrial fibrillation: the geriatric population analysis

Background and purpose

Arrhythmias such as atrial fibrillation (AF) is often associated with depression, with vague anxiety about symptom and the risk of serious complication such as stroke or heart failure. In the geriatric population, geriatric depression often occurs with an increase of physical illness and has substantial costly and quality of life implications for functionality and life satisfaction. However, few studies have investigated relationship between geriatric depression and Quality of Life (QoL), and arrhythmia symptoms (palpitation, dyspnea and chest discomfort).

Method

Between November 2019 and October 2020, elderly people (≥65 years) who participated in the AF awareness symposium were enrolled in this study. They were divided into 4 groups according to the presence or absence of chest symptom and AF, and were examined geriatric depression by Geriatric depression scale (GDS)-15 and Quality of Life (QoL) by the 12-item Short- Form Health Survey (SF-12) including physical and mental health status.

Results

Of the 1511 subjects, 1364 were analyzed after excluding 147 with missing values. Among them, 911 were in the non-AF group without symptom (Group A), 43 in the AF group without symptom (group B), 323 in the non-AF group with symptom (group C), and 87 in the AF group with symptom (group D).

Geriatric depression rates (defined as GDS-15 ≥10) were 2.7% in non-symptomatic group (2.7% in A [n=25] and 2.3% in B [n=1]) and 7.8% in symptomatic group (7.4% in C [n=24] and 9.2% in D [n=8]). (P&lt;0.05) In multivariate regression analysis, an increased risk of geriatric depression was observed in groups C and D (group C: odds ratio [OR]=2.54, CI: 1.40, 4.61, P&lt;0.01 and group D: OR=3.13 CI: 1.16, 7.57, P=0.02).

The mean values of physical and mental health status in SF-12 were 48.5 (±7.9) and 56.7 (±6.8) in A, 44.6 (±10.7) and 57.3 (±7.3) in B, 45.0 (±9.9) and 53.8 (±7.7) in C, and 43.4 (±10.8) and 54.8 (±8.6) in D, respectively. Physical health status in SF-12 was associated with group C (C vs A: estimate −2.95 [CI: −4.03, −1.87], p&lt;0.01) and D (D vs A: estimate −2.93 [CI: −4.88, −0.97], p&lt;0.01), other than heart failure, older age and female. Mental health status in SF-12 was associated with group C (C vs A: estimated −2.34 [CI: −3.72, −1.42], p&lt;0.01), heart failure, hypertension, older age, female and group D (D vs A: estimate −1.63 [CI: −3.31, 0.05], p=0.06), but not statistically significant. Individuals with arrhythmia symptom (group C and D) had lower physical and mental health status than those without (group A and B) (P&lt;0.05).

Conclusion

Older adults with arrhythmia symptoms were more likely to have geriatric depression and low QoL, especially those with symptomatic AF, with a geriatric depressive complication rate of 9.2%. Further studies are needed to investigate whether improving physical health status can improve QoL and geriatric depression.

Funding Acknowledgement

Type of funding sources: None.

Combination of CHARGE AF score and index of 24-hour electrocardiogram to predict incident atrial fibrillation and cardiovascular events

Background

Atrial fibrillation (AF) is associated with increased risks of stroke and heart failure. AF risk prediction can facilitate the efficient deployment of diagnosis or interventions to prevent AF.

Purpose

We sought to assess the combination prediction value of Holter electrocardiogram (Holter ECG) and the CHARGE-AF score (Cohorts for Aging and Research in Genomic Epidemiology-AF) for the new-onset of AF in a single center study. We also investigated the association between clinical findings and the new-onset of cerebral cardiovascular events.

Methods

From January 2008 and May 2014, 1246 patients with aged≥20 undergoing Holter ECG for palpitations, dizziness, or syncope were recruited. Among them, 350 patients were enrolled in this study after exclusion of 1) AF history at the time of inspection or before, 2) post cardiac device implantation, 3) follow-up duration &lt;1 year, and 4) no 12-lead ECG records within 6 months around Holter ECG.

Results

During the 5.9-year follow-up, 40 patients (11.4%) developed AF incidence. Multivariate cox regression analysis revealed that CHARGE-AF score (hazard ratio [HR]: 1.59, 95% confidence interval (95% CI): 1.13–2.26, P&lt;0.01), BMI (HR: 0.91, 95% CI: 0.83–0.99, P=0.03), frequent supraventricular extrasystoles (SVEs) ≥1000 beats/day (HR: 4.87, 95% CI: 2.59–9.13, P&lt;0.001) and first-degree AV block (HR: 3.52, 95% CI: 1.63–7.61, P&lt;0.01) were significant independent predictors for newly AF. The area under the ROC curve (AUC) of the combination of the CHARGE-AF score and frequent SVEs (≥1000) was greater than the CHARGE-AF score alone (0.73, 95% CI: 0.64–0.82 vs 0.66, 95% CI: 0.56–0.75, respectively). On the ROC curve, the CHARGE-AF score of 12.9 was optimum cut-off value for newly AF. Patients with both the CHARGE-AF score≥12.9 and SVEs≥1000 developed AF at 129.0/1000 person-years, compared with those with the CHARGE-AF score&lt;12.9 and SVEs≥1000 (48.9), the CHARGE-AF score≥12.9 and SVEs&lt;1000 (40.0) and the CHARGE-AF score&lt;12.9 and SVEs&lt;1000 (7.4), respectively. In multivariate cox regression analysis, age, past history of congestive heart failure and myocardial infarction, and antihypertensive medication were significant predictors of cerebral cardiovascular events (n=43), all of which signifying the components of the CHARGE-AF score. The AUC of the combination of the CHARGE-AF score and frequent SVEs (≥1000) was not different from the CHARGE-AF score alone (0.73, 95% CI: 0.64–0.81 vs 0.73, 95% CI: 0.64–0.82, respectively).

Conclusion

CHARGE-AF score has higher predictive power of both the new incident AF and cerebral cardiovascular events. The combination of CHARGE-AF score and SVEs≥1000 beats/day in Holter ECG can demonstrate the additional effect of prediction ability for the new incident AF, but not for cerebral cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

Relationship Between Body Mass Index and Incidence of Atrial Fibrillation in Young Japanese Men - The Nishimura Health Survey

BACKGROUND

The associations between body mass index (BMI) and incidence of atrial fibrillation (AF) in young men are scarce, especially in Asian countries, given the differences in BMI between Asians and Western populations.Methods and Results:This study analyzed 17,865 middle-aged Japanese men without AF from a cohort of employees undergoing annual health examinations. AF incidence was evaluated during a follow-up period (median 4.0 years, interquartile range 2.0-7.1 years). Among young men aged 30-49 years, AF incidence was 0.64/1,000 person-years, whereas it was 2.54/1,000 and 7.60/1,000 person-years among men aged 50-59 and ≥60 years, respectively. Multivariable Cox regression analysis among young men revealed age (hazard ratio [HR] 3.28 by 10-years' increase, 95% confidence interval [CI] 1.72-6.25, P<0.001), BMI (BMI-quadratic, HR 1.01, 95% CI 1.00-1.01, P<0.001, BMI-linear, HR 0.95, 95% CI 0.86-1.05, P=0.33), and electrocardiogram (ECG) abnormalities, such as PQ prolongation, supraventricular beat, and p wave abnormality (HR 8.79, 95% CI 3.05-25.32, P<0.001), were significantly associated with AF incidence. There was a reverse J-shaped association between BMI and AF incidence in young men, whereby the presence of ECG abnormality inversely influenced the BMI-incident AF relationship. A linear association between BMI and AF incidence in men aged 50-59 and ≥60 years was present.

CONCLUSIONS

AF incidence displays a reverse J-shaped relationship with BMI in young men, but a linear association in men aged ≥50 years. The paradoxical relationship seen in young men only may reflect atrial electrical or structural abnormalities.

Evaluation of new-onset atrial fibrillation using continuous patch monitor in patients undergoing transcatheter aortic valve replacement

Background

Transcatheter aortic valve replacement (TAVR) has emerged as an important therapeutic option among intermediate- and high-risk patients with symptomatic severe aortic stenosis. Heart rhythm disorders frequently complicate TAVR, particularly atrial fibrillation (AF), which can affect &gt;40% patients undergoing the procedure. There is wide variation in rates of new-onset AF (NOAF) following TAVR across the initial pivotal randomized trials and observational studies, but burden of AF in each patient is not well known. The aim of this study is to evaluate AF burden detected by continuous patch ECG monitor (WR-100; Fukuda-Denshi, Tokyo,Japan) in patients after TAVR.

Method

Among KPUM-TAVR cohort, 58 consecutive patients (mean age:85.5±5.5, 44 females) kept recording continuous patch ECG monitor for 14 days after the procedure of TAVR. We excluded 11 patients with ECG indicating AF before procedure (paroxysmal AF 5, persistent AF 6). Finally, 47 eligible patients were selected according to the study criteria. AF was defined as a presence of AF more than 30sec on ECG monitor. The incidence and burden of NOAF was assessed.

Results

We identified 9 of 47 patients (19.1%) who developed NOAF (94% of transfemoral access patients, 6% of non- transfemoral access patients). Patients developing NOAF and had higher Society of Thoracic Surgeons risk scores (5.9±3.8 vs 9.9±6.3 p=0.0187). AF was first observed from day1 to day13. Despite having a median CHA2DS2-VASc score of 5 (25th and 75th percentile: 5 to 6), only 33% of patients with NOAF were given oral anticoagulation during the follow-up.

Conclusion

By using continuous patch ECG monitor, NOAF can be identified in 19.1% of patients after TAVR, with wide variety of first onset of AF. Given the clinical significance of post-TAVR AF, additional studies are necessary to describe the optimal management strategy in this high-risk population.

Figure 1

Funding Acknowledgement

Type of funding source: None

Gender differences in patterns of relationship between body mass index and AF incidence

Background

Obesity is reportedly associated with the new incidence of atrial fibrillation (AF). However, gender differences in patterns of relationship between body mass index (BMI) and the risk of AF are unknown.

Methods

We analyzed 21,382 middle-aged Japanese subjects (10923 men, 10459 women) without AF from a cohort of employees undergoing annual health examinations, with a follow-up period of 4.8±3.7 years. We examined the relationship between BMI at baseline to AF incidence in unadjusted and adjusted analyses. This relationship was also studied using linear and quadratic models.

Results

AF had developed in 137 subjects (119 men; mean age, 54.4±8.2 years; incidence, 2.19 and 0.38 per 1000 person-years in men and women, respectively). In multivariable Cox proportional-hazard models, increasing age (hazard ratio [HR], 2.72 per year; 95% CI, 2.22 to 3.33; P&lt;0.001), male gender (HR, 3.28; 95% CI, 1.86 to 5.76; P&lt;0.001) and BMI (HR, 1.08; 95% CI, 1.02 to 1.15; P=0.007) were associated with the new incidence of AF in all cohorts. The shape of the BMI-incident AF relationship showed a linear association in women and a J-shaped association in men. (Figure) In particular, a U-shaped relationship was observed in young men aged 40–49, with increased risk among those with higher BMI and with very low BMI. In analyses adjusted for comorbidities and risk factors for CV disease, the U-shaped AF incidence versus BMI curves were not attenuated, suggesting that other genetic or congenital factors may mediate this relationship.

Conclusion

Our results indicate that the shape of the BMI-incident AF relation differs by sex and in particular a U-shaped relationship was observed in young men.

Patterns of relation among BMI and AF

Funding Acknowledgement

Type of funding source: None

Age-Specific Association Between Body Mass Index and the Incidence of Atrial Fibrillation in Japanese Men

Background: Obesity is reportedly associated with the incidence of atrial fibrillation (AF), but the patterns of age-specific associations between body mass index (BMI) and the risk of AF are unknown.

Methods and Results: We analyzed 10,921 Japanese men without AF from a cohort of employees undergoing annual health examinations. During a follow-up period of 5.0±3.8 years, the incidence of AF was 118 (2.18/1,000 person-years). Using a multivariable Cox regression analysis, high BMI was associated with a risk of AF (hazard ratio; 1.07 by 1 unit change of BMI, 95% confidence interval [CI] 1.00–1.13, P=0.05) overall, and the effect of BMI on AF incidence changed with age (P for interaction=0.08); with subjects aged <65 years with BMI <25 as the reference, HR 0.74 (95% CI 0.47–1.17) in subjects aged <65 years with BMI ≥25, HR 2.98 (95% CI 1.36–6.54) in subjects aged ≥65 years with BMI <25, and HR 6.50 (95% CI 2.58–16.38) in subjects aged ≥65 years with BMI ≥25. The 5-year probability of AF incidence in subjects aged <65 years was 0.87% with BMI <25 and 0.64% in those with BMI ≥25, and in subjects aged ≥65 years it was 2.58% with BMI <25 and 5.53% with BMI ≥25.

Conclusions: Our results indicated that the effect of BMI on AF incidence changes with age among Japanese men. Both physicians and cardiologists need to integrate advice on lifestyle measures, particularly for elderly obese men, into their daily medical routine.

Knowledge, perception, and level of confidence regarding COVID-19 care among healthcare workers involved in cardiovascular medicine: a web-based cross-sectional survey in Japan

BACKGROUND

The pandemic of coronavirus disease 2019 (COVID-19) has a significant impact on daily practice in cardiovascular medicine. The preparedness of healthcare workers (HCWs) can affect the spread of infection and the maintenance of the healthcare system. This study aimed to investigate the knowledge, perception, and level of confidence regarding COVID-19 care among HCWs involved in cardiovascular medicine.

METHODS

A cross-sectional, web-based study about COVID-19 was performed between April 22 and May 7, 2020, among 311 HCWs in cardiovascular departments. The demographic information, COVID-19-related knowledge, and perception and level of confidence toward COVID-19 care were assessed.

RESULTS

The median age of the participants was 38 years, and 215 (69.8%) were male. There were 134 (43.1%) physicians and 177 (56.9%) non-physician HCWs. The HCWs, especially non-physician HCWs, had insufficient knowledge about infection-prevention measures for COVID-19, such as how to isolate patients with COVID-19, how to use personal protective equipment, and how to prevent infection during aerosol-generating procedures. Most HCWs showed a low level of confidence toward COVID-19 care, and such poor confidence was associated with the lack of knowledge on optimal infection-prevention measures.

CONCLUSIONS

This survey revealed the lack of knowledge about adequate infection-prevention measures for COVID-19. More attention should be paid to the preparedness of HCWs, and educating and supporting HCWs involved in cardiovascular medicine is an urgent need.

Diagnostic Value of Atrial Fibrillation by Built-in Electrocardiogram Technology in a Blood Pressure Monitor

Background: Hypertension in patients with atrial fibrillation (AF) is a known independent risk factor for stroke. The Complete blood pressure (BP) monitor (Omron Healthcare, Kyoto, Japan) was developed as the first BP monitor with electrocardiogram (ECG) capability in a single device to simultaneously monitor ECG and BP readings. This study investigated whether the Complete can accurately differentiate sinus rhythm (SR) from AF during BP measurement.

Methods and Results: Fifty-six consecutive patients with persistent AF admitted for catheter ablation were enrolled in the study (mean age 65.8 years; 83.9% male). In all patients, 12-lead ECGs and simultaneous Complete recordings were acquired before and after ablation. The Complete interpretations were compared with physician-reviewed ECGs, whereas Complete recordings were reviewed by cardiologists in a blinded manner and compared with ECG interpretations. Sensitivity, specificity, and κ coefficient were also determined. In all, 164 Complete and ECG recordings were simultaneously acquired from the 56 patients. After excluding unclassified recordings, the Complete automated algorithm performed well, with 100% sensitivity, 86% specificity, and a κ coefficient of 0.87 compared with physician-interpreted ECGs. Physician-interpreted Complete recordings performed well, with 99% sensitivity, 85% specificity, and a κ coefficient of 0.85 compared with physician-interpreted ECGs.

Conclusions: The Complete, which combines BP and ECG monitoring, can accurately differentiate SR from AF during BP measurement.

Risk factors for the development of incident atrial fibrillation in patients with cardiac implantable electronic devices

INTRODUCTION

Cardiac implantable electronic devices (CIEDs) can detect atrial fibrillation (AF) early and accurately. Risk factors for the development of new-onset AF in patients with CIEDs remains uncertain.

METHODS

Patients with CIEDs who visited Chiba University Hospital between January 2016 and December 2016 were enrolled. We only included patients without single chamber CIEDs or a known history of AF.

RESULTS

Of 371 patients with CIEDs, 78 (21.0%; median age 61.0 years, 65.5% male) developed new-onset AF. Multivariate analysis demonstrated that independent predictors for the development of new or incident AF were age ≥65 years (odd ratio [OR] 2.76, 95% confidence interval [CI] 1.54-4.96, P = 0.001), diabetes mellitus (OR 2.24, 95% CI 1.20-4.19, P = 0.011), congestive heart failure (OR 1.94, 95% CI 1.06-3.54, P = 0.031), and left atrial volume index >34 ml/m² (OR 3.51, 95% CI 1.96-6.25, P < 0.001). Based on these 4 clinical factors (age ≥ 65, diabetes mellitus, congestive heart failure, left atrial volume index > 34 ml/m²) there was a good predictive ability for new AF development (AUC 0.728) and clinically usefulness using decision curve analysis.

CONCLUSIONS

A substantial number of patients with CIEDs develop new-onset AF. Four clinical factors (age ≥ 65, diabetes mellitus, congestive heart failure, left atrial volume index > 34 ml/m²) independently predicted new-onset AF and may provide an approach to clinically useful risk assessment for incident AF.

Silent Cerebral Infarction in East Asian vs. Non-Asian Atrial Fibrillation Patients - Meta-Analysis

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia in the ageing population in East Asia. Silent cerebral infarction (SCI) is defined as cerebral infarction in the absence of corresponding clinical symptoms, and is a highly prevalent and morbid condition in AF. SCI is increasingly being recognized as a risk factor for future stroke, which can lead to cognitive decline or dementia. The latter is an increasingly common health problem in East Asia.Methods and Results:We conducted a meta-analysis to compare the association of AF and SCI between East Asian and non-Asian patients. AF was associated with SCI in patients with no symptomatic stroke history (relative risk [RR], 2.24; 95% CI: 1.26-3.99, I²=83%; P=0.006) although the prevalence varied widely between studies (P for heterogeneity<0.001). In non-Asian patients, the prevalence of SCI in AF is higher than that in controls (RR, 1.85; 95% CI: 1.65-2.08, I²=17%; P<0.001). There was no significant racial difference between Asian and non-Asian studies (P=0.53).

CONCLUSIONS

In East Asia, AF was significantly associated with SCI and no racial difference was seen between East Asian and non-Asian patients. The present findings offer clinicians new insights into the association between AF and SCI.

Usefulness of ultra-high resolution mapping for detecting epicardial atrial activation during mitral isthmus ablation

We describe a patient with perimitral atrial flutter (PMF) following the atrial fibrillation ablation and the linear ablation at the mitral isthmus (MI). From both the activation and the voltage maps using ultra-high resolution mapping, we detected the epicardial connection through the coronary sinus (CS) within the entire reentrant circuit. Point ablation within the CS, not additional linear MI ablation from the endocardium terminates PMF, with a bidirectional block across the low voltage area at the MI.

Clinical Features and Prognosis in Patients with Atrial Fibrillation and Prior Stroke: Comparing the Fushimi and Darlington AF Registries

Background

Ethnic differences in clinical characteristics, stroke risk profiles and outcomes among atrial fibrillation (AF) patients may exist. We therefore compared AF patients with previous stroke from Japan and the United Kingdom (UK).

Methods

We compared clinical characteristics, stroke risk and outcomes among AF patients from the Fushimi AF registry who had experienced a previous stroke (Japan; n = 688; 19.7%) and the Darlington AF registry (UK; n = 428; 19.0%).

Results

AF patients with previous stroke in Fushimi were significantly younger (76.8 and 79.6 years of age in Fushimi and Darlington; p < 0.01) with a lower proportion of females (37.4% vs. 45.1%; p = 0.01) than those from Darlington. Although the CHA₂DS₂-VASc score was lower in AF patients in Fushimi than those in Darlington (5.18 vs. 5.57; p < 0.01), oral anticoagulation (OAC) was prescribed significantly more frequently in Fushimi (68.3%) than Darlington (61.7%) (p = 0.02). Multivariate logistic regression analysis showed that Japanese ethnicity was associated with a significantly decreased risk of recurrent stroke (OR 0.59. 95% CI 0.36–0.97; p = 0.04) but a significantly increased risk of all-cause mortality (OR 1.76, 95% CI 1.18–2.66; p < 0.01) in AF patients with previous stroke.

Conclusions

AF patients with previous stroke in the UK were at higher risk of recurrent stroke compared to Japanese patients, but OAC was utilised less frequently. There was a lower risk of recurrent stroke in the secondary prevention cohort from the Fushimi registry, but an increased risk of all-cause mortality.

•

The UK vs. Japanese AF patients are at higher risk of recurrent stroke.

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OAC are utilised less frequently in the UK than in Japan.

•

Japanese vs. UK AF patients have increased all-cause mortality.

Ethnic differences in clinical characteristics, stroke risk profiles and outcomes among atrial fibrillation (AF) patients may exist. We therefore compared community-based AF patients with a history of previous stroke (i.e. a secondary prevention cohort) from Japan and the United Kingdom (UK). We found that AF patients with previous stroke in the UK were at higher risk of recurrent stroke compared to Japanese patients, but anticoagulation was utilised less frequently. Ethnicity was related to a lower risk of recurrent stroke in the Japanese secondary prevention cohort, but Japanese AF patients had an increased risk of all-cause mortality.

Evaluation of the HAS-BLED, ATRIA, and ORBIT Bleeding Risk Scores in Patients with Atrial Fibrillation Taking Warfarin

OBJECTIVES

Various bleeding risk prediction schemes, such as the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized Ratio, Elderly, Drugs/alcohol (HAS-BLED), Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), and Outcomes Registry for Better Informed Treatment (ORBIT) scores, have been proposed in patients with atrial fibrillation. We compared the relative predictive values of these bleeding risk scores for clinically relevant bleeding and the relationship of ATRIA and ORBIT scores to the quality of anticoagulation control on warfarin, as reflected by time in therapeutic range.

METHODS

We conducted a post hoc ancillary analysis of clinically relevant bleeding and major bleeding events among 2293 patients receiving warfarin therapy in the AMADEUS trial.

RESULTS

Only HAS-BLED was significantly predictive for clinically relevant bleeding, and all 3 risk scores were predictive for major bleeding. The predictive performance of HAS-BLED was modest, as reflected by c-indexes of 0.59 (P < .001) and 0.65 (P < .002) for clinically relevant bleeding and major bleeding, respectively. The HAS-BLED score performed better than the ATRIA (P = .002) or ORBIT (P = .001) score in predicting any clinically relevant bleeding. Only the HAS-BLED score was significantly associated with the risk for both bleeding outcomes on Cox regression analysis (any clinically relevant bleeding: hazard ratio, 1.85; 95% confidence interval, 1.43-2.40, P < .001; major bleeding: hazard ratio, 2.40; 95% confidence interval, 1.28-4.52; P = .007). There were strong inverse correlations of ATRIA and ORBIT scores to time in therapeutic range as a continuous variable (low risk ATRIA, r = -0.96; P = .003; ORBIT, r = -0.96; P = .003). Improvement in the predictive performance for both ATRIA and ORBIT scores for any clinically relevant bleeding was achieved by adding time in therapeutic range to both scores, with significant differences in c-indexes (P = .001 and P = .002, respectively), net reclassification improvement, and integrated discriminant improvement (both P < .001).

CONCLUSIONS

All 3 bleeding risk prediction scores demonstrated modest predictive ability for bleeding outcomes, although the HAS-BLED score performed better than the ATRIA or ORBIT score. Significant improvements in both ATRIA and ORBIT score prediction performances were achieved by adding time in therapeutic range to both scores.

Female Sex, Time in Therapeutic Range, and Clinical Outcomes in Atrial Fibrillation Patients Taking Warfarin

BACKGROUND AND PURPOSE

Female patients have higher risk for stroke than male patients in nonanticoagulated atrial fibrillation patients, but limited data are available on sex differences in stroke and bleeding outcomes among patients with anticoagulated atrial fibrillation on warfarin, especially in relation to quality of anticoagulation control, as reflected by the time in therapeutic range (TTR).

METHODS

We investigated adverse outcomes in females (n=791) and males (n=1501) among 2292 patients with atrial fibrillation taking warfarin arm in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial.

RESULTS

The combined end point of cardiovascular death and stroke/systemic embolism (SSE) was similar in females versus males. There was no sex differences in either cardiovascular death or SSE. Compared with males, females had a lower risk of major bleeding (hazard ratio, 0.39; 95% confidence interval, 0.18-0.87; P=0.02). No differences were seen in mortality and stroke outcomes between females and males either in the prespecified age subgroups or in relation to TTR categories. TTR was negatively correlated with any clinically relevant bleeding in both females (r=-0.86; P=0.03) and males (r=-0.94; P=0.005). On Cox regression, TTR (but not female sex) emerged as an independent predictor for combined cardiovascular death/SSE and clinically relevant bleeding events.

CONCLUSION

Anticoagulated female patients with atrial fibrillation had a similar rate of cardiovascular death and SSE, but a lower risk of major bleeding, compared with males. TTR (but not female sex) was an independent predictor for combined cardiovascular death and SSE and clinically relevant bleeding events.

Major Bleeding in Patients with Non-Valvular Atrial Fibrillation: Impact of Time in Therapeutic Range on Contemporary Bleeding Risk Scores

Bleeding risk represents a major concern in anticoagulated patients with atrial fibrillation (AF). Several bleeding prediction scores have been described: HAS-BLED, ATRIA, HEMORR₂HAGES and ORBIT. Of these, only HAS-BLED considers quality of anticoagulation control amongst vitamin K antagonist (VKA) users. We hypothesised that predictive value of bleeding risk scores other than HAS-BLED could be improved incorporating time in therapeutic range (TTR) in warfarin-treated patients. Of the 127 adjudicated major bleeding events, 21.3% of events occurred in ‘low-risk’ HAS-BLED category (1.8 per 100 patient-years), compared to higher proportions (≥50% of events; ~2.5 per 100 patient-years) in ‘low-risk’ categories for other scores. Only the ‘low-risk’ HAS-BLED category was associated with the absence of investigator-defined major bleeding events (OR: 1.46;95% CI: 1.00–2.15). ‘High’ or ‘medium/high’ risk categories for the HAS-BLED (p = 0.023) or ORBIT (p = 0.022) scores, respectively, conferred significant risk for adjudicated major bleeding events. On Cox regression analysis, adjudicated major bleeding was associated only with HAS-BLED (HR: 1.62;95% CI: 1.06–2.48) and ORBIT (HR: 1.83;95% CI: 1.08–3.09) ‘high-risk’ categories. Adding ‘labile INR’ (TTR < 65%) to ORBIT, ATRIA and HEMORR₂HAGES significantly improved their reclassification and discriminatory performances. In conclusion, HAS-BLED categorised adjudicated major bleeding events in low-risk and high-risk patients appropriately, whilst ORBIT and ATRIA categorised most major bleeds into their ‘low-risk’ patient categories. Adding TTR to ORBIT, ATRIA and HEMORR₂HAGES led to improved predictive performance for major bleeding.

Non-vitamin K antagonist oral anticoagulants (NOACs) in patients with concomitant atrial fibrillation and heart failure: a systemic review and meta-analysis of randomized trials

BACKGROUND

No pooled analysis has been undertaken to assess the efficacy and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) compared with warfarin in the subgroup of patients with atrial fibrillation (AF) and heart failure (HF), including edoxaban data from recent randomized controlled trials (RCTs).

METHODS

Comprehensive literature searches were conducted using the Cochrane Library, MEDLINE, and Scopus databases from inception to April 2015. Statistical analyses were performed using RevMan 5.3 software.

RESULTS

Four RCTs were included: 19 122 of 32 512 AF patients with HF were allocated to a NOAC (13 384 receiving single-/high-dose NOAC regimens), and 13 390 to warfarin. Among AF patients with HF, single/high-dose NOACs significantly reduced the risk of stroke/systemic embolic (SE) events by 14% [odds ratio0.86, 95% confidence interval (CI) 0.76-0.98), and had a 24% lower risk of major bleeding(OR 0.76, 95% CI 0.67-0.86). For low-dose NOAC regimens, comparable efficacy to warfarin for stroke or SE events (OR 1.02, 95% CI 0.86-1.21) and a non-significant trend for lower major bleeding was observed. Regardless of high- or low-dose NOAC, the incidences of both major bleeding and stroke/SE in AF patients with HF were similar to those without HF. Atrial fibrillation patients with HF on NOACs had a 41% lower risk of intracranial haemorrhage compared with those without HF (OR 0.59, 95% CI 0.40-0.87).

CONCLUSION

Among AF patients with HF, single-/high-dose NOAC regimens have a better efficacy and safety profile, but low-dose regimens had similar efficacy and safety to warfarin. NOACs were similarly effective or even safer (less intracranial haemorrhage) in AF patients with HF compared with those without HF.

Relationship of Age With Stroke and Death in Anticoagulated Patients With Nonvalvular Atrial Fibrillation

Background and Purpose—

The prevalence of atrial fibrillation increases with age, but age-specific data on the incidence of stroke and death in anticoagulated patients with atrial fibrillation are more limited, particularly with regard to comparisons of relative risks of clinical outcomes between the different age strata in relation to quality of anticoagulation control among warfarin users.

Methods—

We investigated the incidence of adverse outcomes between tertiles of age groups (age, <67 [n=722]; age, 67–74 [n=747]; and age, ≥75 [n=824]) in 2293 patients with atrial fibrillation participating in warfarin arm in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. The average time in therapeutic range was calculated as a measure of anticoagulation control and related to clinical outcomes.

Results—

Absolute rates for stroke/systemic embolism (SSE), cardiovascular death, or any clinically relevant bleeding increased with increasing age strata. The combined end point of cardiovascular death and SSE was the highest in the top tertile (adjusted hazard ratio, 2.63; 95% confidence interval, 1.23–5.63) compared with the middle and lowest tertiles ( P for trend=0.01). For bleeding, there was no significant difference in relative risks between the age strata ( P for trend=0.55 in the warfarin group and in the warfarin group with time in therapeutic range ≥60%, P for trend=0.60). The quality of anticoagulation control (time in therapeutic range) significantly correlated with any clinically relevant bleeding ( r =−0.91; P <0.001) and cardiovascular death/SSE rates ( r =−0.76; P =0.01).

Conclusions—

Elderly patients with atrial fibrillation have higher absolute risks of cardiovascular death, SSE, and bleeding, but relative risks of clinically relevant bleeding are not significantly different with increasing age strata. A significant inverse relationship between time in therapeutic range and bleeding and cardiovascular death/SSE emphasizes the importance of good quality anticoagulation control.

The CHADS2 and CHA2DS2-VASc scores for predicting ischemic stroke among East Asian patients with atrial fibrillation: A systemic review and meta-analysis

BACKGROUND

Both the CHADS2 and CHA2DS2-VASc scores are well-validated in Western populations for predicting risk of stroke among patients with atrial fibrillation (AF). There is some uncertainty as to which risk score is best to guide optimal anticoagulant therapy among Asian populations with AF.

METHODS

A systemic literature search of Cochrane library, Scopus, and PubMed databases was conducted using search terms: atrial fibrillation, CHADS2 and CHA2DS2-VASc. Stroke/thromboembolism (TE) outcome events at low, moderate, and high risk groups were compared in relation to both scores. Statistical analyses were performed using Revman 5.3 software.

RESULTS

493 records were retrieved, of which 6 cohort studies focusing on patients from Asian regions were finally appraised and included. Absolute event rates were usually lower when patients were categorized as CHA2DS2-VASc of 0-1, rather than CHADS2 of 0-1, respectively. Meta-analysis revealed that when compared with the CHA2DS2-VASc score, there was a 1.71-fold elevated risk of stroke when patients were stratified as 'low risk' using a CHADS2 score = 0, or a 1.40-fold increase with a CHADS2 score = 1. A 1.19-fold elevated event rate was observed among CHADS2 score ≥ 2 compared to CHA2DS2-VASc, but the total stroke/TE events were numerically higher in patients categorized as CHA2DS2-VASc ≥ 2.

CONCLUSION

The CHA2DS2-VASc score is superior to the CHADS2 score in identifying 'low risk' East Asian AF patients. Rather than a categorical approach, Asian guidelines should adopt a 2 step approach, by initially identifying the truly low risk patients, following which effective stroke prevention can be offered to those with ≥ 1 additional stroke risk factors.

Residual Risk of Stroke and Death in Anticoagulated Patients According to the Type of Atrial Fibrillation

Background and Purpose—

Atrial fibrillation (AF) and heart failure frequently coexist and are associated with increased morbidity and mortality. We investigated the prognosis of anticoagulated patients with permanent AF and nonpermanent AF according to preexisting heart failure in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial.

Methods—

The primary outcome was a composite of cardiovascular death and stroke or systemic embolism, analyzed using a Cox proportional hazards model, adjusted for baseline age, sex, diabetes mellitus, hypertension, creatinine, and previous cardiovascular diseases. The median follow-up was 11.6 months (interquartile range, 6.2–15.2).

Results—

Nonpermanent AF was present in 2072 patients (46% of cohort), of which 339 (16%) had preexisting heart failure. A total of 2484 patients had permanent AF (54% of cohort), with a higher burden of heart failure including 730 patients (29%; P <0.001). Overall, death because of cardiovascular causes occurred in 57 patients and 45 had stroke or systemic embolism (1.4/100 person-years for each). Overall, the adjusted incidence of the composite outcome was higher in patients with permanent AF than in patients with nonpermanent AF. In multivariate analysis, permanency of AF, creatinine, prior cerebrovascular events, and previous coronary disease were independently associated with the primary outcome. The hazard ratio for permanent versus nonpermanent AF was 1.68 (95% confidence interval, 1.08–2.55; P =0.02). The presence of heart failure increased the risk of adverse outcomes in a similar way in both permanent and nonpermanent AF (interaction P value=0.76).

Conclusions—

The risk of cardiovascular death, stroke, or systemic embolism is higher in anticoagulated patients with permanent AF than in those with nonpermanent AF, regardless of preexisting heart failure.

Asymptomatic versus symptomatic atrial fibrillation: A systematic review of age/gender differences and cardiovascular outcomes

Up to 40% of atrial fibrillation (AF) patients are asymptomatic. Despite this, scarce data are available about asymptomatic AF, with regard to its clinical profile and relationship to cerebrovascular and cardiovascular risks. Our objective was to conduct a systematic review and meta-analysis was to study the relationship between age and gender with asymptomatic AF and to establish whether patients with asymptomatic AF have a higher risk of death (all-cause and cardiovascular) and stroke/systemic thromboembolism, when compared to symptomatic AF patients. After a comprehensive search, 6 studies (2 randomized clinical trials and 4 observational studies) were entered in the meta-analysis. Despite significant heterogeneity, our data show that the prevalence of females amongst asymptomatic AF group was significantly less compared to the symptomatic AF group (RR, 0.57; 95% CI: 0.52-0.64). No difference in age between asymptomatic and symptomatic AF patients (P=0.72) was seen. No differences were found in all-cause death between patients with asymptomatic and symptomatic AF (RR, 1.38; 95% CI: 0.82-2.17), nor in cardiovascular death (RR, 0.85; 95% CI: 0.53-1.36) or stroke/thromboembolism (RR, 1.72 95% CI: 0.59-5.08). Asymptomatic AF is more associated with male sex, irrespective of age. Both general and cardiovascular death risks as well as thromboembolic risk do not seem to be affected by the asymptomatic clinical status. Symptomatic status should not determine our approach to stroke prevention and other cardiovascular prevention therapies, amongst patients with AF.