Adherence to oral anticoagulation measured by electronic monitoring in a Belgian atrial fibrillation population

INTRODUCTION

Stroke prevention using oral anticoagulation (OAC) is the first management priority in atrial fibrillation (AF). Despite the importance of good therapy adherence, real-world adherence is still suboptimal. Patient education and adherence monitoring with new technologies are recommended. The main purpose of this sub-analysis of the AF-EduCare trial was to evaluate the effect of personalized follow-up strategies on adherence to OAC.

METHODS

Regimen adherence was monitored by the electronic Medication Event Monitoring System cap at the start of the trial (M1) and after 12 months (M2), each for three months. Patients were part of one of three education groups (In-person, Online or App-based) or the standard care (SC) group. All are qualified for OAC therapy.

RESULTS

A total of 768 patients were evaluated (11.8% SC vs. 86.8% any education group, mean age: 70.1 ± 7.9 years). Patients were taking non-vitamin K OAC (once daily 53.8%; twice daily 35.9%) or vitamin K antagonists (9.4%), equally distributed over the different study arms (p = 0.457). Mean therapy adherence was high (M1:93.8 ± 10.8%; M2:94.1 ± 10.1%). During both monitoring periods, the education group scored significantly higher than SC (M1:94.2 ± 10.0% vs. 91.3 ± 15.0%; p = 0.027; M2:94.4 ± 9.3% vs. 91.6 ± 14.0%; p = 0.006). More patients in the In-person and Online groups were able to keep or improve their adherence to > 90% compared to the SC.

CONCLUSION

Overall adherence to OAC in all study groups, even in SC, was very high, without attrition over time. Nevertheless, targeted education led to a small but significantly improved adherence compared to SC.

Engagement of atrial fibrillation patients with the AF-EduApp, a new mobile application to support AF management

Introduction

A multidisciplinary approach is needed for the management of atrial fibrillation (AF) in which the patient has a central role. Smart devices create opportunities to improve AF management. This paper aimed to evaluate the in-house developed AF-EduApp application on its usability, satisfaction, and communication effectiveness with the care team.

Methods

During a multicenter, prospective randomized controlled trial, 153 AF patients were included in the AF-EduApp study, with a minimum follow-up of 12 months and a maximum follow-up of 15 months if taking oral anticoagulation (OAC). The AF-EduApp contains six main modules: Questionnaires, Education, Measurement data entry, Medication overview with reminders, Appointments, and Communication with the care team. The App focuses on four main goals: (1) to improve AF knowledge, (2) to increase self-care capabilities, (3) electronic monitoring to improve therapy adherence to OAC, and (4) communication with the care team. Patients unable to use the AF-EduApp were assigned to a no-App control group (n = 41) without intervention comparable to the standard care group (SC, n = 346) of the AF-EduCare study.

Results

A total of 152 patients effectively used the App during a mean follow-up of 386.8 ± 108. 1 days (one included patient could not install the application due to an iPhone from the United States). They opened the application on average on 130.1 ± 144.7 days. Of the 109 patients still in follow-up after 12 months (i.e. patients who did not withdraw and on OAC), 90 patients (82.6%) actively used the application at least one day in the next 41 days. The Measurement module was the most used, with a median of used days over the total available days of 6.4%. A total of 75 App patients (49.3%) asked questions, mostly clinical-related questions (e.g. medication use, or actionability on clinical entered parameters). A mean score of 8.1 ± 1.7 about the "perceived quality of follow-up in the past year" was given by the App ITT patients, compared to a score of 7.7 ± 2.0 by the SC group (P = .072). Patients who used the App were more attracted to future follow-up with an application compared to patients who would be capable of using the application of the SC group (31.6% vs. 12.5%; P < .001).

Conclusion

This study showed a positive attitude towards using a mobile application, with AF patients using the application one-third of the available days. Patients used the App most for entering measured parameters, and to contact the care team.

The digital journey: 25 years of digital development in electrophysiology from an Europace perspective

AIMS

Over the past 25 years there has been a substantial development in the field of digital electrophysiology (EP) and in parallel a substantial increase in publications on digital cardiology.In this celebratory paper, we provide an overview of the digital field by highlighting publications from the field focusing on the EP Europace journal.

RESULTS

In this journey across the past quarter of a century we follow the development of digital tools commonly used in the clinic spanning from the initiation of digital clinics through the early days of telemonitoring, to wearables, mobile applications, and the use of fully virtual clinics. We then provide a chronicle of the field of artificial intelligence, a regulatory perspective, and at the end of our journey provide a future outlook for digital EP.

CONCLUSION

Over the past 25 years Europace has published a substantial number of papers on digital EP, with a marked expansion in digital publications in recent years.

Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation

AIMS

Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD is recognized as a risk factor for AF, practical guidance about how and when to screen for COPD is not available. Herein, we describe the implementation of an integrated screening and management pathway for COPD into the existing pre-ablation work-up in an AF outpatient clinic infrastructure.

METHODS AND RESULTS

Consecutive unselected patients accepted for AF catheter ablation in the Maastricht University Medical Center+ were prospectively screened for airflow limitation using handheld (micro)spirometry at the pre-ablation outpatient clinic supervised by an AF nurse. Patients with results suggestive of airflow limitation were offered referral to the pulmonologist. Handheld (micro)spirometry was performed in 232 AF patients, which provided interpretable results in 206 (88.8%) patients. Airflow limitation was observed in 47 patients (20.3%). Out of these 47 patients, 29 (62%) opted for referral to the pulmonologist. The primary reason for non-referral was low perceived symptom burden. Using this screening strategy 17 (out of 232; 7.3%) ultimately received a diagnosis of chronic respiratory disease, either COPD or asthma.

CONCLUSION

A COPD care pathway can successfully be embedded in an existing AF outpatient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although one out of five patients had results suggestive of an underlying chronic respiratory disease, only 62% of these patients opted for a referral. Pre-selection of patients as well as patient education might increase the diagnostic yield and requires further research.

An instrument to measure atrial fibrillation knowledge in Chinese patients: validation of the Jessa Atrial fibrillation Knowledge Questionnaire

Background: There is no validated tool to assess patients' knowledge of oral anticoagulant therapy in atrial fibrillation in China. Methods: Using a standard translation program, the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) was translated into Chinese. The reliability of the JAKQ was assessed by internal consistency (Cronbach's α coefficient), repeatability (test-retest reliability), and sensitivity tests. Effectiveness was assessed by hypothesizing that a lower JAKQ score was a risk factor for bleeding. A total of 447 patients with atrial fibrillation (AF) who were hospitalized between July 2019 and December 2021 were studied and followed up. Participants were followed up 1, 3, 6, and 12 months after enrollment. Bleeding during follow-up was recorded. Data were obtained from hospital databases and telephone follow-up. Result: A total of 447 patients with AF completed JAKQ. The mean age of patients was 67.7 ± 10.2 years. The median JAKQ score was 31.3% (12.5-43.8). The Cronbach's α coefficient of JAKQ was 0.616-0.637, and the test-retest reliability value was 0.902 (p < 0.001). Multivariate logistic regression showed that the higher knowledge level of AF was associated with secondary education or above, an income of more than 2000 yuan, and a history of AF of more than 1 year. Bleeding was associated with a lower JAKQ score, hypertension, and a history of bleeding. Non-bleeding patients on VKA had a better understanding of how often INR should be monitored and what to do if an OAC dose was missed. Conclusion: The Chinese version of JAKQ shows good reliability and validity, indicating that it is a valuable tool for AF and oral anticoagulation (OAC) knowledge assessment. It can be used in clinical practice to guide educational activities and improve the effectiveness and safety of treatment. It was shown that Chinese patients with AF have insufficient knowledge about AF and OAC. Lower JAKQ scores are associated with bleeding, so targeted education is necessary. Targeted educational efforts should focus on patients recently diagnosed with AF and those with lower formal education and income.

Baseline demographics of a contemporary Belgian atrial fibrillation cohort included in a large randomised clinical trial on targeted education and integrated care (AF-EduCare/AF-EduApp study)

Background

As the prevalence of atrial fibrillation (AF) increases worldwide and AF management becomes ever more diversified and personalised, insights into (regional) AF patient demographics and contemporary AF management are needed. This paper reports the current AF management and baseline demographics of a Belgian AF population recruited for a large multicenter integrated AF study (AF-EduCare/AF-EduApp study).

Methods

We analyzed data from 1,979 AF patients, assessed between 2018 and 2021 for the AF-EduCare/AF-EduApp study. The trial randomised consecutive patients with AF (irrespective of AF history duration) into three educational intervention groups (in person-, online-, and application-based), compared with standard care. Baseline demographics of both the included and excluded/refused patients are reported.

Results

The mean age of the trial population was 71.2 ± 9.1 years, with a mean CHA₂DS₂-VASc score of 3.4 ± 1.8. Of all screened patients, 42.4% were asymptomatic at presentation. Being overweight was the most common comorbidty, present in 68.9%, while 65.0% were diagnosed with hypertension. Anticoagulation therapy was prescribed in 90.9% of the total population and in 94.0% of the patients with an indication for thromboembolic prophylaxis. Of the 1,979 assessed AF patients, 1,232 (62.3%) were enrolled in the AF-EduCare/AF-EduApp study, with transportation problems (33.4%) as the main reason for refusal/non-inclusion. About half of the included patients were recruited at the cardiology ward (53.8%). AF was first diagnosed, paroxysmal, persistent and permanent in 13.9%, 47.4%, 22.8% and 11.3%, respectively. Patients who refused or were excluded were older (73.3 ± 9.2 vs. 69.8 ± 8.9 years, p < 0.001) and had more comorbidities (CHA₂DS₂-VASc 3.8 ± 1.8 vs. 3.1 ± 1.7, p < 0.001). The four AF-EduCare/AF-EduApp study groups were comparable across the vast majority of parameters.

Conclusions

The population showed high use of anticoagulation therapy, in line with current guidelines. In contrast to other AF trials about integrated care, the AF-EduCare/AF-EduApp study managed to incorporate all types of AF patients, both out-patient and hospitalised, with very comparable patient demographics across all subgroups. The trial will analyze whether different approaches to patient education and integrated AF care have an impact on clinical outcomes.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT03707873?term=af-educare&draw=2&rank=1, identifier: NCT03707873; https://clinicaltrials.gov/ct2/show/NCT03788044?term=af-eduapp&draw=2&rank=1, identifier: NCT03788044.

Multimorbid management in atrial fibrillation: The Polish perspective in the EHRA-PATHS study

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and places a significant burden on individuals as well as the healthcare system. AF management requires a multidisciplinary approach in which tackling comorbidities is an important aspect.

AIMS

To evaluate how multimorbidity is currently assessed and managed and to determine if interdisciplinary care is undertaken.

METHODS

A 21-item online survey was undertaken over four weeks as part of the EHRA-PATHS study examining comorbidities in Atrial Fibrillation and distributed to European Heart Rhythm Association members in Europe.

RESULTS

A total of 341 eligible responses were received of which 35 (10%) were from Polish physicians. Compared to other European locations, the rates of specialist services and referrals varied but were not significantly different. However, there were higher numbers of specialised services reported in Poland compared to the rest of Europe for hypertension (57% vs. 37%; P = 0.02) and palpitations/arrhythmias (63% vs. 41%; P = 0.01) and the rates of sleep apnea services tended to be lower (20% vs. 34%; P = 0.10) and comprehensive geriatric care (14% vs. 36%; P = 0.01). The only statistical difference between Poland and the rest of Europe in reasons for referral rates was the barrier relating to insurance and financial reasons (31% vs. 11%; P <0.01, respectively).

CONCLUSIONS

There is a clear need for an integrated approach to patients with AF and associated comorbidities. Prepardeness of Polish physicians to deliver such care seems to be similar to other European countries but may be hampered by financial obstacles.

Assessment of functionalities and attitude toward telemedicine for patients with cardiovascular disease

Introduction

Many patients with cardiovascular diseases are only seen by a physician once or twice a year unless urgent symptoms. Recent years have shown an increase in digital technologies to follow patients remotely, that is, telemedicine. Telemedicine can be supportive for follow-up of patients at continuous risk. This study investigated patients' attitude toward telemedicine, the defined features they consider important and future willingness to pay.

Methods

Cardiology patients with various types of prior telemedicine follow-up or who never had a telemonitoring follow-up were included. A new self-developed survey was implemented electronically and took 5-10 min to complete.

Results

In total, 231 patients (191 telemedicine [T] and 40 controls [C]), were included. Most participants owned a smartphone (84.8%) and only 2.2% of the total participants did not own any digital device. The most important feature of telemedicine cited in both groups was personalization (i.e., personalized health tips based on medical history, 89.6%; personalized feedback on entered health parameters 86.1%). The most important motivating factor for the use of telemedicine is recommendation by a physician (84.8%), while the reduction of in-person visits is a minor reason (24.7%). Only half of the participants (67.1%) would be willing to pay for telemedicine tools in the future.

Conclusion

Patients with cardiovascular disease have a positive attitude to telemedicine, especially when it allows for more personalized care, and when it is advocated by the physician. Participants expect that telemedicine becomes part of reimbursed care. This calls for interactive tools with proven efficacy and safety, while guarding unequal access to care.

General practitioners' perceptions on opportunistic single-time point screening for atrial fibrillation: A European quantitative survey

Background

There is no clear guidance on how to implement opportunistic atrial fibrillation (AF) screening in daily clinical practice.

Objectives

This study evaluated the perception of general practitioners (GPs) about value and practicalities of implementing screening for AF, focusing on opportunistic single-time point screening with a single-lead electrocardiogram (ECG) device.

Methods

A descriptive cross-sectional study was conducted with a survey developed to assess overall perception concerning AF screening, feasibility of opportunistic single-lead ECG screening and implementation requirements and barriers.

Results

A total of 659 responses were collected (36.1% Eastern, 33.4% Western, 12.1% Southern, 10.0% Northern Europe, 8.3% United Kingdom & Ireland). The perceived need for standardized AF screening was rated as 82.7 on a scale from 0 to 100. The vast majority (88.0%) indicated no AF screening program is established in their region. Three out of four GPs (72.1%, lowest in Eastern and Southern Europe) were equipped with a 12-lead ECG, while a single-lead ECG was less common (10.8%, highest in United Kingdom & Ireland). Three in five GPs (59.3%) feel confident ruling out AF on a single-lead ECG strip. Assistance through more education (28.7%) and a tele-healthcare service offering advice on ambiguous tracings (25.2%) would be helpful. Preferred strategies to overcome barriers like insufficient (qualified) staff, included integrating AF screening with other healthcare programs (24.9%) and algorithms to identify patients most suitable for AF screening (24.3%).

Conclusion

GPs perceive a strong need for a standardized AF screening approach. Additional resources may be required to have it widely adopted into clinical practice.

The challenge of managing multimorbid atrial fibrillation: a pan-European European Heart Rhythm Association (EHRA) member survey of current management practices and clinical priorities

As part of the EHRS-PATHS study examining comorbidities in atrial fibrillation (AF) across Europe, the aim was (i) to evaluate how multimorbidity is currently addressed by clinicians during AF treatment to characterize the treatment structure and (ii) to assess how the interdisciplinary management of multimorbid AF is currently conducted. An online survey was distributed among European Heart Rhythm Association (EHRA) members in Europe that included 21 questions and a free-text option for comments on detection, assessment, and management of AF-related comorbidities. A total of 451 responses were received with 339 responses eligible for inclusion. Of these, 221 were male (66%), 300 (91.5%) were physicians, and 196 (57.8%) were working in academic university teaching hospitals. Half of the respondents managed between 20 and 50 patients per month with multimorbid AF. Varying rates of specialist services and referral to these services were available at each location (e.g. heart failure and diabetes), with a greater number of specialist services available at academic university teaching hospitals compared with non-teaching hospitals [e.g. anticoagulation clinic 92 (47%) vs. 50 (35%), P < 0.03]. Barriers to referring to specialist services for AF comorbidities included lack of integrated care model (n = 174, 51%), organizational or institutional issues (n = 145, 43%), and issues with patient adherence (n = 126, 37%), highlighting the need for organizational restructuring and developing an integrated collaborative evidenced-based approach to multimorbid AF care. The survey and analyses of free-text comments demonstrated the need for systematic, integrated management of AF-related comorbidities, and these results will inform the next phases of the EHRA-PATHS study.

A new mobile smartphone application, AF-EduApp, for atrial fibrillation patients: what do they use most?

Background

The management of atrial fibrillation (AF) is complex and based on three main pillars: avoid stroke, better symptom control and cardiovascular risk factor management. Therefore, a holistic, multidisciplinary approach is needed in which the patient has a central role. Smartphone ownership increases strongly in the elderly population (in Belgian 65+ years old: 52% in 2018 to 82% in 2020). This digital growth creates opportunities for a closer patient follow-up. An in-house developed application, AF-EduApp, focused on delivering targeted education and guiding self-care, has been validated and is currently being studied in an ongoing clinical trial.

Purpose

Intermediate analysis of the user data of AF-EduApp.

Methods

At two Belgian hospitals, an open, prospective, randomized trial is currently performed. A total of 153 AF patients hospitalized or seen at an out-patient visit were included. Patients could use the application during a follow-up of 12 months. The AF-EduApp consists of six different modules: education, questionnaires with immediate patient feedback, medication overview with reminders, measurements (e.g. blood pressure, heart rate), appointments, and the possibility to ask questions to the caregivers. Knowledge about AF and its treatment was tested through the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) with feedback on incorrectly answered questions. The main aim of the AF-EduApp is to improve patients' medication adherence through improved education and medication reminders.

Results

Currently, a total of 132 patients have completed a follow-up of 12 months (follow-up days: mean 357.3±60.7 and median: 365.5 [350.3–382.0]). The app was used on average 122.5±126.6 days (median: 55.0 [23.3–241.0]), or 34.3% of the available days. As shown in Fig. 1, the measurements and medication modules were the most used module (on 66.1% resp. 55.2% of the days). The education module was the least used module (3.5% of the days); the average education time was 17.0±27.7 min (median: 6.1 [1.4–20.6]). Within the measurement module (mean: 80.9±109.4 days used), the most frequently entered parameter was blood pressure, with on average 208.3±351.3 entries (median: 53.5 [7.0–296.3]) (Fig. 2). AF episodes was the least entered data (average 37.0±185.0 times; median 8.0 [4.0–19.0.3]).

Conclusion

Patients actively engaged with an educational smartphone AF application on 1/3th of the available days. The measurement module was the most used (to enter health data) together with the medication module (to confirm intake after reminder). It shows that many patients appreciate the mHealth tool to “connect” with their condition. The clinical trial tries to answer whether such increasing interaction leads to improved self-management and outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The AF-EduApp study is supported by an BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA) grant.

Time investments and questions raised by atrial fibrillation patients following a personalized educational follow-up strategy

Background

Atrial fibrillation (AF) has a complex treatment strategy. As stated in the recent guidelines for AF management, AF management requires a holistic and multidisciplinary approach in which a personalized follow-up strategy is important to involve patients in their care. This also includes the need for an improved communication method in which patients can contact the healthcare team between in-hospital follow-up moments to easily ask questions with a low threshold.

Purpose

Two personalized follow-up methods for AF management (in-person and online) are currently being studied in a prospective, randomized controlled trial. The aim of this subanalysis is to evaluate time investment to answer patients' questions.

Methods

At three Belgian hospitals, a total of 1.038 AF patients were randomized to two groups with personalized education and follow-up, and a control group. The educational intervention focuses on four elements: improving patients' AF knowledge, improving OAC therapy adherence, encouraging self-care capabilities based on personal AF risk factors, and the reachability of an AF specialized team. Patients in the in-person group were followed personally at the hospital at regular time points, while the patients in the online group received education via an online platform. During the whole follow-up period, patients of both intervention groups could ask questions via e-mail or by phone contact.

Results

A total of 628 questions were raised by 275 patients (137 in-person and 138 online patients) with a mean number of 4.85±2.57 questions per patient. Patients in the online group had a trend towards asking more questions than the in-person group (2.46±2.08 vs. 2.11±1.74; p=0.061). However, there was no significant difference when looking at medical questions (online 2.12±1.80; in-person 2.16±2.42; p=0.55). In both groups, most questions were asked by phone contact (in-person: 72%; online: 51%; Fig. 1, red bars), although significantly less by the online group (p&lt;0.001). In the in-person group, most questions were related to their study visit appointments (27.3%), symptoms (23.9%) and medication (23.2%). In the online group, most questions were related to the online platform (38.9%), symptoms (16.5%) and medication (11.2%). The research team spent on average 7.37±8.18 minutes to answer a question. There was a significant difference in duration to answer questions of the specific categories (p&lt;0.001, Fig, 2). The top three categories on which the most time was spent were questions about symptoms (14.94±12.455 min), treatment and clinical investigations (9.29±7.9 min) and follow-up of clinical parameters (6.94±5.79 min).

Conclusion

A personalized educational follow-up method includes the possibility for patients to ask questions if needed. Most questions are related to AF symptoms and treatment. This indicates that a specialized AF team can be supportive in the management of AF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The AF-EduCare study is a project supported by the Fund for Scientific Research, Flanders (T002917N).

Patient motivation and adherence to an on-demand app-based heart rate and rhythm monitoring for atrial fibrillation management: data from the TeleCheck-AF project

AIMS

The aim of this TeleCheck-AF sub-analysis was to evaluate motivation and adherence to on-demand heart rate/rhythm monitoring app in patients with atrial fibrillation (AF).

METHODS AND RESULTS

Patients were instructed to perform 60 s app-based heart rate/rhythm recordings 3 times daily and in case of symptoms for 7 consecutive days prior to teleconsultation. Motivation was defined as number of days in which the expected number of measurements (≥3/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period.Data from 990 consecutive patients with diagnosed AF [median age 64 (57-71) years, 39% female] from 10 centres were analyzed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 28% of the study population and had a lower percentage of recordings in sinus rhythm [90 (53-100%) vs. 100 (64-100%), P < 0.001] compared with others. Older age and absence of diabetes were predictors of both optimal motivation and adherence [odds ratio (OR) 1.02, 95% coincidence interval (95% CI): 1.01-1.04, P < 0.001 and OR: 0.49, 95% CI: 0.28-0.86, P = 0.013, respectively]. Patients with 100% motivation also had ≥100% adherence. Independent predictors for optimal adherence alone were older age (OR: 1.02, 95% CI: 1.00-1.04, P = 0.014), female sex (OR: 1.70, 95% CI: 1.29-2.23, P < 0.001), previous AF ablation (OR: 1.35, 95% CI: 1.03-1.07, P = 0.028).

CONCLUSION

In the TeleCheck-AF project, more than one-fourth of patients had optimal motivation and adherence to app-based heart rate/rhythm monitoring. Older age and absence of diabetes were predictors of optimal motivation/adherence.

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.

Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference

Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.

Which educational follow-up method do atrial fibrillation patients prefer: in-person, online or app-based education?

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The AF-EduCare study is a project supported by the Fund for Scientific Research, Flanders (T002917N). The AF-EduApp study is supported by an BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA) grant.

Background

Atrial fibrillation (AF) is a common cardiac arrhythmia with a complex treatment strategy based on three pillars: anticoagulation, rate and rhythm control, and risk factor management. Compliance with these pillars leads to improved outcomes. Patient education and involvement are fundamental to optimize AF patients’ care. There is a need for new strategies to involve patients in their care and raise their awareness of their condition.

Purpose

We are studying three personalized follow-up methods for AF management and wanted to evaluate patients’ preference.

Methods

An open, prospective, randomized trial is currently performed at three Belgian hospitals. A total of 1.232 AF patients hospitalized or coming for an out-patient visit were included and randomized to a control group or three education groups: in-person, online or app-based education. The educational intervention focuses on four elements: Improving patients’ knowledge about AF, highlighting the importance of OAC adherence using electronic tools, improving self-care capabilities based on their AF risk factors, and reachability of an AF specialized team. Patients in the in-person group were followed personally at the hospital, while the patients in the online and app group received education via an online platform or mobile application, respectively. Patients were followed up for at least 12 months, at which they received a questionnaire to assess their satisfaction about the educational intervention.

Results

On-treatment analyses were performed for 643 patients (292 in-person, 233 online, 118 app-based). When asked for a general score (on ten) to describe their appreciation of the educational intervention, in-person education scored significantly higher (in-person: 8.75±1.25; online: 8.30±1.55; app: 8.10±1.69; p&lt;0.001). Evaluating which follow-up method(s) they would prefer for the future, in-person scored highest (Fig 1), still there was a clear appreciation for the approach they had received in the year before: online scored higher in the online group than in the other groups (in-person: 12.8%; online: 19.9%; app: 10.5%; p=0.023) and app-based higher in the app-group than in the other groups (in-person: 11.5%; online: 13.3%; app: 32.6%; p&lt;0.001). Moreover, most patients in all groups were satisfied with the answers given to their questions (in-person: 91.6%; online: 89.1%; app: 96.6%; p=0.059) and acknowledged that they had learned more about AF due to the extra education (in-person: 84.2%; online: 85.8%; app: 89.7%; p=0.345). The educational effort improved their motivation to be aware of, and be involved in their health, most significantly in the app group (in-person: 75.4%; online: 77.0%, app: 87.2%; p=0.021).

Conclusion

AF patients are satisfied about additional educational follow-up in general. Despite new electronic tools and the need to come to the hospital, in-person education is subjectively still the preferred modality.

Feasible approaches and implementation challenges to atrial fibrillation screening: a qualitative study of stakeholder views in 11 European countries

OBJECTIVES

Atrial fibrillation (AF) screening may increase early detection and reduce complications of AF. European, Australian and World Heart Federation guidelines recommend opportunistic screening, despite a current lack of clear evidence supporting a net benefit for systematic screening. Where screening is implemented, the most appropriate approaches are unknown. We explored the views of European stakeholders about opportunities and challenges of implementing four AF screening scenarios.

DESIGN

Telephone-based semi-structured interviews with results reported using Consolidated criteria for Reporting Qualitative research guidelines. Data were thematically analysed using the framework approach.

SETTING

AF screening stakeholders in 11 European countries.

PARTICIPANTS

Healthcare professionals and regulators (n=24) potentially involved in AF screening implementation.

INTERVENTION

Four AF screening scenarios: single time point opportunistic, opportunistic prolonged, systematic single time point/prolonged and patient-led screening.

PRIMARY OUTCOME MEASURES

Stakeholder views about the challenges and feasibility of implementing the screening scenarios in the respective national/regional healthcare system.

RESULTS

Three themes developed. (1) Current screening approaches: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity. (2) Feasibility of screening: single time point opportunistic screening in primary care using single-lead ECG devices was considered the most feasible. Software algorithms may aid identification of suitable patients and telehealth services have potential to support diagnosis. (3) Implementation requirements: sufficient evidence of benefit is required. National screening processes are required due to different payment mechanisms and health service regulations. Concerns about data security, and inclusivity for those without primary care access or personal devices must be addressed.

CONCLUSIONS

There is an overall awareness of AF screening. Opportunistic screening appears the most feasible across Europe. Challenges are health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit and a tailored approach adapted to national realities.

European survey on general practitioners’ perceptions on opportunistic single time point screening for atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This study falls within the AFFECT-EU project, which has received funding from the European Union’s Horizon 2020 research and innovation Programme under grant agreement No 847770.

Background

Opportunistic screening for atrial fibrillation (AF) by pulse taking or electrocardiogram (ECG) rhythm strip is recommended by the European Society of Cardiology (ESC) in all patients ≥65 years. Systematic ECG screening should be considered to detect AF in individuals above 75 years, or those at high risk of stroke. There is no clear guidance on how to implement opportunistic or systematic AF screening in daily clinical practice.

Purpose

This study evaluated the perception of general practitioners (GPs) in Europe concerning value and practicalities to implement AF screening in daily clinical practice, focussing on opportunistic single time point screening.

Methods

A descriptive cross-sectional study was conducted with a survey developed to assess (1) the overall perception concerning AF screening, (2) feasibility of opportunistic single lead ECG screening and (3) implementation requirements and barriers. This questionnaire was validated for its content during various iterations by experts in the field. The dissemination of the survey aimed to reach mainly GPs and was carried out through contacting GP organizations and personal GP networks. Results presented here were collected between July and mid-December 2021.

Results

A total of 414 responses were collected (45.0% Eastern, 21.3% Central, 15.0% Northern, 12.8% Western, 5.3% Southern Europe and 0.7% outside Europe). The need for standardised AF screening was rated as 83.2 on a scale from 0 to 100, which was almost as high as for colon (85.6), breast (86.1) and cervical (89.2) cancers. The vast majority (88.6%) indicated that no AF screening programme is established in their region, and three out of four GPs (72.7%, lowest in Eastern and Southern Europe) were equipped with a 12-lead ECG, while a single lead ECG was less common (16.2%, highest in West Europe). Nevertheless, three in five GPs (59.2%) stated that they would feel confident in ruling out AF on a 30-second single lead ECG rhythm strip. To improve their confidence, 31.2% of GPs indicated that more education on ECG in general would be helpful, 25.7% would consider a standardised follow-up pathway with the possibility of a quick referral to the cardiologist of added value, and 22.4% would perceive a tele-healthcare service with advice on ECG tracings as helpful. The main obstacles reported by GPs to implement opportunistic single lead ECG screening were diverse (Figure 1) and several strategies were proposed to overcome these barriers (Figure 2).

Conclusions

Despite the absence of a standardised AF screening programme, there is a strong perceived need for an evidenced based approach. To implement AF screening in clinical practice, integration with other healthcare programmes and software systems with algorithms to identify patients suitable for screening would be helpful.

Adherence to oral anticoagulation in a Belgium atrial fibrillation population measured by a medical event monitoring system

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The AF-EduCare study is a project supported by the Fund for Scientific Research, Flanders (T002917N). The AF-EduApp study is supported by an BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA) grant.

Background

Treatment with oral anticoagulation (OAC) is one of the main pillars in the management of atrial fibrillation (AF). Therapy adherence to both VKA and NOAC is important. Education and intake monitoring are recommended to improve therapy adherence.

Purpose

The main purpose of this project was to evaluate the effect of personalized follow-up strategies on therapy adherence to OAC in AF patients.

Methods

In a multicentre, Belgian randomized controlled trial, the AF-EduCare/AF-EduApp study, the effect of different personalized education strategies (i.e. in-person, online or app-based education) is evaluated on clinical outcome parameters of AF patients compared to standard care (SC). One of the outcome parameters is therapy adherence to OAC. During the first 3 months of the trial, patients’ adherence to NOAC or VKA was measured with the Electronic Medication Event Monitoring System (MEMS). The MEMS cap fits on a medication bottle and registers the date and time of every bottle opening. Regimen adherence was defined as the the number of days with the correct number of openings according to the specific OAC regimen divided by the total number of monitored days. As dabigatran has to be stored in the original package to protect it from moisture and VKAs have a variable scheme between patients, a proxy-medication (i.e. another oral drug that needed to be taken once or twice daily and on the same moment of the day as dabigatran or VKA) was chosen to measure medication adherence. Patients in the education groups received a MEMS cap with LCD screen providing direct feedback by showing the number of openings within 24h. A small sample of the SC group also received a MEMS cap as controls, but without LCD screen to minimally trigger these patients.

Results

A total of 593 AF patients underwent adherence monitoring, of which 514 (86.7%) in the intervention group and 79 (13.3%) in the SC group. The mean age was 70.1±7.7 years, mean time since AF diagnosis was 5.8±6.9 years, and mean CHA2DS2-VASc score was 3.2±1.5. Overall adherence was high: 94.8% of the patients had an adherence &gt;80% and 80.9% had an adherence &gt;90%. A small but significant difference in adherence was observed between the intervention groups and the standard care group (intervention group 97% (5-100); SC 96%(24-100); p=0.024; Figure1). Also between the four study groups a significant difference was seen (in-person 97% (93.5-99); online 98% (94-100); app-based 98% (92-99); p=0.049) driven by a significant difference between the online and SC group (p=0.009).

Conclusion

Overall adherence to OAC in all study groups and even in SC was high. The high adherence percentage in the SC group could be related to the Hawthorne effect of using the MEMS. Nevertheless, electronic monitoring and targeted education slightly improved therapy adherence further in the intervention groups.

Cardiorespiratory Polygraphy for Detection of Obstructive Sleep Apnea in Patients With Atrial Fibrillation

Background: Obstructive sleep apnea (OSA) is a modifiable risk factor of atrial fibrillation (AF) but is underdiagnosed in these patients due to absence of good OSA screening pathways. Polysomnography (PSG) is the gold standard for diagnosing OSA but too resource-intensive as a screening tool. We explored whether cardiorespiratory polygraphy (PG) devices using an automated algorithm for Apnea-Hypopnea Index (AHI) determination can meet the requirements of a good screening tool in AF patients.

Methods: This prospective study validated the performance of three PGs [ApneaLink Air (ALA), SOMNOtouch RESP (STR) and SpiderSAS (SpS)] in consecutive AF patients who were referred for PSG evaluation. Patients wore one of the three PGs simultaneously with PSG, and a different PG during each of three consecutive nights at home. Severity of OSA was classified according to the AHI during PSG (<5 = no OSA, 5–14 = mild, 15–30 = moderate, >30 = severe).

Results: Of the 100 included AF patients, PSG diagnosed at least moderate in 69% and severe OSA in 33%. Successful PG execution at home was obtained in 79.1, 80.2 and 86.8% of patients with the ALA, STR and SpS, respectively. For the detection of clinically relevant OSA (AHI ≥ 15), an area under the curve of 0.802, 0.772 and 0.803 was calculated for the ALA, STR and SpS, respectively.

Conclusions: This study indicates that home-worn PGs with an automated AHI algorithm can be used as OSA screening tools in AF patients. Based on an appropriate AHI cut-off value for each PG, the device can guide referral for definite PSG diagnosis.

Performance of an artificial intelligence algorithm to detect atrial fibrillation on a 24-hour continuous photoplethysmography recording using a smartwatch: ACURATE study

Background

In the awakening era of mobile health, wearable devices capable of detecting atrial fibrillation (AF) are on the rise. Smartwatches and wristbands are equipped with photoplethysmography (PPG) technology that enables (semi)continuous rhythm monitoring. These devices have been pioneered already in a few screening trials. However, such devices are being spread among consumers at a pace that is not paralleled by the evidence supporting their clinical performance. This imbalance reflects the urgent need for validation studies.

Purpose

To determine the diagnostic performance of an artificial intelligence algorithm to detect AF using photoplethysmography acquired by a smartwatch.

Methods

One hundred patients (≥18 years) without a pacemaker-dependent heart rhythm who were referred to a university hospital or a large tertiary hospital for elective 24-hour ECG Holter monitoring were asked to wear a continuous PPG monitoring smartwatch (i.e. Samsung GWA2 or Empatica E4) simultaneously with the Holter. All activities of daily life were allowed. The ECG trace and PPG waveform were synchronised and fragmented in one-minute fragements. The one-minute ECG fragments were labelled as AF, non-AF, or insufficient quality based on the routine clinical interpretation of the 24-hour Holter (i.e. software + physician overreading). The one-minute PPG fragments were analysed by an artificial intelligence (AI) algorithm (i.e. FibriCheck) and were given the same labels. Diagnostic metrics of the PPG AI algorithm were calculated with respect to the ECG interpretation, for all fragments with sufficient quality for both PPG and ECG.

Results

Four patients had to be excluded due to technical error (3 Holter errors, 1 smartwatch error). The mean age in the remaining study population (n=96) was 59±16 years, 51 (53%) were men and 15 (15.6%) were known with permanent AF. In this population, simultaneous ECG and PPG monitoring was recorded for 115,245 one-minute fragments. Fragments of insufficient quality for ECG (n=1,454; 1.3%), PPG (n=25,704; 22.3%) or both (n=15,362; 13.3%) were excluded. PPG fragments were more frequently of insufficient quality (p&lt;0.001). AF was present in 10,255 (14.1%) of the resulting 72,725 high-quality one-minute fragments. The sensitivity of PPG to detect AF was 93.4% (CI 92.9% - 93.8%). The specificity of PPG to exclude AF was 98.4% (CI 98.3% - 98.5%). As a result, the overall accuracy of the PPG algorithm on one-minute fragment level was 97.7% (CI 97.6%- 97.8%).

Conclusion

Continuous out-of-hospital PPG monitoring using a smartwatch in combination with an AI algorithm can accurately discriminate between AF and non-AF rhythms in a heterogenous patient population. PPG quality is more often affected than ECG quality during daily life activities.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Foundation-Flanders, Strategic Basic Research Fund

Atrial fibrillation screening: feasible approaches and implementation challenges across Europe

Background

Atrial fibrillation (AF) screening has the potential to increase early detection and possibly reduce complications of AF. Guidelines recommend screening, but the most appropriate approaches are unknown.

Purpose

We aimed to explore the views of stakeholders across Europe about the opportunities and challenges of implementing four different AF screening scenarios.

Method

This qualitative study included 21 semi-structured interviews with healthcare professionals and regulators potentially involved in AF screening implementation in nine European countries. Data were analysed using thematic analysis.

Results

Three themes evolved. 1) Current approaches to screening: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity by the reach of screening programmes being limited to those who access healthcare services. 2) Feasibility of screening approaches: single time point opportunistic screening in primary care using single lead ECG devices was considered the most feasible approach and AF screening may be possible in previously unexplored settings such as dentists and podiatrists. Software algorithms may aid identification of patients suitable for screening and telehealth services have the potential to support diagnosis. However, there is a need for advocacy to encourage the use of telehealth to aid AF diagnosis, and training for screening familiarisation and troubleshooting.

3) Implementation requirements: sufficient evidence of benefit is required. National rather than pan-European screening processes must be developed due to different payment mechanisms and health service regulations.

There is concern that the rapid spread of wearable devices for heart rate monitoring may increase workload due to false positives in low risk populations for AF. Data security and inclusivity for those without access to primary care or personal devices must be addressed.

Conclusions

There is an overall awareness of AF screening. Opportunistic screening appears to be most feasible across Europe. Challenges that need to be addressed concern health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit, and a tailored approach adapted to national realities.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020 Screening ScenariosGraphical abstract

Polygraphy as a new screening method for obstructive sleep apnea in patients with atrial fibrillation?

Background

Obstructive sleep apnea (OSA) is a modifiable risk factor of atrial fibrillation (AF) but is underdiagnosed in these patients. According to the 2020 European Society of Cardiology guidelines for the diagnosis and management of AF, it seems reasonable to test for OSA in symptomatic AF patients before initiation of rhythm control therapy. A good OSA screening pathway is lacking in the guidelines and in daily clinical practice in most centers today. Polysomnography (PSG) is the gold standard for diagnosing OSA but it is not an ideal screening method, due to its expensiveness, labour-intensiveness and limited availability.

Purpose

The aim of this study was to validate and examine the performance of different (cardiorespiratory) polygraphy (PG) devices, used with their automated algorithm to detect OSA in an AF cohort, compared with PSG as gold standard.

Methods

Prospective study with three PGs (ApneaLink Air (ALA), SOMNOtouch RESP (STR) and SpiderSAS (SpS) combined with ResMed Airview-, SomnoMedics DOMINO- and Microport SYNESCOPE software respectively) in consecutive AF patients who were referred for a PSG evaluation. Patients received the three devices with instructions for use after their PSG and were requested to use each one during three consecutive nights at home. Severity of OSA was classified according to the Apnea-Hypopnea Index (AHI) with &lt;5 events/hour= no OSA, 5–14= mild-, 15–30= moderate-, &gt;30= severe OSA.

Results

A total of 100 AF patients presenting for PSG were included (64.0±8.6 years, 73% male, 87% non-permanent AF, mean Body Mass Index 30.6±5.9 kg/m2, mean CHA2DS2-VASc score 2.4±1.7, mEHRA≥2 in 64%; mean AF history 5.4±5.6 years). PSG diagnosed ≥mild OSA in 90% of patients, ≥moderate in 69%, and severe OSA in 33%. Successful PG execution to determine the AHI, i.e. ≥4 hours of data on automated analysis, was obtained in 72.0%, 73.0% and 79.0% of patients with the ALA, STR and SpS respectively. In screening for clinically relevant OSA (i.e. at least moderate OSA), the PGs had an area under the curve of 0.802, 0.761 and 0.803 for the ALA, STR and SpS respectively (Figure 1).

Conclusions

This first analysis shows that PGs combined with an automated algorithm for AHI determination, can be used as OSA screening tools in AF patients before referral for PSG. Further optimisation is likely by choosing an appropriate AHI cut-off value for each PG.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This study is supported by the Antwerp University Cardiology Research Fund, and is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Figure 1

Assessment of heart rate agreement on continuous photoplethysmography monitoring using a smartwatch versus beat-to-beat synchronized ECG monitoring

Background

In the awakening era of mobile health, wearables equipped with photoplethysmography (PPG) technology to monitor the heart rate (HR) and rhythm are on the rise. Smartwatches and wristbands enable HR monitoring for consumers at massive scale. Unfortunately, once consumers become patients, physicians are limited by insufficient evidence to support the clinical use of PPG based wearables. Accurate identification of heartbeats is the first step in the interpretation of PPG traces and should be validated.

Purpose

To assess the agreement between continuous PPG monitoring using a smartwatch and continuous ECG Holter monitoring in the identification of heartbeats and calculation of the HR.

Methods

One hundred patients (≥18 years) without a pacemaker-dependent heart rhythm who were referred to a university hospital and a large tertiary hospital for elective 24-hour ECG Holter monitoring were asked to wear a continuous PPG monitoring smartwatch (i.e. Samsung GWA2 or Empatica E4) simultaneously with the 24-hour Holter monitor. All activities of daily life were allowed. The ECG trace and PPG waveform were synchronised and fragmented in one-minute fragments. The one-minute ECG fragments were labelled as AF, non-AF, or insufficient quality based on the routine clinical interpretation (i.e. software + physician overreading), and the average HR during each fragment was calculated by Holter algorithm. The PPG fragments were analysed by an artificial intelligence (AI) algorithm (i.e. FibriCheck) that labelled fragments as sufficient or insufficient quality, identified the number of heartbeats and calculated the HR. The agreement between the HR on ECG and PPG in sufficient quality tracings was analysed with linear regression, Pearson's product-moment correlation and Bland-Altman analysis. A subanalysis was performed for AF rhythm and non-AF rhythms.

Results

A total of 72,725 simultaneous ECG and PPG one-minute fragments were recorded in 96 patients, after excluding 4 patients (due to 3 Holter and 1 smartwatch technical error) and 42,520 minutes (36.9%) of insufficient quality (ECG 1,454 (1.3%); PPG 25,704 (22.3%), ECG and PPG 15,362 (13.3%)). The correlation (r=0.935) between ECG and PPG HR was statistically significant (CI 0.934–0.936; P&lt;0.001), with a mean difference between ECG and PPG of 0.8bpm. The lower and upper limit boundary (LLB and ULB; defined as ±1.96 SD) were −8.0bpm and 9.7bpm, respectively, i.e. 95% of PPG measurements identified the HR within 8bpm below or 10bpm above the ECG reference. The mean difference between ECG and PPG HR in the AF subgroup (n=10,255 (14.1%)) was 0.9bpm (LLB −8.4bpm; ULB 10.2bpm) and 0.8bpm in the non-AF subgroup (LLB −0.8bpm; ULB 9.6bpm).

Conclusion

The AI algorithm analysing continuous out-of-hospital PPG tracings can annotate heartbeats and assess HR without a clinically significant bias compared to continuous ECG monitoring, both during AF and non-AF rhythms in a heterogenous patient population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Foundation-Flanders, Strategic Basic Research Fund Correlation plot & Bland-Altman plot

The value of screening questionnaires/scoring scales for obstructive sleep apnoea in patients with atrial fibrillation

BACKGROUND

Obstructive sleep apnoea (OSA) is an important modifiable risk factor for atrial fibrillation (AF) but is underdiagnosed in this population. Currently, polysomnography is the gold standard for diagnosing OSA, but is expensive and requires overnight examination. Alternatively, home sleep apnoea testing can be used as a diagnostic tool, but also requires a complete data review. Therefore, these OSA diagnostic modalities are not ideal screening methods. Several OSA screening tools exist, but their value in patients with AF remains unclear.

AIM

To test the performance of existing screening questionnaires/scales for clinically relevant OSA in patients with AF referred for diagnostic polysomnography.

METHODS

This prospective study compared the performance of seven screening tools (Epworth Sleepiness Scale, Berlin Questionnaire, Sleep Apnea Clinical Score, NoSAS, OSA50, STOP-Bang and MOODS) with polysomnography in the detection of clinically relevant OSA in consecutive patients with AF referred to two sleep clinics.

RESULTS

A total of 100 patients referred for polysomnography and known previous AF were included. Polysomnography indicated at least clinically relevant OSA (i.e., apnoea-hypopnoea index≥15 events/hour) in 69% of cases, and 33% had severe OSA (apnoea-hypopnoea index>30 events/hour). In screening for clinically relevant OSA, only the SACS and NoSAS scores had fair areas under the curve (0.704 and 0.712, respectively). None of the seven screening tools was performant enough (i.e., had a fair area under the curve>0.7) in the detection of severe OSA.

CONCLUSIONS

In this AF cohort referred for polysomnography, clinically relevant OSA was prevalent. None of the selected screening tools showed sufficient performance as a good discriminative screening tool for clinically relevant OSA in patients with AF. Given these findings, other screening modalities for OSA should be considered in the work-up of patients with AF.

App based monitoring of heart rate via FibriCheck to facilitate teleconsultations: from COVID-19 to clinical practice?

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Part of this project was realized with financial support from the city of Antwerp in the context of the call "Innovative solutions for Corona”

Background

During the first peak of the COVID-19 pandemic, face-to-face cardiology visits had to be replaced by teleconsultations but lacking the standard performed electrocardiogram. Instead, app-based monitoring of patients’ heart rate and rhythm using photoplethysmography (PPG) technology was available as an alternative to aid these teleconsultations.

Purpose

Evaluation of the feasibility to initiate remotely PPG recordings with FibriCheck (Qompium, Hasselt, Belgium) and of the value of using FibriCheck before and after teleconsultation to substitute in-person arrhythmia consultations in three Belgian hospitals (Antwerp University Hospital, Heilig-Hart Hospital Lier and Jessa Hospital Hasselt).

Methods

Patients known with AF or with suspected arrhythmia symptoms during teleconsultation were contacted for the activation of FibriCheck seven days before or after a teleconsultation respectively, as shown in Figure 1. Instructions and a QR code were sent to the patients to download and activate FibriCheck. The code automatically links the application to an online platform available for the treating physician. Patients were asked to record their heart rhythm three times a day and when they experienced symptoms.

Results

In total, 92 patients (mean age: 64.7 ± 17.4) were contacted during the first COVID-19 peak, of which a total of 22 patients declined because not owing a smartphone or tablet (n = 11) or they were not willing or not capable to use FibriCheck (n = 11). A significant age difference was seen between the 22 non-participants versus the 70 participants (mean age 73.8 ± 18.7 vs. 61.9 ± 15.9; p = 0.004). Half of the patients, eligible for PPG monitoring (n = 38, 54.9%), were initiated before a planned (tele)consultation. Of these, four patients (10.5%) were diagnosed with an arrhythmia by using FibriCheck, of which two had frequent extrasystoles and two had a recurrence of AF and rate control was adapted. Of the 32 patients who used FibriCheck after a teleconsultation due to symptomatic palpitations, extrasystoles (n = 3) or high suspicion for a new AF diagnosis (n = 2) was established via FibriCheck. Early in-office evaluation was organised for the patients with a new diagnosis of AF, and rhythm control was initiated. In the majority of patients (57.1%), teleconsultation with FibriCheck was reassuring so that they could be followed-up according to their normal schedule.

Conclusion

During the COVID-19 pandemic, cardiologists were able to obtain important additional information using the FibriCheck application when performing teleconsultations. The possibility to successfully complete teleconsultations using the FibriCheck data, and its broad applicability, create opportunities to implement FibriCheck in standard clinical practice as an easy tool to monitor patients before or after in-person consultations or even hospitalisations.

The European TeleCheck-AF project on remote app-based management of atrial fibrillation during the COVID-19 pandemic: centre and patient experiences

Aims

TeleCheck-AF is a multicentre international project initiated to maintain care delivery for patients with atrial fibrillation (AF) during COVID-19 through teleconsultations supported by an on-demand photoplethysmography-based heart rate and rhythm monitoring app (FibriCheck^®). We describe the characteristics, inclusion rates, and experiences from participating centres according the TeleCheck-AF infrastructure as well as characteristics and experiences from recruited patients.

Methods and results

Three surveys exploring centre characteristics (n = 25), centre experiences (n = 23), and patient experiences (n = 826) were completed. Self-reported patient characteristics were obtained from the app. Most centres were academic (64%) and specialized public cardiology/district hospitals (36%). Majority of the centres had AF outpatient clinics (64%) and only 36% had AF ablation clinics. The time required to start patient inclusion and total number of included patients in the project was comparable for centres experienced (56%) or inexperienced in mHealth use. Within 28 weeks, 1930 AF patients were recruited, mainly for remote AF control (31% of patients) and AF ablation follow-up (42%). Average inclusion rate was highest during the lockdown restrictions and reached a steady state at a lower level after easing the restrictions (188 vs. 52 weekly recruited patients). Majority (>80%) of the centres reported no problems during the implementation of the TeleCheck-AF approach. Recruited patients [median age 64 (55–71), 62% male] agreed that the FibriCheck^® app was easy to use (94%).

Conclusion

Despite different health care settings and mobile health experiences, the TeleCheck-AF approach could be set up within an extremely short time and easily used in different European centres during COVID-19.

Motivation of overweight patients with atrial fibrillation to lose weight or to follow a weight loss management program: a cross-sectional study

AIMS

Overweight increases the risk of recurrence and progression of atrial fibrillation (AF). This study assesses the knowledge of overweight AF patients about the relation between their weight and AF, to gauge their motivation losing weight and/or following weight reduction programs.

METHODS

A multicenter cross-sectional descriptive study was performed at three Belgian hospitals. A validated self-developed questionnaire was presented to AF patients with a body mass index (BMI) >27 kg/m² and it addressed: motivation to reduce weight and its related factors; knowledge about the relation between weight and AF; and interest in weight reduction programs.

RESULTS

One hundred and forty-three patients completed the questionnaire. 75.5% was currently motivated to reduce weight. Multivariate regression analysis showed that a higher BMI, a college/university degree, male gender, without hypertension, previous weight loss attempt(s) and living with a partner, were significantly associated with greater motivation for weight reduction. Only 69.9% of the patients was aware of the positive effect of weight reduction on the progression of AF. A completely home-based/telerehabilitation program was the preferred approach for 57.9% of the patients.

CONCLUSIONS

AF patients with overweight need to be better informed about overweight as a risk factor for AF. Female AF patients with a lower degree of education, hypertension, living alone, who have never attempted to reduce weight and with a lower but still elevated BMI need more external motivation to lose weight. A tailored weight reduction program (home-based) is the preferred option for patients. This will require further development and validation of telecoaching programs for this patient group.

The photoplethysmography dictionary: practical guidance on signal interpretation and clinical scenarios from TeleCheck-AF

Aims

Within the TeleCheck-AF project, numerous centres in Europe used on-demand photoplethysmography (PPG) technology to remotely assess heart rate and rhythm in conjunction with teleconsultations. Based on the TeleCheck-AF investigator experiences, we aimed to develop an educational structured stepwise practical guide on how to interpret PPG signals and to introduce typical clinical scenarios how on-demand PPG was used.

Methods and results

During an online conference, the structured stepwise practical guide on how to interpret PPG signals was discussed and further refined during an internal review process. We provide the number of respective PPG recordings (FibriCheck^®) and number of patients managed within a clinical scenario during the TeleCheck-AF project. To interpret PPG recordings, we introduce a structured stepwise practical guide and provide representative PPG recordings. In the TeleCheck-AF project, 2522 subjects collected 90 616 recordings in total. The majority of these recordings were classified by the PPG algorithm as sinus rhythm (57.6%), followed by AF (23.6%). In 9.7% of recordings, the quality was too low to interpret. The most frequent clinical scenarios where PPG technology was used in the TeleCheck-AF project was a follow-up after AF ablation (1110 patients) followed by heart rate and rhythm assessment around (tele)consultation (966 patients).

Conclusion

We introduce a newly developed structured stepwise practical guide on PPG signal interpretation developed based on presented experiences from TeleCheck-AF. The present clinical scenarios for the use of on-demand PPG technology derived from the TeleCheck-AF project will help to implement PPG technology in the management of AF patients.

Usefulness of different screening questionnaires and scoring systems for obstructive sleep apnea in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): This study is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital.

OnBehalf

Research Group Cardiovascular Diseases, University of Antwerp

Background

Obstructive sleep apnea (OSA) influences the progression of atrial fibrillation (AF) but is underdiagnosed in this population. Studies have shown that its treatment can help to reduce AF recurrences and improve symptoms. Polysomnography (PSG) is currently the gold standard for diagnosing OSA but being expensive and requiring overnight examination it is therefore not the ideal screening method. Different OSA screening tools such as questionnaires and scoring systems already exist but their value in AF patients remains unclear.

Purpose

The aim of this study was to examine the performance of different screening questionnaires and scoring systems for diagnosing OSA in an AF cohort, compared with PSG as gold standard.

Methods

Prospective study of the predictive performance of seven screening questionnaires and scoring systems (the Epworth Sleepiness Scale (ESS), the Berlin Questionnaire (BQ), Sleep Apnea Clinical Score (SACS), OSA50, STOP-BANG, NoSAS, MOODS) in consecutive AF patients referred to two sleep clinics.

Results

A total of 100 AF patients presenting for PSG were included (64.0 ± 8.6 years, 73% male, 87% non-permanent AF, mean Body Mass Index 30.6 ± 5.9 kg/m2, mean CHA2DS2-VASc score 2.4 ± 1.7, mEHRA≥2 in 64%; mean AF history 5.4 ± 5.6 years).  Forty-two percent of patients were referred to the sleep clinic by cardiologists. PSG diagnosed ≥mild OSA in 90% of patients, ≥moderate in 69%, and severe OSA in 33%. In screening for mild OSA, NoSAS, STOP-BANG and MOODS screening questionnaires had a fair area under the curve (AUC) of 0.773, 0.710 and 0.709 respectively. For at least moderate OSA, only the SACS and the NoSAS questionnaires had an AUC of 0.704 and 0.712 respectively (Figure 1). None of the seven screening questionnaires/scoring systems were performant enough (i.e. a fair AUC &gt; 0.7) to detect severe OSA.

Conclusions

Our analysis shows that screening questionnaires and scoring systems such as ESS, BQ, SACS, NoSAS, OSA50, STOP-BANG and MOODS are not very useful to predict clinically relevant OSA (i.e. at least moderate OSA) in AF patients. Therefore, other screening modalities for OSA in AF patients should be investigated and validated. Abstract Figure 1

Pacemaker guided screening for severe sleep apnea, a possible option for patients with atrial fibrillation: A systematic review and meta-analysis

INTRODUCTION

Obstructive sleep apnea is often underdiagnosed in atrial fibrillation (AF) patients although it is an important risk factor. A systematic review and meta-analysis was performed to assess which techniques cardiac implantable electronic devices (CIED) and Holter monitors use to screen for sleep apnea (SA), and to evaluate if these are suitable for AF patients from a diagnostic accuracy perspective.

METHODS

The search was conducted in accordance with the PRISMA-guidelines. PICO was defined as (P) patients with AF, (I) Holter monitors or CIED suitable for screening for SA, (C) overnight polysomnography (PSG), (O) positive screening with subsequent positive polysomnographic diagnosis of SA. Optimal index test cut-off points corresponding to reference test cut-off for severe SA (PSG-AHI ≥ 30) were compared. Meta-analysis was conducted for the diagnostic odds ratio (DOR), with forest plot and ROC-curve for summary DOR.

RESULTS

A total of five prospective cohort studies (n = 192) were included in the systematic review of which four studies (n = 132) were included in the meta-analysis. All included studies use transthoracic impedance measurement as a screening parameter. No studies evaluating Holter monitors were included. The population consisted of patients indicated for pacemaker implantation. The summary DOR was 27.14 (8.83; 83.37), AUC was 0.8689 (0.6872; 0.9456) and Q* was 0.8390 (0.7482; 0.9013).

CONCLUSION

At optimal pacemaker-cut-off, pacemaker-guided screening for severe SA in patients with AF can be an effective triage tool for clinical practice. Further studies with larger sample sizes are needed to strengthen the evidence for this conclusion.

Obstructive sleep apnoea testing and management in atrial fibrillation patients: a joint survey by the European Heart Rhythm Association (EHRA) and the Association of Cardiovascular Nurses and Allied Professions (ACNAP)

Obstructive sleep apnoea (OSA) is highly prevalent in atrial fibrillation (AF) patients and associated with reduced response to rhythm control strategies. However, there is no practical guidance on testing for OSA in AF patients and for OSA treatment implementation. We sought to evaluate current practices and identify challenges of OSA management in AF. A descriptive cross-sectional study was performed with a content-validated survey to evaluate OSA management in AF by healthcare practitioners. Survey review, editing, and dissemination occurred via the European Heart Rhythm Association and the Association of Cardiovascular Nursing and Allied Professions and direct contact with arrhythmia centres. In total, 186 responses were collected. OSA-related symptoms were ranked as the most important reason to test for OSA in AF patients. The majority (67.7%) indicated that cardiologists perform 'ad-hoc' referrals. Only 11.3% initiated systematic testing by home sleep test or respiratory polygraphy and in addition, 10.8% had a structured OSA assessment pathway in place at the cardiology department. Only 6.7% of the respondents indicated that they test >70% of their AF patients for OSA as a component of rhythm control therapy. Various barriers were reported: no established collaboration between cardiology and sleep clinic (35.6%); lack in skills and knowledge (23.6%); lack of financial (23.6%) and personnel-related resources (21.3%). Structured testing for OSA occurs in the minority of AF patients. Centres apply varying methods. There is an urgent need for increased awareness and standardized pathways to allow OSA testing and treatment integration in the management of AF.

A new smartphone application for integrated transmural care of atrial fibrillation, AF-EduApp: Usability and validation study

Introduction

Digital technology creates the opportunity to develop and evaluate new tools, such as smartphone applications, to support integrated atrial fibrillation management. This study aimed to develop, evaluate, and validate a new, integrated care application (AF-EduApp) mainly focusing on targeted atrial fibrillation education to improve patient self-care capabilities and therapy adherence.

Methods

The newly developed AF-EduApp, available for Android and iOS, consists of six different modules. The prototype was validated and optimized for its usability and functionality at Jessa Hospital Hasselt and Antwerp University Hospital in two phases: (1) validity evaluation with interviews of an expert panel with 15 healthcare professionals and 10 atrial fibrillation patients, and (2) a pilot study of 1 month with 20 atrial fibrillation patients.

Results

Both experts and patients found that the application aids atrial fibrillation management. Based on the input of patients and experts, the main optimizations concerned the medication module (patient choice on setting reminder; interactivity of reminders with a “taken” or “snooze” function) and development of a clinical dashboard for the caregivers allowing telemonitoring of measurements and feedback to the patients. After the pilot study ( n = 20), 16 patients indicated they wanted to use the app for a longer period. The measurement (27%) and education (17%) modules were the two most used modules with a significant improvement in knowledge (71.9% to 87.5%; P = 0.013).

Discussion

The AF-EduApp received a positive evaluation from health professionals and atrial fibrillation patients. Further development should be focused on the medication module and improvement of the clinical dashboard.

Real-world adherence to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation measured by an electronic medication event monitoring system

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are recommended as first choice therapy for thrombo-embolic prevention in patients with non-valvular atrial fibrillation (AF) and an elevated CHA2DS2-VASc score. A critical determinant for both safety and effectiveness of NOAC treatment is adherence to the prescribed medication regimen. Real-life adherence is suboptimal for many cardiovascular drugs. Measuring and improving NOAC adherence is primordial for optimising AF care.

Purpose

We measured adherence to any of the four NOACs in a population of AF patients who participate to a clinical trial during which they received targeted education on AF and its treatment.

Methods

This analysis is part of a prospective, multicenter, randomized controlled trial which is currently ongoing at three Belgian hospitals (AF-EduCare study). Ambulatory or hospitalised AF patients of that trial, treated with a NOAC, and who received a short targeted education session about AF and NOAC therapy at initiation, form the study group of this analysis. Monitoring of NOAC intake was performed by an electronic Medication Event Monitoring System (MEMS), starting immediately after initiation of the study and the education session (for 3 months). A special cap fits on a medication bottle and records the exact date and time of bottle openings. An LCD screen on the cap displays the number of openings of the medication bottle over a period of 24 hours, providing feedback about the correct intake. Dabigatran was replaced by a proxy medication as Dabigatran should be stored in the original package in order to protect it from moisture. Regimen adherence was calculated as the number of days on which one bottle opening in case of Rivaroxaban or Edoxaban and two bottle openings in case of Apixaban or Dabigatran is/are registered, divided by the total number of monitored days and multiplied by 100.

Results

A total of 233 patients (mean age 71.0±7.7 years; 71.2% males; CHA2DS2-VASc score 3.4±1.5; mean duration of AF history 5.8±7.5 years) were given a MEMS. Of these patients 32.2%, 31.3%, 26.2% and 10.3% were respectively on Edoxaban, Apixaban, Rivaroxaban and Dabigatran. Regimen adherence for these NOACs was 95.9±9.3%, 91.6±13.7%, 95.6±5.6% and 94.0±7.1% respectively. Overall, 94.4% of the patients had an adherence &gt;80% and 81.1% had an adherence &gt;90%. Adherence for the once and twice daily regimens was 95.8±0.7% and 92.2±1.3%, respectively (p=0.0003; Mann-Whitney U test).

Conclusions

This is a first prospective study investigating adherence for all NOACs using electronic monitoring. In this sample of AF patients who underwent a targeted education session before the 3 month monitoring period, mean adherence to NOAC intake was &gt;90% for all NOACS. This high adherence may be related to both the education and the use of MEMS, which provided direct feedback to the patient.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The AF-EduCare study is a project supported by the Fund for Scientific Research, Flanders (T002917N).

On-demand mobile health infrastructures to allow comprehensive remote atrial fibrillation and risk factor management through teleconsultation

Background

Although novel teleconsultation solutions can deliver remote situations that are relatively similar to face‐to‐face interaction, remote assessment of heart rate and rhythm as well as risk factors remains challenging in patients with atrial fibrillation (AF).

Hypothesis.

Mobile health (mHealth) solutions can support remote AF management.

Methods

Herein, we discuss available mHealth tools and strategies on how to incorporate the remote assessment of heart rate, rhythm and risk factors to allow comprehensive AF management through teleconsultation.

Results

Particularly, in the light of the coronavirus disease 2019 (COVID‐19) pandemic, there is decreased capacity to see patients in the outpatient clinic and mHealth has become an important component of many AF outpatient clinics. Several validated mHealth solutions are available for remote heart rate and rhythm monitoring as well as for risk factor assessment. mHealth technologies can be used for (semi‐)continuous longitudinal monitoring or for short‐term on‐demand monitoring, dependent on the respective requirements and clinical scenarios. As a possible solution to improve remote AF care through teleconsultation, we introduce the on‐demand TeleCheck‐AF mHealth approach that allows remote app‐based assessment of heart rate and rhythm around teleconsultations, which has been developed and implemented during the COVID‐19 pandemic in Europe.

Conclusion

Large scale international mHealth projects, such as TeleCheck‐AF, will provide insight into the additional value and potential limitations of mHealth strategies to remotely manage AF patients. Such mHealth infrastructures may be well suited within an integrated AF‐clinic, which may require redesign of practice and reform of health care systems.

P348Motivation of overweight patients with atrial fibrillation to lose weight or to follow a weight loss management program: a cross-sectional study

Funding Acknowledgements

none

Background

Overweight and obesity increase the risk of recurrence and progression of atrial fibrillation (AF). Studies evaluating weight reduction programs in AF patients have shown benefits in AF burden, symptoms and quality of life. Despite this proof, AF patients often lack the will to tackle overweight and they do not commonly participate in cardiac rehabilitation programs.

Purpose

The objective of this study was to assess the motivation of AF patients with overweight or obesity to lose weight and/or to follow weight reduction programs.

Methods

A multicenter descriptive cross-sectional study was performed at three Belgian hospitals. A self-developed questionnaire was presented to AF patients with a BMI &gt;27kg/m2 who presented for an outpatient cardiology visit or were hospitalized at the cardiology ward. The questionnaire was validated for its content by an expert panel and it addressed the following topics: knowledge about the relation between weight and AF; patients’ history of weight reduction efforts and its success; current motivation to reduce weight; factors related to motivation; interest in following weight reduction programs.

Results

A total of 143 patients (mean age 65.7 ± 9.2 years; mean BMI 32.3 ± 4.7kg/m2; 68.5% males; 47.6% hospitalized; mean duration of AF history 5.7 ± 6.0 years) out of 560 screened AF patients completed the questionnaire (figure 1).

Only 69.9% of patients was aware of the positive effect of weight reduction on the progression of AF.

Prior attempts to reduce weight were made by 76.2% of the patients in which a minority participated in a hospital-based weight reduction program (9.2%) or a structured fitness program (10.1%).

Of the study patients, 75.5% were currently motivated to reduce weight, mainly driven by health considerations (78.7%). Univariate analysis showed that a higher educational degree, higher income, living with a partner, and higher BMI were positively correlated with motivation to reduce weight (p &lt; 0.05). Multivariate regression analysis showed that a higher BMI (OR = 1.20; CI = 1.05-1.38; p = 0.010), younger age (0.96 (0.91-1.01); p = 0.108), a college/university degree (5.03 (1.57-16.16); p = 0.007) and living with a partner (4.31 (1.55-11.95); p = 0.005) were associated with greater odds ratio of motivation for weight reduction.

A completely home-based program (including tele-rehabilitation) was the preferred approach for 57.9% of the patients, and 57.3% would consider a weight reduction program only if reimbursement was available.

Conclusions

AF patients with overweight still need to be better informed about overweight as a risk factor for AF. AF patients with a lower degree of education, living alone and a lower BMI need more external motivation to lose weight. A tailored weight reduction program, mainly home based, is the preferred option for patients. This will require further development and validation of tele-coaching programs for this patient group.

Abstract Figure 1: Enrollment procedure

Minor bleeding affects the level of knowledge in patients with atrial fibrillation on oral anticoagulant therapy

BACKGROUND

Anticoagulant therapy in patients with atrial fibrillation (AF) increases the risk of minor bleeding, which is mostly accepted by patients. We aimed to assess whether continuation of anticoagulation despite minor bleeding is associated with a higher level of knowledge on AF and anticoagulation.

METHODS AND RESULTS

In 1525 patients with AF on oral anticoagulation who completed the Jessa AF Knowledge Questionnaire (JAKQ) (median age: 72 years [range, 65-79 years]; men: 54.6%), persistent self-reported minor bleeding was recorded. Minor bleeding was observed in 567 patients (37.2%) including 224 patients (39.5%) on vitamin K antagonists (VKAs) and 343 (60.5%) on non-vitamin K antagonist oral anticoagulants (NOACs). The risk of minor bleeding was lower among patients on NOACs than on VKAs (33.5% vs 44.6%; P < .0001). Multiple logistic regression showed that minor bleeding was associated with the use of NOACs (odds ratio [OR] 0.75; 95% CI 0.59-0.97), female gender (OR 2.19; 95% CI, 1.74-2.75; P < .0001), history of major bleeding (OR 2.85; 95% CI, 1.96-4.14; P < .0001), time since AF diagnosis (OR 1.04; 95% CI, 1.01-1.06; P < .0001), concomitant vascular disease (OR 1.43; 95% CI, 1.10-1.87; P = .0008) and diabetes mellitus (OR 1.3; 95% CI, 1.02-1.65, P = .03). Patients with minor bleeding, compared with the remaining subjects scored higher on the JAKQ (median, 62.5% vs 56.2%, respectively, P < .0001). The former group knew more about the purpose of anticoagulant therapy (71.8% vs 65.7%, P = .01) and bleeding as its key side effect (66.1% vs 52.7%, P < .0001), and were better informed on the safest painkillers to use in combination with anticoagulation (48% vs 35%, P < .0001).

CONCLUSION

This study suggests that AF patients who accept persistent minor bleeding have better knowledge on the disease and anticoagulation therapy compared with those free of these side effects.

The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation

The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).

Nightly sleep apnea severity in patients with atrial fibrillation: Potential applications of long-term sleep apnea monitoring

In patients with atrial fibrillation (AF), the prevalence of moderate-to-severe sleep-disordered breathing (SDB) ranges between 21% and 72% and observational studies have demonstrated that SDB reduces the efficacy of rhythm control strategies, while treatment with continuous positive airway pressure lowers the rate of AF recurrence. Currently, the number of apneas and hypopneas per hour (apnea-hypopnea-index, AHI) determined during a single overnight sleep study is clinically used to assess the severity of SDB. However, recent studies suggest that SDB-severity in an individual patient is not stable over time but exhibits a considerable night-to-night variability which cannot be detected by only one overnight sleep assessment. Nightly SDB-severity assessment rather than the single-night diagnosis by one overnight sleep study may better reflect the exposure to SDB-related factors and yield a superior metric to determine SDB-severity in the management of AF. In this review we discuss mechanisms of night-to-night SDB variability, arrhythmogenic consequences of night-to-night SDB variability, strategies for longitudinal assessment of nightly SDB-severity and clinical implications for screening and management of SDB in AF patients.

Knowledge gaps in patients with venous thromboembolism: usefulness of a new questionnaire

INTRODUCTION The current awareness of venous thromboembolism (VTE) and knowledge of thromboprophylaxis among patients receiving oral anticoagulation therapy (OAC) are insufficient. OBJECTIVES We sought to develop and evaluate the usefulness of the Jessa AF Knowledge Questionnaire (JAKQ), modified for VTE patients. PATIENTS AND METHODS Consecutive patients at least 1 month since the VTE event (n = 273, mean [SD] age, 51 [17] years; 52.7%, women; 55.9%, unprovoked event) were enrolled to the study. RESULTS The median percentage of correct responses was 64.2% (interquartile range, 53%-73%; minimum, 12%; maximum, 100%). Younger patients had better knowledge about VTE in general, including a higher proportion of correct responses to the question about the definition of PE (71.4% vs 57.7%, P = 0.03), about the possible consequence of DVT, including PE (81.1% vs 62%, P = 0.001) and VTE risk related to long travels (78.1% vs 59.2%, P = 0.002). There was no difference in overall scoring between patients taking new oral anticoagulants and those taking vitamin K antagonists (mean [SD], 64.1% [16.3%] vs 63.9% [13.8%], respectively, P = 0.7). Regardless of the type of anticoagulants, 39.3% of patients knew that VTE is not always symptomatic, 33.6% knew what to do when they missed an OAC dose, and 50% did not know which painkillers are the safest in combination with anticoagulants. Education applied in 27 patients resulted in an increase in the median percentage of correct responses from 60% to 80% (P = 0.0001). CONCLUSIONS Knowledge on VTE and anticoagulation is suboptimal among patients on VKA and NOACs. Education of VTE patients should be improved especially in older individuals on NOACs.