Quality of care among patients diagnosed with atrial fibrillation in Greenland

This cross-sectional study sought to assess the prevalence of atrial fibrillation (AF) diagnosis in Greenland among various age groups and examine the corresponding quality of care. We collected data from Greenland's electronic medical records and evaluated the quality of care using six internationally recommended indicators, which are: percentage of AF patients with an assessment of smoking status within the previous year, an assessment of body mass index within the previous year, assessment of blood pressure within the previous year, measurement of thyroid stimulating hormone (TSH), treatment with an anticoagulant and percentage of patients with a measurement of serum-creatinine. We found the prevalence of AF among patients aged 20 years or older in Greenland to be 1.75% (95% CI 1.62-1.88). We found an increasing prevalence of AF with age and a greater proportion of men than women until the age of 74 years. Our study suggests that the associated quality of care could be higher as the requirement of only one of the six quality indicators was met. A lack of registration may partly explain this, and initiatives to improve the quality of care are recommended.

Oral anticoagulation therapy initiation in patients with atrial fibrillation in relation to world region of origin: a register-based nationwide study

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia and results in a high risk of stroke. The number of immigrants is increasing globally, but little is known about potential differences in AF care across migrant populations.

AIM

To investigate if initiation of oral anticoagulation therapy (OAC) differs for patients with incident AF in relation to country of origin.

METHODS

A nationwide register-based study covering 1999-2017. AF was defined as a first-time diagnosis of AF and a high risk of stroke. Stroke risk was defined according to guidelines from the European Society of Cardiology (ESC). Poisson regression adjusted for sex, age, socioeconomic position and comorbidity was made to compute incidence rate ratios (IRR) for initiation of OAC.

RESULTS

The AF population included 254 586 individuals of Danish origin, 6673 of Western origin and 3757 of non-Western origin. Overall, OAC was initiated within -30/+90 days relative to the AF diagnosis in 50.3% of individuals of Danish origin initiated OAC, 49.6% of Western origin and 44.5% of non-Western origin. Immigrants from non-Western countries had significantly lower adjusted IRR of initiating OAC according to all ESC guidelines compared with patients of Danish origin. The adjusted IRRs ranged from 0.73 (95% CI: 0.66 to 0.80) following the launch of the 2010 ESC guideline to 0.89 (95% CI: 0.82 to 0.97) following the launch of the 2001 ESC guideline.

CONCLUSION

Patients with AF with a high risk of stroke of non-Western origin have persistently experienced a lower chance of initiating OAC compared with patients of Danish origin during the last decades.

Incidence of atrial fibrillation and flutter in Denmark in relation to country of origin: a nationwide register-based study

BACKGROUND

Atrial fibrillation and flutter (AF) is the most common sustained arrhythmia with an increasing prevalence in Western countries. However, little is known about AF among immigrants compared to non-immigrants.

AIM

To examine the incidence of hospital-diagnosed AF according to country of origin.

METHOD

Immigrants were defined as individuals born outside Denmark by parents born outside Denmark. AF was defined as first-time diagnosis of AF. All individuals were followed from the age of 45 years from 1998 to 2017. The analyses were adjusted for sex, age, comorbidity, contact with the general practitioner and socioeconomic variables. Adjustment was conducted using standardised morbidity ratio weights, standardised to the Danish population in a marginal structural model.

RESULTS

The study population consisted of 3,489,730 Danish individuals free of AF and 108,914 immigrants free of AF who had emigrated from the 10 most represented countries. A total of 323,005 individuals of Danish origin had an incident hospital diagnosis of AF, among the immigrants 7,300 developed AF. Adjusted hazard rate ratios (HRRs) of AF for immigrants from Iran (0.48 [95%CI:0.35;0.64]), Turkey (0.74 [95%CI:0.67;0.82]) and Bosnia-Herzegovina (0.42 [95%CI:0.22;0.79]) were low compared with Danish individuals. Immigrants from Sweden, Germany and Norway had an adjusted HRR of 1.13 [95%CI:1.03;1.23], 1.12 [95%CI:1.05;1.18] and 1.11 [95%CI:1.03;1.21], respectively (Danish individuals as reference).

CONCLUSIONS

Substantial variation in the incidence of hospital-diagnosed AF according to country of origin was observed. The results may reflect true biological differences but could also reflect barriers to AF diagnosis for immigrants. Further efforts are warranted to determine the underlying mechanisms.

Efficacy of a web-based healthcare innovation to advance the quality of life and care of patients with an implantable cardioverter defibrillator (ACQUIRE-ICD): a randomized controlled trial

AIMS

Modern clinical management of patients with an implantable cardioverter defibrillator (ICD) largely consists of remote device monitoring, although a subset is at risk of mental health issues post-implantation. We compared a 12-month web-based intervention consisting of goal setting, monitoring of patients' mental health-with a psychological intervention if needed-psychoeducational support from a nurse, and an online patient forum, with usual care on participants' device acceptance 12 months after implantation.

METHODS AND RESULTS

This national, multi-site, two-arm, non-blinded, randomized, controlled, superiority trial enrolled 478 first-time ICD recipients from all 6 implantation centres in Denmark. The primary endpoint was patient device acceptance measured by the Florida Patient Acceptance Survey (FPAS; general score range = 0-100, with higher scores indicating higher device acceptance) 12 months after implantation. Secondary endpoints included symptoms of depression and anxiety. The primary endpoint of device acceptance was not different between groups at 12 months [B = -2.67, 95% confidence interval (CI) (-5.62, 0.29), P = 0.08]. Furthermore, the secondary endpoint analyses showed no significant treatment effect on either depressive [B = -0.49, 95% CI (-1.19; 0.21), P = 0.17] or anxiety symptoms [B = -0.39, 95% CI (-0.96; 0.18), P = 0.18].

CONCLUSION

The web-based intervention as supplement to usual care did not improve patient device acceptance nor symptoms of anxiety and depression compared with usual care. This specific web-based intervention thus cannot be recommended as a standardized intervention in ICD patients.

Gastrointestinal bleeding with direct oral anticoagulants in patients with atrial fibrillation and anaemia

INTRODUCTION

A high risk of gastrointestinal bleeding has been reported with the use of some direct oral anticoagulants (DOACs). This risk may be of particular concern in individuals with associated anaemia. The aim of this study is to investigate potential differences in the risks of gastrointestinal bleeding and stroke among the four available DOACs in patients with atrial fibrillation (AF) and moderate or severe anaemia.

MATERIALS AND METHODS

All Danish patients diagnosed with incident AF who had a baseline haemoglobin measurement and subsequently initiated DOAC therapy between 2012 and 2021 were identified through administrative registries. Only patients with moderate or severe anaemia (N = 7269) were included and evaluated regarding the risk of hospitalization for gastrointestinal bleeding and stroke. Standardized absolute 1-year risks of stroke and gastrointestinal bleeding were calculated from multivariable Cox regression analyses. DOACs were compared pairwise RESULTS: Compared with apixaban, both dabigatran and rivaroxaban were associated with a significantly increased risk of gastrointestinal bleeding with standardized 1-year risk ratios of 1.73 (95 % confidence interval [CI], 1.10-2.35) and 1.56 (95 % CI, 1.18-1.93), respectively, while no significant difference was seen in the comparison of apixaban with edoxaban 1.32 (95 % CI, 0.41-2.32). No significant differences in gastrointestinal bleeding were observed with pairwise comparisons of dabigatran, rivaroxaban and edoxaban. Finally, no significant difference in stroke risk among the four DOACs was observed.

CONCLUSION

In AF patients with moderate or severe anaemia, apixaban was associated with a significantly lower risk of gastrointestinal bleeding than dabigatran and rivaroxaban. No significant difference in stroke risk was observed across all four available DOACs.

A web-based intervention for patients with an implantable cardioverter defibrillator - A qualitative study of nurses' experiences (Data from the ACQUIRE-ICD study)

Objective

The aim of this study was to explore cardiac nurses' experiences with a comprehensive web-based intervention for patients with an implantable cardioverter defibrillator.

Methods

We conducted an explorative qualitative study based on individual semi-structured interviews with 9 cardiac nurses from 5 Danish university hospitals.

Results

We found one overall theme: "Between traditional nursing and modern eHealth". This theme was derived from the following six categories: (1) comprehensive content in the intervention, (2) patient-related differences in engagement, (3) following the protocol is a balancing act, (4) online communication challenges patient contact, (5) professional collaboration varies, and (6) an intervention with potential. Cardiac nurses were positive towards the web-based intervention and believe it holds a large potential. However, they felt challenged by not having in-person and face-to-face contact with patients, which they found valuable for assessing patients' wellbeing and psychological distress.

Conclusion

Specific training in eHealth communication seems necessary as web-based care entails a shift in the nursing role and requires a different way of communication.InnovationFocusing on the user experience in web-based care from the perspective of cardiac nurses is innovative, and by applying implementation science this leads to new knowledge to consider when developing and implementing web-based care.

Atrial pacing minimization in sinus node dysfunction and risk of incident atrial fibrillation: a randomized trial

BACKGROUND AND AIMS

High percentages of atrial pacing have been associated with an increased risk of atrial fibrillation. This study is aimed at evaluating whether atrial pacing minimization in patients with sinus node dysfunction reduces the incidence of atrial fibrillation.

METHODS

In a nationwide, randomized controlled trial, 540 patients with sinus node dysfunction and an indication for first pacemaker implantation were assigned to pacing programmed to a base rate of 60 bpm and rate-adaptive pacing (DDDR-60) or pacing programmed to a base rate of 40 bpm without rate-adaptive pacing (DDD-40). Patients were followed on remote monitoring for 2 years. The primary endpoint was time to first episode of atrial fibrillation longer than 6 min. Secondary endpoints included longer episodes of atrial fibrillation, and the safety endpoint comprised a composite of syncope or presyncope.

RESULTS

The median percentage of atrial pacing was 1% in patients assigned to DDD-40 and 49% in patients assigned to DDDR-60. The primary endpoint occurred in 124 patients (46%) in each treatment group (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.76-1.25, P = .83). There were no between-group differences in atrial fibrillation exceeding 6 or 24 h, persistent atrial fibrillation, or cardioversions for atrial fibrillation. The incidence of syncope or presyncope was higher in patients assigned to DDD-40 (HR 1.71, 95% CI 1.13-2.59, P = .01).

CONCLUSIONS

Atrial pacing minimization in patients with sinus node dysfunction does not reduce the incidence of atrial fibrillation. Programming a base rate of 40 bpm without rate-adaptive pacing is associated with an increased risk of syncope or presyncope.

Workforce affiliation in primary and secondary prevention Implantable Cardioverter Defibrillator patients - a nationwide Danish study

BACKGROUND AND AIM

There are a paucity of studies investigating workforce affiliation in connection with first-time ICD-implantation. This study explored workforce affiliation and risk markers associated with not returning to work in patients with ICDs.

METHODS

Using the nationwide Danish registers, patients with a first-time ICD-implantation between 2007-2017 and of working age (30-65 years) were identified. Descriptive statistic and logistic regression models were used to describe workforce affiliation and to estimate risk markers associated with not returning to work, respectively. All analyses were stratified by indication for implantation (primary and secondary prevention).

RESULTS

Of the 4,659 ICD-patients of working age, 3,300 patients (71%) were members of the workforce (employed, on sick leave or unemployed) (primary: 1428 (43%); secondary:1872 (57%)). At baseline, 842 primary and 1477 secondary prevention ICD-patients were employed. Of those employed at baseline, 81% primary and 75% secondary prevention ICD-patients returned to work within one-year, whereof more than 80% remained employed the following year. Among patients receiving sick leave benefits at baseline, 25% were employed after one-year. Risk markers of not returning to work were 'younger age' in primary prevention ICD-patients, while 'female sex', 'LVEF ≤40', 'lower income' and '≥3 comorbidities' were risk markers in secondary prevention ICD-patients. Lower educational level was a risk marker in both patient groups.

CONCLUSIONS

High return-to-work proportions following ICD-implantation, with a subsequent high level of employment maintenance were found. Several significant risk markers of not returning to work were identified including 'lower educational level', that posed a risk in both patient groups.Trial registration number: Capital Region of Denmark, P-2019-051.

Long-term risk of cardiovascular implantable electronic device reinterventions following external cardioversion of atrial fibrillation and flutter: A nationwide cohort study

BACKGROUND

External cardioversion (ECV) is an essential part of rhythm control of atrial fibrillation and flutter in patients with and without cardiovascular implantable electronic devices (CIEDs). Long-term follow-up data on ECV-related CIED dysfunctions are limited.

OBJECTIVE

The purpose of this study was to investigate the risk of CIED reintervention following ECV in a nationwide cohort.

METHODS

We identified CIED implants and surgical reinterventions from 2005 to 2021 in the Danish Pacemaker and ICD Register. We included CIED patients undergoing ECV from 2010 to 2019 from the Danish National Patient Registry. For each ECV-exposed generator, 5 matched generators without ECV were identified, and for each ECV-exposed lead, 3 matched leads were identified. The primary endpoints were generator replacement and lead reintervention.

RESULTS

We compared 2582 ECV-exposed patients with 12,910 matched patients with a pacemaker (47%), implantable cardioverter-defibrillator (ICD) (29%), cardiac resynchronization therapy-pacemaker (6%), or cardiac resynchronization therapy-defibrillator (18%). During 2 years of follow-up, 210 ECV-exposed generators (8.1%) vs 670 matched generators (5.2%) underwent replacements, and 247 ECV-exposed leads (5.6%) vs 306 matched leads (2.3%) underwent reintervention. Unadjusted hazard ratios were 1.61 (95% confidence interval [CI] 1.37-1.91; P <.001) for generator replacement and 2.39 (95% CI 2.01-2.85; P <.001) for lead reintervention. One-year relative risks were 1.73 (95% CI 1.41-2.12; P <.001) for generator replacement and 2.85 (95% CI 2.32-3.51; P <.001) for lead reintervention, and 2-year relative risks were 1.39 (95% CI 1.19-1.63; P <.001) and 2.18 (95% CI 1.84-2.57; P <.001), respectively.

CONCLUSION

ECV in patients with a CIED is associated with a higher risk of generator replacement and lead reintervention. The risks of reinterventions were more pronounced within the first year after cardioversion.

Does targeted positioning of the left ventricular pacing lead towards the latest local electrical activation in cardiac resynchronization therapy reduce the incidence of death or hospitalization for heart failure?

BACKGROUND

Cardiac resynchronization therapy (CRT) improves symptoms, health-related quality of life and long-term survival in patients with systolic heart failure (HF) and shortens QRS duration. However, up to one third of patients attain no measurable clinical benefit from CRT. An important determinant of clinical response is optimal choice in left ventricular (LV) pacing site. Observational data have shown that achieving an LV lead position at a site of late electrical activation is associated with better clinical and echocardiographic outcomes compared to standard placement, but mapping-guided LV lead placement towards the site of latest electrical activation has never been investigated in a randomized controlled trial (RCT). The purpose of this study was to evaluate the effect of targeted positioning of the LV lead towards the latest electrically activated area. We hypothesize that this strategy is superior to standard LV lead placement.

METHODS

The DANISH-CRT trial is a national, double-blinded RCT (ClinicalTrials.gov NCT03280862). A total of 1,000 patients referred for a de novo CRT implantation or an upgrade to CRT from right ventricular pacing will be randomized 1:1 to receive conventional LV lead positioning preferably in a nonapical posterolateral branch of the coronary sinus (CS) (control group) or targeted positioning of the LV lead to the CS branch with the latest local electrical LV activation (intervention group). In the intervention group, late activation will be determined using electrical mapping of the CS. The primary endpoint is a composite of death and nonplanned HF hospitalization. Patients are followed for a minimum of 2 years and until 264 primary endpoints occurred. Analyses will be conducted according to the intention-to-treat principle. Enrollment for this trial began in March 2018, and per April 2023, a total of 823 patients have been included. Enrollment is expected to be complete by mid-2024.

CONCLUSIONS

The DANISH-CRT trial will clarify whether mapping-guided positioning of the LV lead according to the latest local electrical activation in the CS is beneficial for patients in terms of reducing the composite endpoint of death or nonplanned hospitalization for heart failure. Results from this trial are expected to impact future guidelines on CRT.

CLINICALTRIALS

GOV IDENTIFIER

NCT03280862.

Impact of Percutaneous Intervention Compared to Pharmaceutical Therapy on Complex Arrhythmias in Patients With Chronic Total Coronary Occlusion. Rationale and Design of the CTO-ARRHYTHMIA Study

Chronic total coronary occlusions (CTO) occur in up to 50 % of patients with coronary artery disease by angiography. In CTO-patients, clinically significant arrhythmia is potentially important and insufficiently investigated. Therefore, the purpose of the CTO-ARRHYTHMIA study was to investigate the incidence of loop recorder detected clinically significant arrhythmias and the effect on arrhythmias of revascularization by CTO-PCI. The study is an independent sub-study of the NOrdic-Baltic Randomized Registry Study for Evaluation of PCI in Chronic Total Coronary Occlusion (NOBLE-CTO); ClinicalTrials.gov Identifier NCT03392415. NOBLE-CTO prospectively collects procedural data, quality of life measures, echocardiographic and cardiac MRI findings before and after treatment as well as clinical outcomes in all CTO patients that may be treated by PCI.

Is the Pattern Changing? Atrial Fibrillation and Screening with Holter Electrocardiograms among Ischemic Stroke Patients in Greenland from 2016 to 2021

A standardized examination regime for ischemic stroke (IS) patients was implemented in Greenland in 2010. Prevalence of atrial fibrillation (AF) of 32% was found among discharged IS patients from 2011 to 2012, and our study aims to estimate the use of Holter ECGs for AF diagnostics and the current prevalence of AF among IS patients in Greenland. Patients discharged from Queen Ingrid's Hospital in Nuuk between 2016 and 2021 with an ICD-10 diagnosis of IS or stroke without specification were included. Data on Holter recordings, age, gender, medical treatment with rivaroxaban or warfarin, and ICD-10 and ICPC codes for AF were extracted for each patient. The overall incidence of IS from 2016 to 2021 was 133/100,000 and unchanged since 2012. Sixty-eight of the study's IS patients (14.5%) had AF, and 46% of IS patients with Holter data accessible had a recording according to international recommendations. Our results indicate that fewer IS patients in Greenland have AF than previously. However, the insufficient use of Holter as a diagnostic tool may explain part of the drop, as well as improved preventive treatment with rivaroxaban among AF patients in Greenland. Regardless, IS remains common, and a focus on diagnostics and preventable risk factors should be maintained.

Adynamic response to cold pain reflects dysautonomia in type 1 diabetes and polyneuropathy

Cardiac autonomic neuropathy (CAN), widely assessed by heart rate variability (HRV), is a common complication of long-term diabetes. We hypothesized that HRV dynamics during tonic cold pain in individuals with type 1 diabetes mellitus (T1DM) could potentially demask CAN. Forty-eight individuals with long-term T1DM and distal symmetrical polyneuropathy and 21 healthy controls were included. HRV measures were retrieved from 24-h electrocardiograms. Moreover, ultra-short-term HRV recordings were used to assess the dynamic response to the immersion of the hand into 2 °C cold water for 120 s. Compared to healthy, the T1DM group had expectedly lower 24-h HRV measures for most components (p < 0.01), indicating dysautonomia. In the T1DM group, exposure to cold pain caused diminished sympathetic (p < 0.001) and adynamic parasympathetic (p < 0.01) HRV responses. Furthermore, compared to healthy, cold pain exposure caused lower parasympathetic (RMSSD: 4% vs. 20%; p = 0.002) and sympathetic responses (LF: 11% vs. 73%; p = 0.044) in the T1MD group. QRISK3-scores are negatively correlated with HRV measures in 24-h and ultra-short-term recordings. In T1DM, an attenuated sympathovagal response was shown as convincingly adynamic parasympathetic responses and diminished sympathetic adaptability, causing chronometric heart rhythm and rigid neurocardiac regulation threatening homeostasis. The findings associate with an increased risk of cardiovascular disease, emphasizing clinical relevance.

Prospects of self-powering leadless pacemakers using piezoelectric energy harvesting technology by heart kinetic motion

This paper studies the possibility of heart kinetic motion for designing a self-powered intracardiac leadless pacemaker by piezoelectric energy harvesting. A Doppler laser displacement sensor measures in vivo heart kinetic motion. Cantilevered and four-point bending piezoelectric harvesters are studied under the measured in vivo heart kinetic motion. The heart movement is above 15 mm. The cantilevered and four-point bending harvesters generate a maximum voltage of ~ 0.28 V and 0.8 V, respectively with the measured heart motion with a heart rate of 168 beats per minute. Two DC/DC converters, LTC3588 and MAX17220, combined with full-bridge rectifiers and their start-up performance are tested.Clinical Relevance-This paper analyzed the heart kinetic motion and establishes the piezoelectric energy harvesting for a new era of self-powered leadless pacemakers.

Long-term cardiovascular outcomes among immigrants and non-immigrants in cardiac resynchronization therapy: a nationwide study

AIMS

To date, potential differences in outcomes for immigrants and non-immigrants with a cardiac resynchronization therapy (CRT), in a European setting, remain underutilized and unknown. Hence, we examined the efficacy of CRT measured by heart failure (HF)-related hospitalizations and all-cause mortality among immigrants and non-immigrants.

METHODS AND RESULTS

All immigrants and non-immigrants who underwent first-time CRT implantation in Denmark (2000-2017) were identified from nationwide registries and followed for up to 5 years. Differences in HF related hospitalizations and all-cause mortality were evaluated by Cox regression analyses. From 2000 to 2017, 369 of 10 741 (3.4%) immigrants compared with 7855 of 223 509 (3.5%) non-immigrants with a HF diagnosis underwent CRT implantation. The origins of the immigrants were Europe (61.2%), Middle East (20.1%), Asia-Pacific (11.9%), Africa (3.5%), and America (3.3%). We found similar high uptake of HF guideline-directed pharmacotherapy before and after CRT and a consistent reduction in HF-related hospitalizations the year before vs. the year after CRT (61% vs. 39% for immigrants and 57% vs. 35% for non-immigrants). No overall difference in 5-year mortality among immigrants and non-immigrants was seen after CRT [24.1% and 25.8%, respectively, P-value = 0.50, hazard ratio (HR) = 1.2, 95% confidence interval (CI): 0.8-1.7]. However, immigrants of Middle Eastern origin had a higher mortality rate (HR = 2.2, 95% CI: 1.2-4.1) compared with non-immigrants. Cardiovascular causes were responsible for the majority of deaths irrespective of immigration status (56.7% and 63.9%, respectively).

CONCLUSION

No overall differences in efficacy of CRT in improving outcomes between immigrants and non-immigrants were identified. Although numbers were low, a higher mortality rate among immigrants of Middle Eastern origin was identified compared with non-immigrants.

Severity of Brugada syndrome disease manifestation and risk of new-onset depression or anxiety: a Danish nationwide study

AIMS

Reduced psychological health is associated with adverse patient outcomes and higher mortality. We aimed to examine if a Brugada syndrome (BrS) diagnosis and symptomatic disease presentation were associated with an increased risk of new-onset depression or anxiety and all-cause mortality.

METHODS AND RESULTS

All Danish patients diagnosed with BrS (2006-2018) with no history of psychiatric disease and available for ≥6 months follow-up were identified using nationwide registries and followed for up to 5 years after diagnosis. The development of clinical depression or anxiety was evaluated using the prescription of medication and diagnosis codes. Factors associated with developing new-onset depression or anxiety were determined using a multivariate Cox proportional hazards regression model. Disease manifestation was categorized as symptomatic (aborted cardiac arrest, ventricular tachycardia, or syncope) or asymptomatic/unspecified at diagnosis. A total of 223 patients with BrS and no history of psychiatric disease were identified (72.6% male, median age at diagnosis 46 years, 45.3% symptomatic). Of these, 15.7% (35/223) developed new-onset depression or anxiety after BrS diagnosis (median follow-up 5.0 years). A greater proportion of symptomatic patients developed new-onset depression or anxiety compared with asymptomatic patients [21/101 (20.8%) and 14/122 (11.5%), respectively, P = 0.08]. Symptomatic disease presentation (HR 3.43, 1.46-8.05) and older age (lower vs. upper tertile: HR 4.41, 1.42-13.63) were significantly associated with new-onset depression or anxiety. All-cause mortality in this group of patients treated according to guidelines was low (n = 4, 1.8%); however, 3/4 developed depression or anxiety before death.

CONCLUSION

Approximately, one-sixth of patients with BrS developed new-onset depression or anxiety following a diagnosis of BrS. Symptomatic BrS disease manifestation was significantly associated with new-onset depression or anxiety.

The role of contractile dyssynchrony in pacing-induced cardiomyopathy: detailed assessment using index of contractile asymmetry

AIMS

The pathophysiological effects of chronic right ventricular pacing and the role of right ventricular lead position are not well understood. Therefore, we investigated the association between left ventricular contractile dyssynchrony and pacing-induced cardiomyopathy (PICM) in patients with chronic right ventricular pacing. Furthermore, we assessed the association between right ventricular lead location and left ventricular contractile dyssynchrony.

METHODS

This was a retrospective study using data from 153 pacemaker patients with normal (≥ 50%) pre-implant left ventricular ejection fraction (LVEF). Baseline and follow-up echocardiograms were analyzed, and PICM was defined as LVEF < 50% with ≥ 10% decrease in LVEF after pacemaker implantation. Relative index of contractile asymmetry (rICA), a novel strain rate-based method, was calculated to quantify left ventricular contractile dyssynchrony between opposing walls in the three apical views. Right ventricular lead position was categorized into anterior septum, posterior septum, free wall, and apex based on contrast-enhanced cardiac computed tomography.

RESULTS

Forty-seven (31%) developed PICM. Overall contractile dyssynchrony, measured by mean rICA, was higher in the PICM group compared with the non-PICM group (1.19 ± 0.21 vs. 1.03 ± 0.19, p < 0.001). Left ventricular anterior-inferior dyssynchrony, assessed in the apical two-chamber view, was independently associated with PICM (p < 0.001). Thirty-seven (24%) leads were implanted anterior septal, 11 (7.2%) posterior septal, 74 (48.4%) apical, and 31 (20.3%) free wall. Left ventricular anterior-inferior dyssynchrony was significantly different between the four pacing lead locations (p < 0.01) with the highest rICA observed in the posterior septal group (1.30 ± 0.37).

CONCLUSIONS

PICM is significantly associated increased contractile dyssynchrony assessed by rICA. This study suggests that especially left ventricular dyssynchrony in the anterior-inferior direction is associated with PICM, and pacing the right ventricular posterior septum resulted in the highest degree of anterior-inferior dyssynchrony. Quantification of left ventricular dyssynchrony by rICA provides important insights to the potential pathophysiology of PICM and the impact of right ventricular lead position.

Use of Nonrecommended Drugs in Patients With Brugada Syndrome: A Danish Nationwide Cohort Study

Background Patients with Brugada syndrome (BrS) are recommended to avoid drugs that may increase their risk of arrhythmic events. We examined treatment with such drugs in patients with BrS after their diagnosis. Methods and Results All Danish patients diagnosed with BrS (2006-2018) with >12 months of follow-up were identified from nationwide registries. Nonrecommended BrS drugs were grouped into drugs to "avoid" or "preferably avoid" according to http://www.brugadadrugs.org. Cox proportional hazards analyses were performed to identify factors associated with any nonrecommended BrS drug use, and logistic regression analyses were performed to examine associated risk of appropriate implantable cardioverter defibrillator therapy, mortality, and a combined end point indicating an arrhythmic event of delayed implantable cardioverter defibrillator implantation, appropriate implantable cardioverter defibrillator therapy, and mortality. During a median follow-up of 6.8 years, 93/270 (34.4%) patients with BrS (70.4% male, median age at diagnosis 46.1 years [interquartile range, 32.6-57.4]) were treated with ≥1 nonrecommended BrS drugs. No difference in any nonrecommended BrS drug use was identified comparing time before BrS diagnosis (12.6%) with each of the 5 years following BrS diagnosis (P>0.05). Factors associated with any nonrecommended BrS drug use after diagnosis were female sex (hazard ratio [HR]) 1.83 [95% CI, 1.15-2.90]), psychiatric disease (HR, 3.63 [1.89-6.99]), and prior use of any nonrecommended BrS drug (HR, 4.76 [2.45-9.25]). No significant association between any nonrecommended BrS drug use and implantable cardioverter defibrillator therapy (n=20/97, odds ratio [OR], 0.7 [0.2-2.4]), mortality (n=10/270, OR, 3.4 [0.7-19.6]), or the combined end point (n=38/270, OR, 1.7 [0.8-3.7]) was identified. Conclusions One in 3 patients with BrS were treated with a nonrecommended BrS drug after BrS diagnosis, and a BrS diagnosis did not change prescription patterns. More awareness of nonrecommended drug use among patients with BrS is needed.

Novel non-invasive ECG imaging method based on the 12-lead ECG for reconstruction of ventricular activation: A proof-of-concept study

Aim

Current non-invasive electrocardiographic imaging (ECGi) methods are often based on complex body surface potential mapping, limiting the clinical applicability. The aim of this pilot study was to evaluate the ability of a novel non-invasive ECGi method, based on the standard 12-lead ECG, to localize initial site of ventricular activation in right ventricular (RV) paced patients. Validation of the method was performed by comparing the ECGi reconstructed earliest site of activation against the true RV pacing site determined from cardiac computed tomography (CT).

Methods

This was a retrospective study using data from 34 patients, previously implanted with a dual chamber pacemaker due to advanced atrioventricular block. True RV lead position was determined from analysis of a post-implant cardiac CT scan. The ECGi method was based on an inverse-ECG algorithm applying electrophysiological rules. The algorithm integrated information from an RV paced 12-lead ECG together with a CT-derived patient-specific heart-thorax geometric model to reconstruct a 3D electrical ventricular activation map.

Results

The mean geodesic localization error (LE) between the ECGi reconstructed initial site of activation and the RV lead insertion site determined from CT was 13.9 ± 5.6 mm. The mean RV endocardial surface area was 146.0 ± 30.0 cm² and the mean circular LE area was 7.0 ± 5.2 cm² resulting in a relative LE of 5.0 ± 4.0%.

Conclusion

We demonstrated a novel non-invasive ECGi method, based on the 12-lead ECG, that accurately localized the RV pacing site in relation to the ventricular anatomy.

External cardioversion of atrial fibrillation and flutter in patients with cardiac implantable electrical devices

BACKGROUND

Atrial fibrillation and flutter are often treated with external electrical cardioversion (ECV) in patients with potentially electrically sensitive cardiovascular implantable electronic devices (CIED). Long-term follow-up data on contemporary CIED undergoing ECV is sparse. The aim is to investigate shock-related complications and impact on CIEDs.

METHODS

All ECV procedures from 2010 to 2020 in patients with CIED performed at a tertiary university hospital were identified in the Danish National Patient Registry. Changes in device measurements after ECV were retrospectively studied and procedure-related complications were identified by review of medical records.

RESULTS

We analyzed 763 ECV procedures in 372 patients, median device implant time 1.9 years. The mean age of patients was 69.9 ± 9.9 years of which 73.4% were men. We identified two cases of device programming changes and four cases of premature battery depletion (≤3 years after device implant). Minor changes in device measurements were found for impedances, sensing, and pacing thresholds. No patients died due to ECV-related device dysfunctions within the first 12 months after cardioversions.

CONCLUSION

External cardioversion in patients with contemporary pacemakers and implantable cardioverter-defibrillators seems safe in the majority of patients. Clinically important changes in device function following cardioversion were rarely observed but may be critical for device function. In an observational study, causality between cardioversion and device dysfunction cannot be established. For patient safety, we suggest that routine device interrogation after cardioversion still should be part of standard care.

Sex differences in the course of implantable cardioverter defibrillator concerns (Results from the Danish national DEFIB-WOMEN study)

OBJECTIVE

The implantable cardioverter defibrillator (ICD) is used to treat malignant ventricular arrhythmias. Since 33% of patients experience ICD-related concerns, we examined sex differences in ICD concerns and correlates of ICD concerns during 24 months of follow-up after implantation of an ICD.

METHODS

Patients from the DEFIB-WOMEN study (n = 1515; 81.6% male patients) completed questionnaires on ICD concerns, anxiety, depression, and Type D personality at five measure points (baseline, 3-, 6-, 12- and 24-months post-implantation).

RESULTS

Male patients scored on average 7.0 (6.8) points on ICD concerns at the time of implantation and female patients scored on average 10.5 (8.2) points. We found statistically significant sex differences in ICD concerns at all measurement points, with female patients scoring 2.77 points (8.7% of the maximum score of 32) higher than male patients. ICD concerns decreased in both sexes the first 6 months and then levelled out. For both sexes, ICD concerns at baseline were significantly correlated with ICD concerns at 24-months follow-up. Anxiety at baseline was correlated with ICD concerns in female patients, while depression at baseline and at least one experienced shock correlated with ICD concerns in male patients.

CONCLUSION

Female patients reported more ICD concerns at all measurement points compared to male patients, but for both sexes ICD concerns decreased in the first 6 months. ICD shock, anxiety, depression, and ICD concerns at baseline were correlates of ICD concerns at 24-months follow-up.

Patients with an implantable cardioverter defibrillator at risk of poorer psychological health during 24 months of follow-up (results from the Danish national DEFIB-WOMEN study)

OBJECTIVE

Identify implantable cardioverter defibrillator (ICD) patients at risk of distress (i.e., depression, anxiety, and ICD concerns) and associated risk factors.

METHOD

First-time ICD patients (n = 1503) from the Danish national DEFIB-WOMEN study completed questionnaires at baseline, 3, 6, 12 and 24 months.

RESULTS

Of patients with low scores on distress, only 4%-7.2% experienced an increase in distress during 24 months of follow-up (FU), while 30.5%-52.5% with increased levels were likely to maintain increased levels at FU. Higher education, higher age, female sex, and good physical functioning at baseline were associated with less depression, anxiety and ICD concerns at FU. Previous psychological problems, smoking, Type D personality, NYHA class III-IV - all assessed at baseline - and shocks during FU were associated with depression, anxiety and ICD concerns.

CONCLUSIONS

Generally, patients' psychological health improved, but patients with increased baseline scores were more likely to have increased scores at FU. We need to be vigilant if patients report elevated distress, particularly if they have depression at baseline, as depression seems more persistent. Given the impact of depression on health-related quality of life and prognosis, they should be screened and monitored closely.

Risk and Subtypes of Stroke Following New-Onset Postoperative Atrial Fibrillation in Coronary Bypass Surgery: A Population-Based Cohort Study

Background New-onset postoperative atrial fibrillation (POAF) develops in approximately one-third of patients undergoing cardiac surgery and is associated with a higher incidence of ischemic stroke and increased mortality. However, it remains unknown to what extent ischemic stroke events in patients with POAF are cardioembolic and whether anticoagulant therapy is indicated. We investigated the long-term risk and pathogenesis of postoperative stroke in patients undergoing coronary artery bypass grafting experiencing POAF. Methods and Results This was a register-based cohort study. Data from the WDHR (Western Denmark Heart Registry) were linked with the DNPR (Danish National Patient Register), the Danish National Prescription Register, and the Cause of Death Register. All stroke diagnoses were verified, and ischemic stroke cases were subclassified according to pathogenesis. Furthermore, investigations of all-cause mortality and the use of anticoagulation medicine for the individual patient were performed. A total of 7813 patients without a preoperative history of atrial fibrillation underwent isolated coronary artery bypass grafting between January 1, 2010, and December 31, 2018, in Western Denmark. POAF was registered in 2049 (26.2%) patients, and a postoperative ischemic stroke was registered in 195 (2.5%) of the patients. After adjustment, there was no difference in the risk of ischemic stroke (hazard ratio [HR], 1.08 [95% CI, 0.74-1.56]) or all-cause mortality (HR, 1.09 [95% CI, 0.98-1.23]) between patients who developed POAF and non-POAF patients. Although not statistically significant, patients with POAF had a higher incidence rate (IR; per 1000 patient-years) of cardioembolic stroke (IR, 1 [95% CI, 0.6-1.6] versus IR, 0.5 [95% CI, 0.3-0.8]), whereas non-POAF patients had a higher incidence rate of large-artery occlusion stroke (IR, 1.1 [95% CI, 0.8-1.5] versus IR, 0.7 [95% CI, 0.4-1.4]). Early initiation of anticoagulation medicine was not associated with a lower risk of ischemic stroke. However, patients with POAF were more likely to die of cardiovascular causes than non-POAF patients (P<0.001). Conclusions We found no difference in the adjusted risk of postoperative stroke or all-cause mortality in POAF versus non-POAF patients. Patients with POAF after coronary artery bypass grafting presented with a higher, although not significant, proportion of ischemic strokes of the cardioembolic type.

Validation of the national Danish ablation database: a retrospective, registry-based validation study

Aim.To validate the National Danish Ablation Database (NDAD) by investigating to what extent data in NDAD correspond to medical records.Type of study. Non-blinded, registry-based, retrospective, validation study. Material and methods. A sample of patients who underwent ablation for atrial fibrillation in Denmark between 1 January 2016 and 31 December 2016 were included. By utilizing medical records as gold standard, positive predictive (PPV) and negative predictive values (NPV) for NDAD were assessed and presented as five main categories: arrhythmia characteristics, demographics, cardiac history, complications, and medication. PPV's and NPV's exceeding 90% were considered as high agreement. Results. 597 patients (71.0% males) were included in the study. Median age was 63.1 (IQR: 54.9-68.4) years. The median PPV and NPV estimates across all variables were respectively 90.4% (95% CI: 68%-95.2%) (PPV) and 99.4% (95% CI: 98.4%-99.8%) (NPV) at baseline, and 91.7% (95% CI: 67.4%-95.4%) (PPV) and 99.3% (98.2%-99.3%) (NPV) at follow-up. Conclusion. The data registered in NDAD agrees to a great extent with the patients' medical records, suggesting NDAD is a database with high validity. As a result of low complication rate, the PPV- and NPV-estimates among complication variables were prone to somewhat greater uncertainty compared to the rest.

Safety and efficacy of direct oral anticoagulants in patients with anaemia and atrial fibrillation: an observational nationwide Danish cohort study

AIMS

The aim of this study was to evaluate the risk of stroke and bleeding among patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOACs) despite anaemia at treatment initiation time.

METHODS AND RESULTS

All Danish patients (N = 41 321) diagnosed with incident AF, having a baseline haemoglobin (Hb), and subsequently initiated DOAC therapy between 2012 and 2019 were identified through administrative registry databases. Patients with anaemia were subdivided according to the World Health Organization classification of anaemia and evaluated regarding risk of stroke and composite bleeding endpoint [hospitalization due to urogenital, gastrointestinal (GI), or intracranial bleeding or epistaxis]. Standardized absolute 1-year risks of stroke and composite bleeding endpoint were calculated using multivariable Cox regression analyses. The standardized absolute 1-year risk difference for composite bleeding increased by 0.96% [95% confidence interval (CI) 0.38-1.54] for patients with moderate/severe anaemia compared with patients with no anaemia. This risk was mainly driven by an increase in standardized absolute 1-year risk for serious GI bleeding, which increased by 0.41% (95% CI 0.19-0.63). No significant difference in standardized absolute 1-year bleeding risk was observed among patients with mild anaemia compared with patients with no anaemia 0.36% (95% CI -0.10 to 0.82). No significant difference in standardized absolute 1-year risk of stroke was observed among patients with mild anaemia, -0.16% (95% CI -0.13 to 0.15), and moderate/severe anaemia, -0.47% (95% CI -0.16 to 0.19), compared with patients with no anaemia.

CONCLUSION

For AF patients receiving DOACs, moderate/severe anaemia is a risk factor for serious GI bleeding, while stroke risk is the same regardless of whether anaemia was present at baseline or not.

Heart failure hospitalizations and diuretic use before and after first-time pulmonary vein isolation ablation for atrial fibrillation among patients with heart failure

Background

Small randomized clinical trials have found that patients with heart failure (HF) and atrial fibrillation (AF) randomized to an ablation strategy for AF experienced improved cardiovascular outcomes. We examined the relation in routine clinical practice.

Purpose

We aimed to assess if first-time pulmonary vein isolation ablation (PVI) for AF among patients with HF was associated with decrease in HF hospital admissions rates and furosemide dosage in the year after PVI compared with the year before.

Methods

We identified patients with HF and available left ventricular ejection fraction (LVEF) treated with a first-time PVI using the Danish Ablation Registry, and alive at 1-year follow-up. Patient comorbidities and concomitant pharmacotherapy (including furosemide dosage and HF hospital admissions) were identified utilizing Danish nationwide registries. For inclusion, patients were required to have been diagnosed with HF in an in- or outpatient setting &lt;10 years of first-time PVI or have a LVEF at the time of PVI ≤45%. Patients were grouped according to LVEF at time of PVI: ≤35%, 36–45%, and &gt;45%. For comparison of HF hospital admission and furosemide usage before and after PVI, McNemars test were used. Wilcox signed-rank test were used to test difference in furosemide dosage before and after PVI.

Results

We identified 668/3450 patients with HF treated with first-time PVI for AF between 2010–2017 (median age 62 years [Q1,Q3=56,69 years], 81% male, and median LVEF 45% [Q1,Q3=40,60%]). Of these, 13 patients (2%) died during one-year follow-up. Overall, 36% of patients with HF had one or more HF hospital admissions the year before PVI compared with 7% in the year after PVI (p&lt;0.0001) (Figure 1). Patients with LVEF ≤35% had the highest proportion of HF hospital admissions the year before PVI (53%) and was reduced more than 4-fold (13%) in the year after first-time PVI, with consistent findings in all LVEF groups (Figure 1). At the time of PVI, 36% of patients with HF were treated with furosemide compared with 30% in the year after PVI (p&lt;0.0001) (Figure 2). Moreover, we identified significant reductions in furosemide dose in the year after PVI compared with the year before (median dose 60 mg [Q1,Q3=30,80 mg] and 20 mg [Q1,Q3=0,60 mg], respectively, p=0.001). Here, reductions in furosemide requirements were consistent across LVEF subgroups.

Conclusion

Patients with HF treated with a first-time PVI strategy for AF had a 5-fold decrease in HF hospital admissions in the following year compared with the year before PVI. Among patients treated with furosemide at time of PVI, significant reductions in dose one year after PVI was identified but also significant reductions in proportion of patients requiring any furosemide at all.

Funding Acknowledgement

Type of funding sources: None.

Risk of lead explantation after first-time implantation of cardiac implantable electronic device as a function of comorbidity: a nationwide study

Background

The benefit of cardiac implantable electronic devices (CIEDs) is challenged by the risk of procedure-related complications and lead explantation. Whether patient comorbidity burden is associated with risk of lead explantation &lt;6 months of implantation is unknown.

Purpose

We assessed the risk of lead explantation and its association with comorbidity burden within 6 months after first-time CIED implantation.

Methods

The study population comprised patients ≥18 years old with first-time CIED implantation (i.e., pacemaker [PM], implantable cardioverter defibrillator [ICD], and cardiac resynchronisation therapy with defibrillator [CRT-D] or without [CRT-P]) using Danish nationwide registries including the Danish Pacemaker and ICD registry (1 January 2000 to 30 June 2018). Patients were followed from their first-time CIED implantation and 6 months forward. Patient comorbidity burden was categorised in four groups according to the Charlson Comorbidity Index (CCI) score: 0 (none), 1–2 (mild), 3–4 (moderate), and ≥5 (severe). Multivariable cause-specific Cox regression was performed to assess risk of lead explantation according to comorbidity burden, with death as competing risk. Comorbidity burden was adjusted for sex, age, type of CIED, and body mass index categories.

Results

We identified 73,491 patients with first-time CIED implantation including 55,733 (75.8%) with PM, 11,351 (15.5%) with ICD, 2,989 (4.1%) with CRT-P, and 3,418 (4.7%) with CRT-D. In total, 1,049 (1.4%) patients underwent lead explantation. The median age of the study population was 75.1 years [25th-75th percentile 66.2–82.5 years], and 62.1% were male. Patients undergoing lead explantation had higher median CCI score, compared with those not undergoing lead explantation (2 [1–3] and 1 [0–3], respectively). The median age and distribution of sex were similar in both groups. In the multivariable Cox regression model (Figure 1), an increase in patient comorbidity burden was associated with higher hazard ratio [HR] of lead explantation, compared with CCI score 0 (CCI score 1–2: HR=1.38 [95% confidence interval [CI]: 1.12–1.69], CCI score 3–4: HR=1.61 [95% CI: 1.28–2.03], and CCI score ≥5: HR=1.60 [95% CI: 1.25–2.05]).

Conclusion

Risk of lead explantation within 6 months after first-time implantation of cardiac implantable electronic device was 1.4% and associated with higher comorbidity burden.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Independent Research Fund Denmark

Incidence in atrial fibrillation in Denmark in relation to country of origin: a nationwide register-based study

Background

Immigrants' healthcare needs can be a considerable challenge, as their risk profile can differ from the native population, and they may experience barriers to accessing health services in recipient countries. Immigration is projected to increase further due to conflicts and climate changes, and awareness on immigrants' health status is therefore warranted. Atrial fibrillation (AF) is the most common sustained arrhythmia with an estimated prevalence of approximately 2%. However, there is a paucity of data on AF epidemiology among immigrants.

Purpose

The aim of this study is to examine incidence of AF hospital diagnoses according to country of origin and to study if there is a difference in risk between immigrants and Danish born individuals.

Methods

The study period included 1st of January 1998 to 31st of December 2017 and the population consisted of all Danish citizens aged 45 or older. We included individuals as they turned 45 during the study period. Individuals who had been diagnosed with AF were excluded. Data was obtained from the Danish National Patient Registry and the Civil Registration System. Country of origin was based on the ten most represented counties in the population. Immigrants were defined as people born outside Denmark with none of the parents being both Danish citizens and born in Denmark. AF was defined as a hospital diagnosis according to international Classification of Diseases (ICD) version 8 and 10. Poisson regression were used to compute relative risk (RR) and associated 95% confidence intervals (CI). RRs were adjusted for sex, age, socioeconomic status, visits to general practitioner and comorbidity.

Results

The study population consist of 3,596,234 Danish-Born and 215,401 immigrants. A total of 334,636 had an incident AF diagnosis during the study period. Compared to Danish-born individuals, migrants from the Nordic countries had a higher adjusted RR of being diagnosed with AF: Norway 1.21 [95% CI: 1.05; 1.40], Sweden 1.16 [95% CI: 0.99; 1.35] and Germany 1.17 [95% CI: 1.06; 1.28]. In contrast, lower adjusted RRs were observed for individuals from Poland (0.82 [95% CI: 0.67; 1.01]), UK (0.89 [95% CI: 0.73; 1.08]), and the US (0.95 [95% CI: 0.72; 1.25]), respectively, and in particular for individuals from the non-Western countries: Turkey (0.49 [95% CI: 0.40; 0.59], Iran (0.48 [95% CI: 0.36; 0.65]), Iraq (0.32 [95% CI: 0.22; 0.45] and Bosnia-Herzegovina (0.63 [95% CI: 0.49; 0.79]).

Conclusion

Substantial variation in the incidence rate of incident AF hospital diagnoses according to country of origin. Further studies are warranted in order to clarify to what extent these differences reflets true differences in AF incidence or ethnic inequalities in the detection of AF in the health care system.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Karen Elise Jensen Foundation

History of betablocker treatment breaks and risk of ventricular tachyarrhythmias among patients with heart failure and implantable cardioverter defibrillator: a nationwide cohort study

Background

Beta-blockers have in randomized clinical trials been shown to reduce the risk of life-threatening arrhythmias and sudden cardiac death (SCD) in patients with heart failure (HF), and treatment is a class 1A recommendation in current guidelines. Thus, beta-blocker treatment breaks (i.e. planned break, beta-blocker related side-effects, or poor adherence) may increase risk of life-threatening arrhythmias and SCD. Whether patients with HF and a history of beta-blocker treatment breaks before implantable cardioverter defibrillator (ICD) is associated with increased risk of device related therapy and mortality is largely unknown.

Aims

In patients with HF and an ICD alone or combined with cardiac resynchronization therapy (CRT-D), we examined the association between a history of a beta-blocker treatment breaks prior to device implantation and the risk of appropriate and inappropriate device related therapy (i.e., anti-tachycardia pacing [ATP] or DC shock [DC]), and all-cause mortality.

Methods

Using the Danish Pacemaker and ICD Registry, we identified all patients with HF receiving a first-time ICD (2000–2018). Beta-blocker treatment breaks &gt;60 consecutive days up to 3 years prior to device implantation were identified using the National Prescription Registry. Patients were able to switch between beta-blockers and were required to be in treatment at the time of implantation. We used multivariable Cox regressions to compare the 1-year risks of device-related therapy and all-cause mortality between patients with and without a history of a beta-blocker treatment break.

Results

We identified 9,239 patients with HF and an ICD (82.6% male; median age 67 years). A total of 82.5% had ischemic heart disease, 33.9% atrial fibrillation, and 33.1% of ICDs were secondary prophylaxis. During one-year follow-up, 5.7% of all patients died and appropriate DC and appropriate ATP was identified for 3.9% and 6.7% of patients, respectively. Overall, 14.6% of all HF patients had one or more beta-blocker treatment break &gt;60 days. Compared with HF patients with no history of treatment breaks, a history of treatment breaks &gt;60 days were associated with increased risk of appropriate DC (hazard ratio (HR)=1.33; 95% confidence interval [CI], 1.02–1.73) and appropriate ATP (HR 1.30; CI, 1.06–1.59), but also inappropriate DC and ATP therapy (Figure 1). There was no difference between groups with respect to all-cause mortality (HR=0.96; CI: 0.76–1.22). Treatment breaks of &gt;30 or &gt;90 days were also evaluated and yielded similar results as the main analysis.

Conclusion

Patients with heart failure who had a history of treatment breaks with beta-blockers prior to ICD implantation was associated with a higher 1-year risk of appropriate and inappropriate shocks and anti-tachycardia pacing, but not all-cause mortality.

Funding Acknowledgement

Type of funding sources: None.

Staphylococcus aureus bacteremia in Danish patients with cardiac implantable electronic devices: an explorative epidemiological study

Background

Device-related infection is the most common serious complication in patients with cardiac implantable electronic devices (CIED). Staphylococcus aureus accounts for up to 30% of CIED-related infections. There is a lack of scientific literature investigating risk of Staphylococcus aureus bacteremia (SAB) in CIED-patients.

Purpose

We aimed to describe the risk of SAB in Danish patients with a CIED through the years 2000–2018 compared to the background population.

Methods

Patients who received a CIED from 2000–2018 were identified from The Danish National Pacemaker and ICD Register. Patients were matched 1:5 on age and gender with the background population. We identified the primary endpoint of first time SAB from The National Danish Staphylococcus Aureus Bacteremia Database. The cumulative incidence of SAB was calculated using the Aalen-Johansen estimator, adding competing risk of death into account. Hazard ratios were estimated by Cox regression models adjusting for age and gender. Crude rates of relapse SAB, defined as a new SAB episode 14–180 days after first SAB, and device extractions were reported for all patients who survived 14 days from SAB diagnosis.

Results

We identified 79,324 CIED-patients (pacemaker (PM) = 61,227; Implantable Cardioverter Defibrillator (ICD) = 11,635; Cardiac resynchronization therapy, PM or ICD (CRT) = 6,364 and 396,590 matched controls (median age 75.5±13.3 years; 61% males). Age and gender distribution differed significantly by device type (age: PM 76.1±12.1; ICD 62.4±13.4; CRT 68.0±11.1; males: PM: 55.6%, ICD% 75.5: CRT: 80.9%). Across a mean follow-up of 5.9 (±4.6) years, we observed first episode of SAB in 1,430 (1.8%) CIED-patients, compared to 2,599 (0.7%) patients in the control population (p&lt;0.001).

The 10-year cumulative incidence of SAB was 1.0% for controls and 2.2% for CIED patients. The risk of SAB differed substantially by device type (Figure 1). Compared to controls and adjusted for age and gender, increasing hazard ratios for SAB were observed with more advanced devices: PM 1.12 (1.11–1.13); ICD 1.36 (1.33–1.39); CRT 1.55 (1.51–1.59). However, CIED-patients with SAB did not have higher 30-day mortality rates than the non-CIED control population with SAB (Controls 34.8%; PM 35.1%; ICD 28.1% CRT 26.1%, p=0.016). Out of all SAB patients who survived 14 days from SAB diagnosis (Controls=1,672; CIED=1,107), relapse SAB occurred in 52 (3.1%) controls and in 51 (4.6%) CIED-patients (PM 4.0%; ICD 5.8%; CRT 6.3%). Device extraction within 14 and 30 days from SAB diagnosis was undertaken in less than 30% of the CIED-patients (PM: 11.3/13.6%; ICD: 22.7/27.5%; CRT: 17.4/20.1%).

Conclusion

The occurrence of SAB was higher in CIED patients compared with controls and increased with more advanced devices. There was no difference in 30-day mortality after SAB between CIED patients and controls. Relapse SAB occurred in less than 7%, despite a low percentage of early device extractions.

Funding Acknowledgement

Type of funding sources: None.

Risk of pacing-induced cardiomyopathy in patients with high-degree atrioventricular block – comparison between right ventricular pacing sites using computed tomography

Background

Right ventricular (RV) pacing may induce significant left ventricular (LV) dyssynchrony resulting in pacing-induced cardiomyopathy (PICM). LV activation sequence is affected by RV pacing site and previous studies suggest that RV septal pacing may be superior compared to traditional RV apical pacing. However, results are conflicting and randomized controlled trials have failed to show clear benefits from RV septal pacing. Traditionally, studies have applied fluoroscopy to determine RV lead implantation site. However, locating pacing site using this method is known to be inaccurate and poorly reproducible compared with cardiac computed tomography (CT). The purpose of our study was to evaluate the association between RV pacing site determined by cardiac CT and risk of PICM.

Methods

We retrospectively included 153 patients with pre-implant LV ejection fraction (LVEF) ≥50% who underwent fluoroscopy-guided dual chamber pacemaker implantation due to high-degree atrioventricular block between March 2012 and May 2020. All patients attended a follow-up visit including cardiac CT and transthoracic echocardiography. RV lead position was evaluated from CT dividing the RV into three segments: apical, septum or free wall (Figure 1). Furthermore, RV lead position estimated by the implanting physician, using fluoroscopy during pacemaker implantation, was retrieved from medical records. The primary endpoint was PICM defined as ≥10% decrease in LVEF from time of pacemaker implantation to follow-up, resulting in LVEF &lt;50%.

Results

Mean duration of follow-up was 3.7 years (range 2.1–8.7). The implanting physician estimated 131 (85.6%) leads to be located septal, 5 (3.3%) located non-septal and 17 (11.1%) were unknown. Based on CT, 48 (31.4%) leads were located septal and 105 (68.6%) were located non-septal of which 31 were located on the free wall (20.4%). With CT as the golden standard, 47 (35%) leads were estimated correctly during fluoroscopy-guided implantation. No significant differences between patient characteristics in the CT-estimated septal and non-septal groups were observed except for ischemic heart disease (P=0.05) (Table 1). There were 16 (33.3%) patients in the septal group who developed PICM compared to 31 (29.5%) in the non-septal group (P=0.6). Adjusting for ischemic heart disease did not change this result. In the septal group, the change in LVEF from baseline to follow-up was −9.0±10.4% compared to −7.5±9.1% in the non-septal group (P=0.4).

Conclusion

In total 31% developed PICM despite having a normal pre-implant LVEF with no observed difference between RV septal and non-septal pacing. With CT as the golden standard, RV leads were inaccurately located during fluoroscopy-guided pacemaker implantation with only 35% being located correctly. Misclassification of pacing sites in previous studies may have contributed to the inconsistent results.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Svend Andersens FondKarl G Andersens Fond

Long-term risk of replacement of cardiovascular implantable electronic devices following external cardioversion

Introduction

External cardioversion (ECV) with transthoracic shock is a recommended and important part of the rhythm control strategy regardless of cardiovascular implantable electronic devices (CIED). Studies and case reports have demonstrated rare, but serious CIED malfunctions related to the ECV procedure. However, follow-up data on contemporary CIEDs undergoing ECV procedures are limited. The aim of this study is to investigate the long-term risk of generator replacements following an ECV procedure.

Methods

All CIED implants and surgical re-interventions in Denmark were identified in the Danish Pacemaker and ICD Register from January 2005 to April 2021. The ECV procedures were identified in the Danish National Patient Registry from January 2010 to February 2019. For each patient undergoing ECV, five matched (age, sex, and type of CIED) controls without previous ECV were identified. Time to generator replacement was estimated using competing risk analyses, with death, extraction and up-/down-grade being competing events. Risks were estimated by the pseudo-observation method.

Results

We identified in total 3,924 ECV-events in 2,610 CIED patients with 74.4% male. Mean age of patients at first ECV-procedure were 68.6±11.7 years, and median implant time was 1.5 year. The type of CIED included 50% of pacemakers, 28% of Implantable Cardioverter Defibrillators, and 22% of Cardiac Resynchronization Therapy-systems. During the first 5 years of follow-up, 451 (17.3%) of the shock-exposed devices were replaced vs. 2,000 (15.2%) of the unexposed devices. The relative risks (RR) of device replacement were 1.43 (95% CI: 0.5; 2.4) after 12 months, 1.44 (95% CI: 0.1; 2.8) after 24 months, and −0.53 (95% CI: −2.8; 1.7) after 5 years. The cumulated incidence of first endpoint: Replacement, death, extraction, and up-/down-grade are illustrated in Figure 1. A larger proportion of patients died in the shock-exposed group with n=427 (16.4%) compared to n=1,588 (12.2%) in the unexposed group during 5-years of follow-up with RR=3.2 (95% CI: 1.2; 5.3) of dead before other events.

Conclusion

Contemporary CIEDs do not indicate different risk of generator replacement following external cardioversion with transthoracic shocks. Shock-exposed device patients were more prone for extraction and death.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This is work was financed by Department of Cardiology, Aalborg University Hospital and supported by Karl G. Andersen foundation.

Risk of pacemaker implantation after femur fracture in patients with and without a history syncope: a Danish nationwide registry-based follow-up study

BACKGROUND

It has previously been described that fall-associated injuries including fractures are commonly observed among patients with bradyarrhythmia. However, knowledge on the risk of pacemaker implantation after admission due to femur fracture from large population-based epidemiologic data is lacking. Therefore, we investigated the risk of pacemaker implantation following femur fracture in patients with and without a history of previous syncope.

METHODS

All patients with femur fracture between 2005-2017 were identified using the Danish Nationwide Patient Registry. Among these, patients already having a pacemaker were excluded. Primary outcome was one-year risk of pacemaker implantation and secondary outcome was one-year all-cause mortality. Multivariable logistic regression was used to obtain absolute and relative risks of the study endpoint in relation to patients with versus without history of syncope and standardized to the age, sex, selected comorbidity and pharmacotherapy distribution of all patients.

RESULTS

Of 93,093 patients with femur fracture, 5508 (5.9%) had a history of syncope within five years. Patients with prior syncope were slightly older (84 vs. 83 years), more often male (33.6% vs. 29.4%), and had more often comorbidities relative to those without history of syncope. All-cause mortality was significantly higher among those with previous history of syncope compared to those without previous syncope (29.9% vs. 28.6%, P = 0.021). The relative mortality risk was 1.05 (95% CI: 1.01-1.09, P = 0.021). A total of 695 (0.8%) patients underwent pacemaker implantation within 5 years following femur fracture, and a significantly higher proportion of patients with syncope had a pacemaker implanted within one year (1.6% vs. 0.7%, P < 0.001; relative risk, 2.01 [95% CI: 1.55-2.46]).

CONCLUSIONS

In patients with femur fracture, a history of syncope was significantly associated with a higher one-year risk of pacemaker implantation.

Non-invasive estimation of QLV from the standard 12-lead ECG in patients with left bundle branch block

Background: Cardiac resynchronization therapy (CRT) is a treatment for patients with heart failure and electrical dyssynchrony, i.e., left bundle branch block (LBBB) ECG pattern. CRT resynchronizes ventricular contraction with a right ventricle (RV) and a left ventricle (LV) pacemaker lead. Positioning the LV lead in the latest electrically activated region (measured from Q wave onset in the ECG to LV sensing by the left pacemaker electrode [QLV]) is associated with favorable outcome. However, optimal LV lead placement is limited by coronary venous anatomy and the inability to measure QLV non-invasively before implantation. We propose a novel non-invasive method for estimating QLV in sinus-rhythm from the standard 12-lead ECG.

Methods: We obtained 12-lead ECG, LV electrograms and LV lead position in a standard LV 17-segment model from procedural recordings from 135 standard CRT recipients. QLV duration was measured post-operatively. Using a generic heart geometry and corresponding forward model for ECG computation, the electrical activation pattern of the heart was fitted to best match the 12-lead ECG in an iterative optimization procedure. This procedure initialized six activation sites associated with the His-Purkinje system. The initial timing of each site was based on the directions of the vectorcardiogram (VCG). Timing and position of the sites were then changed iteratively to improve the match between simulated and measured ECG. Noninvasive estimation of QLV was done by calculating the time difference between Q-onset on the computed ECG and the activation time corresponding to centroidal epicardial activation time of the segment where the LV electrode is positioned. The estimated QLV was compared to the measured QLV. Further, the distance between the actual LV position and the estimated LV position was computed from the generic ventricular model.

Results: On average there was no difference between QLV measured from procedural recordings and non-invasive estimation of QLV (ΔQLV=−3.0±22.5 ms, p=0.12). Median distance between actual LV pacing site and the estimated pacing site was 18.6 mm (IQR 17.3 mm).

Conclusion: Using the standard 12-lead ECG and a generic heart model it is possible to accurately estimate QLV. This method may potentially be used to support patient selection, optimize implant procedures, and to simulate optimal stimulation parameters prior to pacemaker implantation.

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.

Palpebral Fissure Response to Phenylephrine Indicates Autonomic Dysfunction in Patients With Type 1 Diabetes and Polyneuropathy

Purpose

The superior and inferior tarsal muscles are sympathetically innervated smooth muscles. Long-term diabetes often leads to microvascular complications, such as, retinopathy and autonomic neuropathy. We hypothesized that diabetes induces (1) sympathetic paresis in the superior and inferior tarsal muscles and that this measure is associated with (2) the severity of diabetic retinopathy, (3) the duration of diabetes, and (4) autonomic function. In addition, association between the severity of retinopathy and autonomic function was investigated.

Methods

Forty-eight participants with long-term type 1 diabetes and confirmed distal symmetrical polyneuropathy were included. Palpebral fissure heights were measured bilaterally in response to topically applied 10% phenylephrine to the right eye. The presence of proliferative diabetic retinopathy (PDR) or nonproliferative diabetic retinopathy and disease duration were denoted. Time and frequency derived heart rate variability parameters obtained from 24-hour continuous electrocardiography were recorded.

Results

The difference in palpebral fissure heights between phenylephrine treated and untreated eyes (∆PFH) was 1.02 mm ± 0.29 (P = 0.001). The ∆PFH was significantly lower in the PDR group (0.41 mm ± 0.43 vs. 1.27 mm ± 1.0), F(1,35) = 5.26, P = 0.011. The ∆PFH was lower with increasing diabetes duration, r(37) = -0.612, P = 0.000. Further, the ∆PFH was lower with diminished autonomic function assessed as total frequency power in electrocardiogram (r = 0.417, P = 0.014), and sympathetic measures of very low (r = 0.437, P = 0.010) and low frequency power (r = 0.384, P = 0.025).

Conclusions

The ∆PFH is a simple ambulatory sympathetic measure, which was associated with the presence of PDR, disease duration, and autonomic function. Consequently, ∆PFH could potentially be an inexpensive and sensitive clinical indicator of autonomic dysfunction.

External cardioversion of atrial fibrillation and flutter in patients with cardiac implantable electrical devices

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial tachyarrhythmias are often treated with external cardioversion (ECV) with direct current shocks in patients with potentially electrically sensitive cardiovascular implantable electronic devices (CIED). Long-term follow-up data on contemporary pacemakers and implantable cardioverter defibrillators (ICD) undergoing ECV is sparsely described. This study investigated shock-related complications and impact on CIEDs.

Methods

All ECV procedures of atrial fibrillation and flutter from 2010 to 2020 in patients with CIED performed at a tertiary hospital (Denmark) were identified in the Danish National Patient Registry. Data on device interrogation before and after ECV and procedure-related complications were retrieved retrospectively by review of medical records.

Results

We analysed 664 ECV-events performed in 362 CIEDs, median implant time 1.5 year. Mean age of patients at first ECV-event were 69.4±9.7 years and 72.2% were men. We identified two cases of major programming changes and two cases of premature battery depletion (≤3 years after generator implant) following ECV. Minor shock-related device changes were found for impedances, atrial sensing values and pacing thresholds of right ventricle lead. In two cases increased pacing threshold of right ventricle leads following ECV triggered exit-blocks after few months. No patients died due to shock-related device dysfunctions.

Conclusion

Following external cardioversion with transthoracic direct current shocks, sporadic (&lt;1%) but potentially critical changes in device function were identified in patients with contemporary pacemakers and implantable cardioverter-defibrillators. The present study suggests that routine post-cardioversion device interrogation is imperative for patient safety.

A webbased intervention for patients with an implantable cardioverter defibrillator, a qualitative study of nurses experiences

Funding Acknowledgements

Type of funding sources: None.

Background

Implantable cardioverter defibrillator (ICD) therapy is the gold standard for prevention of sudden cardiac death. Patients generally adapt well to living with an ICD, but 20% have difficulties adjusting, with increased risk of anxiety and depression and decreased quality of life. New web-based interventions engaging patients with an ICD might be efficient, but there is sparse knowledge on experiences with web-based care from the perspective of cardiac nurses.

Purpose

The aim of the study was to explore cardiac nurses’ experiences with a web-based intervention designed to empower patients with an ICD.

Methods

We conducted a qualitative study based on semi-structured interviews. The informants (n=9) were experienced cardiac nurses across 5 Danish university hospitals. They were delivering a comprehensive web-based intervention for patients with an ICD, including patient education, chats, monitoring of anxiety and depression and a patient forum. The intervention was tested in a randomized controlled trial. The interviews were transcribed verbatim, coded and analyzed using qualitative content analysis with NVivo software.

Results

We identified an overall theme: "Between traditional nursing and modern eHealth". The theme emerged from six categories, each covering three or four subcategories (Figure 1). The categories were: (1) comprehensive intervention, (2) patient-related differences in engagement, (3) following the protocol is a balancing act, (4) online communication challenges patient contact, (5) professional collaboration varies, and (6) an intervention with potential. Cardiac nurses were in general positive towards the concept of this web-based intervention and believe it holds a large potential. On the other hand, they were challenged by not establishing a personal relation and by losing face-to-face contact with patients, which they found valuable for getting a feeling for patients’ wellbeing and potential mental health issues. Ensuring face-to-face contact by either starting the intervention with a personal contact or including the possibility of video contacts might enhance the value of web-based interventions from the perspective of cardiac nurses. The nurses found the intervention especially suitable for patients who had suffered a cardiac arrest.

Conclusion

Specific training in eHealth communication is necessary as web-based care entails a shift in nursing role and a new format of communication for cardiac nurses. Future evaluations of web-based cardiac rehabilitation interventions in clinical practice are needed to assess the potential impact in "real-life" cardiac care.

Novel non-invasive 12-lead ECG-based imaging method with potential to guide and optimise right ventricular lead implantation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Svend Andersens Foundation

Karl G Andersens Foundation

Helsefonden

Background

Right ventricular (RV) pacing may induce electrical and mechanical dyssynchrony which may lead to heart failure. Often, the physician aims for lead implantation at the RV septum as this is expected to result in a more physiologic activation compared to alternative RV lead locations. Fluoroscopy, often in combination with QRS morphology derived from the 12-lead ECG, is used to guide lead implantation. However, this method is inaccurate and can result in a non-optimal RV lead location. We present a novel non-invasive method to create patient-specific 3D electrical activation maps from the 12-lead ECG that has potential to support RV lead implantation.

Methods

Data from 34 patients with an implanted dual chamber pacemaker were used. A contrast-enhanced cardiac CT scan showing the RV lead implantation site was obtained as well as recording of a 12-lead ECG during RV pacing together with a 3D photo documenting the ECG electrode positions. Discrete patient-specific torso and heart models were created from the CT scans. Each torso model was merged with the 3D photo for precise placement of the ECG electrodes in relation to the heart (figure 1). Combining the 12-lead ECGs and the heart/torso models, patient-specific 3D electrical activation maps originating from the RV were created using a novel inverse-ECG technique applying electrophysiological rules. The accuracy of the inverse-ECG method was determined by comparing the earliest site of activation from the 3D activation map with the known RV insertion site marked on the CT scan.

Results

Documented by the implanting physician in the medical records, 33 RV leads were estimated to be septal and one apical. Estimated from the CT scan 9 leads were placed septal, 18 apical and 7 on the free wall. The mean geodesic distance between the initial site of activation in the 3D activation map and the marked RV insertion site from CT was 13.6 ±5.7 mm (range 4.3-28.6). The distance for each patient is shown in figure 2. The initial site of activation was constrained to the discrete nodes of the ventricular model whereas the marker for RV lead position was localized freely on the CT scan. The average distance from the RV CT marker to the nearest discrete node was 4.3 ±2.2 mm. Correcting for this error, the geodesic distance between the initial site of activation and RV CT marker was 9.3 ±5.4 mm (range 0.0-24.6). The average time used for 3D activation map computation was 1.1 ±0.4 s per ECG.

Conclusions

We demonstrated a novel non-invasive 12-lead ECG-based method to accurately and effectively localize the RV lead in relation to the ventricular anatomy during RV pacing. Furthermore, we confirmed that the RV lead was often implanted in an unintended position. With further advancements, this method has the potential to support physicians during pacemaker implantation to ensure optimal RV lead positioning. Further studies are needed to confirm the accuracy.

Early mortality and complications following first-time catheter ablation of atrial fibrillation in a nationwide cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is the most common clinical arrhythmia. Pulmonary vein isolation (PVI) by catheter ablation has become a cornerstone in the treatment of AF. Serious complications to PVI have been reported to be at an acceptable level and risk of death after AF ablation is low.

Purpose

In a contemporary nationwide cohort of patients undergoing first-time PVI by catheter ablation, we wanted to investigate the 30-day mortality after ablation, and to examine risk and potential risk factors of PVI-related complications.

Methods

Population-based cohort study in patients who underwent first-time PVI by catheter ablation between 2011-2018 identified from the National Danish Ablation Registry. Primary outcome was early post-procedural mortality, defined as death of any cause within 30 days of index PVI procedure, or in connection to a hospitalization started within 30 days. Secondary outcomes were all-cause rehospitalization and complication, including postoperative infection, cardiac, vascular, neurological, vascular, and pulmonary complications within 30 days. Data on mortality and complications were collected from national health and administrative registries. Binary regression was used to estimate risk ratio (RR) with 95% confidence intervals (CI) for association between selected predictors and any complication, and adjusted gender, age, BMI, prior ablation, calendar period (ablation from 2011-2013, 2014-2016, and &gt;2016).

Results

We included 8560 patients. Median age was 62, 66% were men, 12% had a history of heart failure, and median CHA2DS2VASc score was 1 (Interquartile range [IQR]; 1-2). Charlton Comorbidity index (CCI) was none in 66%, moderate in 29% and severe in 5%. A total of 10 (0.12%) patients died within 30 days of ablation, of which 4 patients died during initial hospitalization. Median time to death was 20 (IQR, 12 to 29) days. Patients who died were more likely to have experienced a procedure-related complication (40% vs. 4%, P&lt;0.001). Procedure-related complications occurred in 298 (3.5%), and the risk was 4.4%, 3.0% and 3.3% in the time periods between 2011-2013, 2014-2016 and &gt;2016, respectively. Most common complications were postoperative infection (26%), cardiac complication (26%), and vascular complications (18%). Complication risk was increased in patients with higher age (aRR, 65-74 year; 1.67 [1.32-2.11] and &gt;74 years; 2.48 [1.60-3.84]), moderate CCI (aRR 1.45 [1.14-1.83]), cardiovascular disease (aRR 1.52 [1.09-2.11]) and antithrombotic treatment (aRR 1.41 [1.05-1.89]). After first-time PVI, 1.963 (23%) patients were re-hospitalized within 30 days, and most common primary discharge diagnoses were AF (87%) and direct cardioversion was performed in 765 (39%) patients.

Conclusion

In a nationwide cohort of patients who underwent first-time PVI, number of deaths within 30 days of ablation was low (0.12%). Risk of complication was low and 23% of the patients were re-hospitalized within 30 days.

Association Between Newly Diagnosed Atrial Fibrillation and Work Disability (from a Nationwide Danish Cohort Study)

It is previously shown that cardiovascular conditions have a negative effect on the ability to work. However, it is unknown if incident atrial fibrillation (AF) influences the ability to work. We examined the association between AF and the risk of work disability and the influence of socioeconomic factors. All Danish residents with a hospital diagnosis of AF and aged ≥30 and ≤63 years in the period January 1, 2000, to September 31, 2014, were included and matched 1:10 with an AF-free gender and age-matched random person from the general population. Permanent social security benefit was used as a marker of work disability. Risk difference (RD) and 95% confidence interval (95% CI) of work disability were calculated over 15 months. The analyses were furthermore stratified in low, medium, and high levels of socioeconomic factors. In total, 28,059 patients with AF and 312,667 matched reference persons were included. The risk of receiving permanent social security benefits within 15 months was 4.5% (4.3% to 4.8%) for the AF cohort and 1.3% (95% CI 1.3% to 1.4%) for the matched reference cohort. Adjusted RD (95% CI) was 2.3% (2.0% to 2.5%). Stratified on income, RDs were higher in low-income groups (adjusted RD 3.7% [95% CI 3.1% to 4.3%]) versus high-income groups (RD 1.3% [1.0% to 1.5%]). In conclusion, the risk of work disability within 15 months after incident AF was more than 3 times as high in patients with AF compared with the general population, especially when comparing individuals in lower socioeconomic strata.

Disparities in oral anticoagulation initiation in patients with schizophrenia and atrial fibrillation: a nationwide cohort study

Aims

Schizophrenia is associated with poor anticoagulation control and clinical prognosis in patients with atrial fibrillation (AF). Little is known about initiation of oral anticoagulation therapy (OAC) in this patient population.

Methods

In the nationwide Danish health registries, we identified all patients with incident AF and schizophrenia with indication for OAC treatment. Patients with schizophrenia (n = 673) were matched 1:5 on sex, age, stroke risk score, and calendar‐period to incident AF patients without schizophrenia. We calculated absolute risk and risk difference (RD) of OAC initiation, adjusting for stroke and bleeding risk factors. Analyses were stratified by calendar period (2000–2011 and 2012–2018) to account for changes after the introduction of non‐vitamin K OACs (NOAC).

Results

Among patients with schizophrenia (mean age 69.5 years, 50.3% females), 33.7% initiated OAC within the first year after AF diagnosis, compared with 54.4% of patients without schizophrenia, corresponding to an adjusted RD of −20.7 (95% confidence interval [CI]: −24.7 to −16.7). OAC initiation increased over time regardless of schizophrenia status. During 2000–2011, 18.3% of patients with schizophrenia and 42.9% without schizophrenia initiated OAC (adjusted RD −23.6%, 95% CI −28.8 to −18.6). During 2012–2018, this was 48.5% and 65.7%, respectively (adjusted RD −14.4%, 95% CI −20.4 to −8.4).

Conclusion

Initiation of OAC was substantially lower among patients with AF and schizophrenia compared with matched AF peers. These findings accentuate the importance of close attention to disparities in initiation of OAC treatment, and potential missed opportunities for prevention of disabling strokes in AF patients with schizophrenia.

The prevalence of atrial fibrillation in Greenland: a register-based cross-sectional study based on disease classifications and prescriptions of oral anticoagulants

   Previous studies of the prevalence of atrial fibrillation (AF) in Greenland are based on either single-point electrocardiograms (ECGs) or patients admitted with stroke. This study estimates the prevalence of AF based on disease classifications in the electronic medical record system (EMR) and prescriptions of oral anticoagulants (OACs). Patients given a diagnose classification code for AF or atrial flutter or prescribed the vitamin K antagonist Warfarin or the direct-acting oral anticoagulant Rivaroxaban were identified in the EMR. Descriptive data and selected laboratory values were extracted, and a minimum CHA₂DS₂-VASc score was calculated for the 790 patients identified in the EMR (66% men). A total prevalence of AF of 1.4% was found in the general population (1.8% among men and 1.0% among women), with a significantly lower prevalence among women younger than 70 years. There was a significant increase in AF-prevalence with advancing age (p<0.001) for both men and women. A minimum CHA₂DS₂-VASc was estimated and app. 10% of the patients may be undertreated with OACs. The prevalence of AF found in this study is higher than that found in previous studies in Greenland and comparable to the prevalence found in other Western countries, indicating that AF is common in Greenland.

Perception of pharmacological prevention and subsequent non-adherence to medication in patients with ischaemic heart disease: a population-based cohort study

OBJECTIVE

A patient-focused approach is advocated to embody risk of non-adherence to medication and subsequent adverse clinical outcomes following ischaemic heart disease (IHD). This study aimed to explore how patient perceived information on pharmacological prevention was associated with subsequent non-adherence to medication (measured by non-initiation, non-implementation and non-persistence) in patients with incident IHD.

DESIGN

Cohort study.

SETTING

Denmark.

PARTICIPANTS

Register-based cohort of 829 patients with incident IHD in 2013.

MEASURES

Perception covered whether patients' experienced being adequately informed about their pharmacological prevention. Information on such was obtained from a survey and divided into 'Well informed', 'Moderately informed' and 'Poorly informed'. Information on baseline characteristics, and reimbursed prescriptions of medication (antiplatelets, statins, ACE-inhibitors/angiotensin receptor blockers and β-blockers) during follow-up were obtained by linkage to nationwide public registers. Non-initiation and non-implementation of medication, measured as proportion of days covered, were analysed by Poisson regression. Non-persistence to medication, measured as risk of discontinuation, was analysed by multivariable Cox proportional hazard regression.

PRIMARY AND SECONDARY OUTCOME MEASURES

Non-implementation and non-persistence to medication up to 365 days of follow-up were primary outcomes. Secondary outcomes included non-initiation as well as non-implementation and non-persistence to medication at 180 days of follow-up.

RESULTS

A dose-response association was in general found between perception of pharmacological prevention and risk of non-implementation and non-persistence. For example, the hazard of non-persistence to antiplatelets was 1.18 (95% CI 0.71 to 1.96) times higher for patients reporting 'Moderately informed' and 1.89 (95% CI 1.10 to 3.25) times higher for patients reporting 'Poorly informed', compared with patients reporting 'Well informed of perception of pharmacological prevention' up to 365 days of follow-up.

CONCLUSION

Lower levels of perception of pharmacological prevention were associated with subsequent non-implementation and non-persistence to medication in patients with incident IHD.

Omega-3 fatty acids in adipose tissue and risk of atrial fibrillation

BACKGROUND

The aim of the present study was to examine the relation between adipose tissue content of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and the risk of incident atrial fibrillation (AF).

METHODS

In this case-cohort study based on data from the Danish Diet, Cancer and Health cohort, a total of 5255 incident cases of AF was identified during 16.9 years of follow-up. Adipose tissue biopsies collected at baseline from all cases and from a randomly drawn subcohort of 3440 participants were determined by gas chromatography. Data were analysed using weighted Cox regression.

RESULTS

Data were available for 4741 incident cases of AF (2920 men and 1821 women). Participants in the highest vs. the lowest quintile of EPA experienced a 45% lower risk of AF (men HR 0.55 (95% CI 0.41-0.69); women HR 0.55 (0.41-0.72)). For DHA, no clear association was found in men, whereas in women, participants in the highest quintile of DHA in adipose tissue had a 30% lower risk of incident AF (HR 0.70 (0.54-0.91)) compared to participants in the lowest quintile.

CONCLUSIONS

A monotonous inverse association was found for the content of EPA in adipose tissue and risk of AF in both men and women. The content of DHA was inversely associated with the risk of AF in women, whereas no clear association was found for men.