We all know A and B, but what about C? Exploring the management of modifiable risk factors in patients with atrial fibrillation

Background

The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) advise to treat AF according to the ABC pathway: A, anticoagulation, B, better symptom control, and C, comorbidities and cardiovascular risk factor management. Optimal treatment of comorbidities and risk factors slows AF progression and improves success rates of rhythm interventions for AF. However, several studies report underdiagnosis and therefore possible undertreatment for common cardiovascular comorbidities.

Purpose

This study aims to evaluate how common modifiable cardiovascular risk factors are managed in AF patients referred for catheter ablation.

Methods

This is a substudy of the ISOLATION study, a prospective cohort study including consecutive patients with paroxysmal or persistent AF referred for AF ablation. Screening for common modifiable risk factors for AF is structurally embedded in the work-up for AF ablation in the two participating centres. In the present study the prevalence of the following risk factors at this screening moment was assessed: (1) body mass index (BMI) above the target BMI for ablation (≥27 kg/m2), (2) hypertension, defined as on-site systolic blood pressure >130 mmHg and/or diastolic blood pressure >80 mmHg, (3) decreased glucose tolerance or diabetes mellitus, defined as HbA1c ≥6.5%, (4) dyslipidaemia, defined as low-density lipoprotein (LDL) ≥2.5 mmol/l, (5) regular alcohol consumption, defined as self-reported consumption of >15 standardized units/week, and (6) sleep disordered breathing (SDB), defined as apnoea-hypopnoea index (AHI) ≥15 assessed with home sleep tests (subset of patients).

Results

Among the 981 patients studied (median age 65 [59–71] years old, 64% male, 69% paroxysmal AF), previously diagnosed comorbidities were common (46% hypertension, 7% diabetes, 22% dyslipidaemia, 10% SDB), and a large proportion of patients received targeted treatment (Table 1). However, non-optimally managed risk factors remained significant (Figure 1). BMI ≥27 kg/m2 was present in 56% of patients. High systolic and diastolic blood pressure were present in 62% and 51% of patients, respectively, and any form of high blood pressure (either systolic or diastolic) was seen in 72% of patients. HbA1c was found to be above target ranges in 9% patients and LDL in 56%. A weekly alcohol consumption of ≥15 units was reported by 4% of patients. Screening for SDB was performed in a subset of patients (n=287), for whom AHI was ≥15 in 52%. Overall, 9% of patients had 4 or more non-optimally controlled modifiable risk factors, whereas the median number of modifiable risk factors was 2 [1–3].

Conclusions

Structural screening revealed a high prevalence of non-optimally controlled modifiable cardiovascular risk factors in patients referred for AF catheter ablation. According to recent ESC guidelines, improving treatment of comorbidities may improve AF ablation success rates and even reduce mortality.

Funding Acknowledgement

Type of funding sources: None.

The impact of a structured polygraphy screening incorporated in a novel remote mobile health pathway on sleep apnoea prevalence in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Untreated obstructive sleep apnoea (OSA) contributes to progression of atrial fibrillation (AF) and reduces the success rate of heart rhythm control strategies. OSA remains one of the most frequently underdiagnosed modifiable risk factors in AF patients due to a lack of standardized screening methods and low awareness.

Purpose

To assess the impact of implementation of a structured remote OSA screening and management pathway on the prevalence of OSA in AF patients scheduled for AF ablation procedures.

Methods

In October 2020, a novel remote OSA screening and management pathway (VIRTUAL-SAFARI) was introduced in two AF outpatient clinics in the Netherlands. Consecutive patients scheduled for AF ablation were offered OSA screening consisting of sending a portable home sleep test to patients’ homes to perform a remote sleep recording for one night, analysis by a sleep physician, discussion of results with the patient, and initiation of treatment (when applicable). The impact of this structural screening strategy was assessed by comparing the prevalence of concomitant OSA (defined as apnoea-hypopnoea index ≥5) for patients scheduled for AF ablation in the year before and after introduction of the OSA management pathway.

Results

A total of 733 patients was studied, 308 in the year before (Oct ’19 - Sep ’20) and 425 in the year after (Oct ’20 - Sep ’21) introduction of the VIRTUAL-SAFARI pathway. Median age was 65 [58-71], 64% was male and median body mass index (BMI) was 27 [25-30] kg/m2. Baseline characteristics were comparable for the groups before and after introduction of the pathway (Table 1).

In the cohort before pathway introduction, OSA had been diagnosed in 26 patients (8%, Figure 1) and was treated with positive airway pressure in 10 cases (3%).

In the cohort after pathway introduction, OSA had previously been diagnosed in 53 patients (12%). Eighty-eight percent of patients without previous OSA screening was referred via the remote pathway. Results of the sleep recordings were available for 213 (59%) at the time of this analysis. Previously unknown OSA was diagnosed in 184 patients (86% of available recordings), increasing the prevalence of confirmed OSA to 237 (55%). For 22% of patients, results of sleep recordings are pending. Absence of OSA was confirmed in 9%, and 13% of patients had not been screened (e.g. because of patient preference or logistical reasons). After pathway introduction, 82 patients (19%) were treated or received advice to start treatment with positive airway pressure. Treatment decisions are pending for 9% of the cohort.

Conclusion

After the implementation of structured remote OSA screening in a well characterized cohort of consecutive patients scheduled for AF ablation, the prevalence of diagnosed OSA increased from 8% to 55%. Whether appropriate risk factor management, including treatment of OSA identified by structured screening, will improve AF outcomes needs to be tested in future studies.

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

Funding Acknowledgements

Type of funding sources: None.

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

P2834Diagnostic yield of holter recording after atrial fibrillation ablation - detection of asymptomatic recurrences during a one-year follow-up period

Background

Strategies to detect recurrences after atrial fibrillation (AF) catheter ablation vary widely. Whereas a symptom-based approach may overestimate procedural success due to asymptomatic recurrences, continuous invasive monitoring with implantable devices may be refused by patients and is not routinely recommended. In trial settings, Holter monitoring is recommended at one year after ablation, though more frequent and intensive follow-up is encouraged for more accurate detection of arrhythmia recurrences.

Purpose

To study the diagnostic yield of Holter monitoring in the detection of asymptomatic recurrent arrhythmias after cryoballoon catheter ablation for AF.

Methods

Prospective registry on AF patients who underwent cryoballoon ablation with subsequent follow-up in our centre. Follow-up comprised routine (i.e. at 3, 6, and 12 months) and symptom-driven electrocardiographic (ECG) registrations after a three-month blanking period. In addition, patients were scheduled for six-day Holter monitoring shortly after the blanking period, at six months and at the end of the one-year follow-up period. For the current analysis, we studied the Holter recordings of the patients without previously detected arrhythmia recurrence and determined the proportion of asymptomatic recurrences at each respective monitoring period.

Results

We studied 364 patients with a median age of 60 years (IQR 54–66) and a median CHA2DS2-VASc score of 1 (IQR 1–2). One-year recurrences were documented in 119 (32.7%) patients, of which 90 were initially detected on Holter recording and 39 on ECG registrations (Table). A total of 34 patients did not report symptoms during the documentation of recurrent arrhythmia and comprised 28.6% (34/119) of all recurrences and 37.8% (34/90) of the Holter-detected recurrences. At the three-month Holter registration, 33.3% of the patients with recurrences did not report symptoms, which was 29.4% and 62.5% at the six- and twelve-month registrations, respectively (Figure).

Timing and detection of recurrences Time after ablation 3 months 3–6 months 6 months 6–12 months 12 months Patients with Holter-detected recurrences 57/119 (47.9%) 17/119 (14.3%) 16/119 (13.4%) Patients with ECG-documented recurrences 18/119 (15.1%) 11/119 (9.2%)

Proportions of asymptomatic recurrences

Conclusions

In this cohort of AF patients with serial six-day Holter monitoring after cryoballoon ablation, up to one-third of the patients had asymptomatic recurrences. Whereas Holter monitoring shortly after the blanking period detected nearly half of all one-year recurrences, the proportion of asymptomatic detected recurrences was higher in recordings at one year and seems therefore important in the detection of asymptomatic recurrences after catheter ablation.

P5682Cardiac resynchronization therapy with a single left ventricular septal pacing electrode: acute hemodynamic and electrophysiological effects

Background

Cardiac resynchronization therapy (CRT) is usually performed with a right (RV) and left ventricular (LV) lead. In a previous patient study, pacing the interventricular septum permanently on the LV endocardial side (LV septum) proved feasible in patients with sinus node dysfunction.

Objective

To investigate the effects of LV septal pacing as compared to conventional biventricular (BiV) pacing with respect to acute hemodynamic and electrophysiological effects in CRT indicated heart failure patients.

Methods

Temporary LV septal pacing (transarterial approach) and pacing in the conventional BiV mode using the implanted leads was performed in 26 patients (QRS duration 163±17 ms, 23 left bundle branch block patients) undergoing CRT implantation. Acute hemodynamic response (relative to baseline AAI pacing) was assessed by LVdP/dtmax. Multi-electrode body-surface mapping, what has been used previously to characterize electrical dyssynchrony in CRT patients, was evaluated using the standard deviation of activation times (SDAT) (figure, right panel).

Results

LV septal pacing resulted in a significant LV dP/dtmax increase, that was comparable to conventional BiV pacing (figure, left panel). Combined RV and LV septal pacing did not provide an additional increase. LV septal pacing resulted in a significantly larger reduction in SDAT than RV plus LV septal pacing and conventional BiV pacing (figure, middle panel).

Conclusions

LV septal pacing results in acute hemodynamic improvement and electrical resynchronization that is at least as good as conventional BiV pacing. These results suggest that LV septal pacing with a single ventricular lead may serve as an alternative to conventional BiV pacing for cardiac resynchronization.

Acknowledgement/Funding

Medtronic is a subsidising party.

P6016His bundle pacing versus biventricular pacing in cardiac resynchronization therapy: acute hemodynamic and electrophysiological effects

Background

Cardiac resynchronization therapy (CRT) is usually performed with a right (RV) and left ventricular (LV) lead. Previous observational studies showed promising results with His bundle pacing (HBP) in patients with left bundle branch block (LBBB) by capturing and recruiting the native His-Purkinje system as an alternative to provide ventricular resynchronization.

Objective

To investigate the effects of HBP as compared to conventional biventricular (BiV) pacing with respect to acute hemodynamic and electrophysiological effects in heart failure patients with LBBB.

Methods

RV apical and BiV pacing, using the implanted leads, and temporary HBP, using an electrophysiology catheter, was performed in 13 patients (QRS duration 168±16 ms) undergoing CRT implantation. Hemodynamic response (relative to baseline AAI pacing) was assessed as change in LVdP/dtmax. Multi-electrode body-surface mapping, what has been used previously to characterize electrical dyssynchrony in CRT patients, was evaluated using the standard deviation of activation times (SDAT) (figure, right panel).

Results

HBP resulted in a significant LV dP/dtmax increase, that was comparable to the increase during BiV pacing and significantly larger than RV pacing (figure, left panel). HBP resulted in a more homogenized electrical activation and larger reduction in SDAT than both conventional BiV pacing and RV pacing (figure, middle panel).

Conclusions

Acute HBP results in hemodynamic improvement and electrical resynchronization that is as good as conventional BiV pacing. These results suggest that HBP may serve as an alternative for conventional BiV pacing in LBBB patients, however prospective studies are needed to prove chronic clinical outcomes.

Acknowledgement/Funding

Medtronic is a subsidising party.

Safety and long-term effects of renal denervation: Rationale and design of the Dutch registry

BACKGROUND

Percutaneous renal denervation (RDN) has recently been introduced as a treatment for therapy-resistant hypertension. Also, it has been suggested that RDN may be beneficial for other conditions characterised by increased sympathetic nerve activity. There are still many uncertainties with regard to efficacy, safety, predictors for success and long-term effects. To answer these important questions, we initiated a Dutch RDN registry aiming to collect data from all RDN procedures performed in the Netherlands.

METHODS

The Dutch RDN registry is an ongoing investigator-initiated, prospective, multicentre cohort study. Twenty-six Dutch hospitals agreed to participate in this registry. All patients who undergo RDN, regardless of the clinical indication or device that is used, will be included. Data are currently being collected on eligibility and screening, treatment and follow-up.

RESULTS

Procedures have been performed since August 2010. At present, data from 306 patients have been entered into the database. The main indication for RDN was hypertension (n = 302, 99%). Patients had a mean office blood pressure of 177/100 (±29/16) mmHg with a median use of three (range 0-8) blood pressure lowering drugs. Mean 24-hour blood pressure before RDN was 157/93 (±18/13) mmHg. RDN was performed with different devices, with the Simplicity™ catheter currently used most frequently.

CONCLUSION

Here we report on the rationale and design of the Dutch RDN registry. Enrolment in this investigator-initiated study is ongoing. We present baseline characteristics of the first 306 participants.

[A woman with anginal symptoms and normal coronary arteries]

Angina pectoris is usually the first manifestation ofischaemic heart disease. Men are more often affected than women, but women are often denied the full diagnostic work-up of ischaemic heart disease. A 58-year-old woman had typical angina, positive exercise electrocardiography and a negative coronary arteriogram: syndrome X. She was treated with a beta blocker, aspirin, a statin and an angiotensin-converting enzyme (ACE) inhibitor, and eventually obtained relief of her symptoms.