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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Venoplasty can be performed safely and successfully in patients with subtotal and total venous occlusion needing additional transvenous electrodes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Lead failure, but also upgrade procedures from pacemaker to implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) can be hampered by venous obstruction occurring in 10-25% of patients with prior transvenous electrodes. A relatively underused technique to overcome venous obstruction are lead percutaneous venous dilation procedures (venoplasty).

Purpose

We aimed to identify the feasibility of venoplasty procedures in two Dutch tertiary referral centers.

Methods

84 consecutive patients where venoplasty was attempted were included in the study and baseline parameters as well as procedural characteristics and complications were recorded. 42% of patients needed replacement of a defective electrode and 58% an upgrade to CRT or from pacemaker to ICD. Venous stenosis was defined as significant (70-90%), subocclusive (90-99%) and occlusive (100%) and the region was divided into three segments: subclavian vein, brachiocephalic vein and junction to the vena cava superior.

Results

The study included 30 pacemaker and 54 ICD patients, 68±12 years old, 80% were male. Body mass index was 26±3, left ventricular ejection fraction 32±12% and eGFR 63±24ml/min/1,73m2. At the time of the procedure, 2,1±0,8 electrodes were present and 1,2±0,2 electrodes were implanted, in 15% atrial, 52% RV and 52% LV electrodes. The procedures took 123±58 minutes and fluoroscopy dose was 5334±5390µGy/m2. There were 79 total occlusions of any segments and in addition, 51 subocclusive lesions needing venoplasty (table). 8 procedures were unsuccessful (9%), mostly due to failure to pass the occlusion. 3 patients (4%) had pocket hematoma not needing reintervention and one patient (1%) needed lead repositioning due to dislocation. There was no damage to any existing lead during the procedures. 89% of patients had a successful procedure without a complication needing reintervention.

Conclusions

Venoplasty is safe in subocclusive and occlusive venous stenosis and can be performed with high success using modern material potentially avoiding lead extraction or contralateral tunneling procedures.