Signs of heart failure with preserved ejection fraction in atrial fibrillation patients normalise in many patients after restoration of sinus rhythm

Background

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) coexist in many patients. AF and HFpEF are closely intertwined, but there are important knowledge gaps in the pathogenesis, risk, prevention and treatment of AF with concomitant HFpEF, in particular with respect to reversal of HFpEF signs.

Purpose

To assess the proportion of AF patients with (any) HFpEF criteria (including patients with heart failure with moderately reduced ejection fraction (HFmrEF)) who – after successful AF ablation – no longer meet the criteria for HFpEF on neurohumoral and echocardiographic level. Furthermore, to assess whether normalisation of HFpEF criteria positively affects AF recurrence.

Methods

Patients (n=526) underwent thoracoscopic AF ablation, consisting of pulmonary vein isolation (PVI) alone or PVI with additional lines in the case of persistent AF and were prospectively followed-up. Patients (n=338) with a left ventricular ejection fraction (LVEF) ≥40% and a successful ablation at 6 months follow-up, that is freedom of AF, or any atrial tachycardia of more than 30 seconds, were included in this study. Participants were grouped based on N-terminal pro-b type natriuretic peptide (NT-proBNP) into those with a NT-proBNP <125pg/ml, defined as control patients (group 1), and those with a NT-proBNP level ≥125pg/ml, defined as HFpEF patients (group 2). HFpEF patients were further classified in different degrees of HFpEF severity, based on the number of diagnostic echocardiographic criteria for diastolic dysfunction present into possible HFpEF (group 2a, <2 criteria), likely HFpEF (group 2b, 2 criteria) and definite HFpEF (2c, ≥3 criteria). The primary outcome was the change in HFpEF defining signs on neurohumoral (NT-proBNP) level and echocardiographic (number of echocardiographic criteria for diastolic dysfunction) level 6 months after restoration of sinus rhythm.

Results

In total, 69% of AF patients (with a preserved ejection fraction of ≥40%) fulfilled the criteria for HFpEF. In 23% of these patients, neurohumoral levels normalised after elimination of AF, and a normalisation of echocardiographic markers was seen in 58% of patients. Normalisation of HFpEF on a neurohumoral level was associated with numerically fewer AF recurrence at 1 year follow-up (23% versus 33% in patients with and without NT-proBNP <125 pg/ml respectively, p=0.212). This favourable outcome was not observed in patients with a normalisation of echocardiographic markers.

Conclusion

In AF patients with definite restoration of sinus rhythm HFpEF may be reversed. This suggests that neurohumoral and echographic changes are caused by AF rather than by HFpEF. Normalisation of neurohumoral changes after definite restoration of sinus rhythm led to better outcome with regards to AF-recurrence, which could be used in prediction of prognosis.

Funding Acknowledgement

Type of funding sources: None.

Age-adjusted risk factors are independently associated with an increased risk of ischaemic stroke, transient ischaemic stroke and systemic embolism in the ETNA-AF-Europe registry

Background

Oral anticoagulation is highly effective in preventing ischaemic stroke in patients with atrial fibrillation, but 1–2% of the patients suffer an ischaemic stroke upon anticoagulation. Outcomes are further influenced by various factors, and recent research has focussed on identifying risk factors that could be helpful in predicting stroke outcomes in anticoagulated patients. This could further assist clinicians in timely identification and management of high-risk patients.

Purpose

The present analysis aims to assess the age-adjusted risk predictors of ischaemic stroke and systemic embolic events (SEE) (including transient ischaemic attack [TIA]) during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and stroke and SEE after adjusting for age, given that age is a well-known, strong predictor of stroke.

Results

A total of 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. The mean weight was 81.0±17.3 kg, estimated glomerular filtration rate was 74.4±30.5 ml/min/1.73m2 and males were 56.6%. The mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively.

Univariate analysis demonstrated that history of TIA at baseline was the strongest age-adjusted predictor of stroke and SEE (Wald Chi-square: 77.69; p<0.0001) (Figure 1), followed by CHA2DS2-VASc score (41.09; p<0.0001) (Figure 2), history of ischaemic stroke (29.47; p<0.0001), history of any stroke (all strokes combined including stroke of unknown/unspecified type) (29.18; p<0.0001), subjective frailty as assessed by physician (20.60; p<0.0001), and HAS-BLED score (17.22; p<0.0001).

Conclusion

History of TIA, CHA2DS2-VASc score, history of stroke, frailty and HAS-BLED score are independently associated with an increased age-adjusted risk of ischaemic stroke, TIA and SEE in anticoagulated patients with AF. These findings highlight the importance of optimising anticoagulation therapy in secondary prevention of TIA and in patients with high CHA2DS2-VASc scores, ensuring the correct use of NOACs - adherence and correct dosing - in this high-risk population. These findings also suggest that additional therapies could be needed to prevent stroke in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. History of TIA as a predictorFigure 2. CHA2DS2-VASc score as a predictor

Rate and rhythm control treatment in the elderly and very elderly patients with atrial fibrillation: an observational cohort study of 1,497 patients

Aim

Stroke prevention and rate or rhythm control are crucial parts of the treatment of atrial fibrillation (AF). There is limited evidence for the efficacy or safety of rate and rhythm control in elderly or very elderly patients, although this population is rapidly increasing. Therefore, we analyzed electronic health record data from outpatient cardiology clinics to give insight in prescribing patterns and mortality of both treatment strategies in the elderly patients.

Methods and results

We extracted data from all patients with AF who were aged >75 years, used a pharmacological rate or rhythm control strategy and visited one of the independent outpatient cardiology clinics in the Netherlands between 2007 and February 2018. This resulted in 1,497 selected patients (54% women), of whom 316 (21%) were prescribed rhythm control (consisting of class 1 or 3 antiarrhythmic drugs) and 1,181 (79%) rate control (beta blockers, calcium antagonists or digoxin). Patients aged >85 years (OR: 2.28) and those with permanent AF (OR: 2.71) were more likely to receive rate control (OR: 2.28, OR: 2.71 respectively), whereas those with paroxysmal AF were more likely to receive rhythm control (OR: 0.42). After correcting for relevant confounders, the mortality risk for patients using rhythm control was similar to patients using rate control (HR: 0.89; 95% CI: 0.70; p=0.31).

Conclusion

Considering the similar mortality risks in both groups, a more liberal approach in prescribing a rhythm control strategy to the healthier elderly patient with AF seems safe. Our data underscores the need for a non-inferiority trial to provide definite answers on safety of rhythm control in elderly patients with AF.

Funding Acknowledgement

Type of funding sources: None.

Age-adjusted risk factors are independently associated with an increased risk of major bleeding during the two-year follow-up of the ETNA-AF-Europe registry

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are a preferred treatment option over warfarin for anticoagulation in patients with atrial fibrillation (AF). Management decisions for thromboprophylaxis in AF need to balance the risk of stroke against the risk of bleeding. Various patient characteristics have been identified as independent risk factors for bleeding. A substantial number of bleeding events might be prevented if independent predictors of bleeding were identified.

Purpose

The present analysis aims at assessing age-adjusted risk predictors of major bleeding during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and major bleeding after adjusting for age, given that age is a well-known, strong predictor of anticoagulation-related bleeding in patients with AF.

Results

Overall, 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. Mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively. 438 (3.3%) patients had a history of bleeding events at baseline, of which 138 (1.0%) had a history of major bleeding event.

Univariate analysis demonstrated that recalculated glomerular filtration rate (Cockcroft-Gault Equation) (GFR-CG) at baseline was the strongest age-adjusted predictor of major bleeding (Wald Chi-Square: 31.84; p<0.0001) (Figures 1 and 2), followed by history of major or clinically relevant non-major (CRNM) bleeding (24.08; p<0.0001), HAS-BLED score (21.10; p<0.0001), history of heart failure (derived) (16.59; p<0.0001), subjective frailty as assessed by physician (17.35; p=0.0002), history of major bleeding (14.14; p=0.0002), chronic obstructive pulmonary disease (COPD) (12.84; p=0.0003), CHA2DS2-VASc (12.14; p=0.0005), history of myocardial infarction (MI) (7.79; p=0.005), and left ventricular ejection fraction (LVEF) categorised by 40% (5.45; p=0.02).

Conclusion

Bleeding events on therapy with edoxaban can be predicted by quantifying kidney disease and capturing information on heart failure, frailty, prior bleeding, chronic obstructive lung disease and history of myocardial infarction. These data highlight the need for optimal management of anticoagulation therapy and close follow-up of patients with such risk profiles.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. GFR-CG as a predictor of major bleedingFigure 2. Predictors of major bleeding

Low mortality rate after atrial fibrillation ablation: results from the Netherlands Heart Registration

Background

Ablation therapy is widely used as a treatment of atrial fibrillation (AF) and is associated with 3.6% minor and major complications in the Netherlands. Mortality following AF ablation is rare, but has been reported 0.46% in the United States in recent literature. We hypothesize that in the Netherlands, where AF ablation is performed in high volume centres only, 30-day mortality rate is low.

Purpose

To describe 30-day mortality in the Netherlands after AF ablation.

Methods

In the Netherlands Heart Registration, all 16 Dutch ablation centres participate and 14 out of 16 centres reported AF ablation outcomes using predefined variables for quality purposes. The number of reported procedures per centre was on average 236/year [range, 33–593], where 87.5% of the centres perform >150 AF ablations per year. All patients who underwent AF ablation were eligible for this analysis irrespective of ablation method used, or whether it was the first or a redo AF ablation. 30-day mortality was derived from, the municipal death registration, and individually checked by each participating ablation centre. No further analysis was available on the cause of death.

Results

In total, 20,230 patients who underwent AF ablation between 01-01-2013 and 31-12-2018 were included. The majority of patients were male (68%), mean age was 60.9±9.8 years, mean body mass index was 27.3±4.2kg/m2, and the average CHA2DS2VASc score was 1.6±1.3. Reduced left ventricular (LV) ejection fraction (<50%) was present in 13.2% of the patients. Paroxysmal AF was present in 72.7% of patients, persistent AF in 24.9% and longstanding persistent in 2.3%. The index procedure was a redo-ablation in 22.7%. Mortality outcomes were available for 18,413 (91.0%) procedures, as some centres had a backlog of patients that needed death certificate checking [range, 0% - 19.4%], this factor was considered random. In total 12 patients (0.07%) died within 30-days after an AF ablation procedure. These patients were 68.5 years old [range, 55–76 years], 91.7% had a history of paroxysmal AF and 8.3% persistent AF, LV ejection fraction was <50% in 8.3% and 25% of the patients had a previous AF ablation (p=0.02 for age, others p=NS).

Conclusion

Patients undergoing AF ablation in the Netherlands mainly presented with paroxysmal AF. In a setting where AF ablation is performed in high volume centres only, such as the Netherlands, 30-day mortality is very low after AF ablation.

Funding Acknowledgement

Type of funding source: None

Atrial fibrillation up to 50 days after cardiac surgery should be considered postoperative atrial fibrillation

Introduction

Postoperative atrial fibrillation (POAF) occurs in up to 45% of patients following cardiothoracic surgery and is defined as any atrial tachyarrhythmia occurring ≤30 days after surgery. Consequently, atrial arrhythmias after 30 days are regarded as new-onset AF. However, biological and clinical data on the association between POAF and new-onset AF, or empirical data supporting the cut-off of 30 days, are lacking.

Purpose

We hypothesize that patients with POAF are biologically different with respect to atrial fibrosis compared to patients who develop new-onset AF.

Methods

PREDICT AF is a prospective, multicenter, observational trial that included patients with a CHA2DS2VAsc score≥2 without a history of AF. Patients underwent CABG or valve surgery and the left atrial appendage (LAA) was removed during surgery. The LAA was obtained for expression analysis of extracellular matrix (ECM) genes such as collagen 1 (COL1A1), collagen 3 (COL3A1) and fibronectin (FN1) by qPCR. Patients were monitored during hospitalisation and followed-up at 1, 6, 12 and 24 months with 24-h Holters and ECGs. The primary endpoint was any recorded atrial tachyarrhythmia lasting >30 seconds. We documented all new-onset arrhythmias over time in order to determine potential cut-offs for POAF (Figure A). We then compared the effects of using a 30-, 50- or 70-day cut-off on the rate of new-onset AF and the differences in expression of fibrosis related genes.

Results

PREDICT AF included 150 cardiac surgery patients: 115 CABG, 11 valve surgeries and 24 combined surgeries. Participants had a median follow-up of 1.9 years [1.0–2.0], were 68±7 years old and 19 (13%) were female. POAF <30 days occurred in 63 (42%) patients. New-onset AF >30 days developed in 21 (14%) patients. Of the 21 patients with new-onset AF, 20 (95%) also had had POAF. New-onset AF defined by a cut-off of 50 days, developed in 15 (10%) patients. In total, 9 patients had an episode of AF between 30 and 50 days, of whom 6 (66.6%) had no AF episodes thereafter. Most of these patients under–went (concomitant) aortic valve surgery. The gene expression of ECM components was significantly more predictive of new-onset AF when using a cut-off of 50 days or even 70 days than when using a cut-off of 30 days (Figure B).

Conclusion

With stringent monitoring we detected 42% POAF <30 days. One in three POAF patients developed new-onset AF within two years after surgery. However, the majority of the patients who developed new-onset AF between 30 and 50 days postoperatively had no later episodes of AF. Moreover, applying a 50-day cut-off to discriminate POAF from new-onset AF enhanced the prediction of new-onset AF based on the ECM gene expression levels. Our data suggest that both from a biological and a clinical perspective, the cut-off for POAF should be stretched to 50 days postoperatively.

New-onset AF prediction with ECM genes

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): NWO VIDI