bluuebunny/crossref_metadata_2025 huggingface dataset:
Low voltage and low wave speed are rarely present outside the left atrium-pulmonary veins junction in paroxysmal atrial fibrillation but frequently present in persistent forms
Authors: Parreira L , Silva J , Marinheiro R , Mesquita D , Amador P , Farinha J , Chambel D , Encarnacao C , Contreiras P , Lopes C , Duarte L , Lopes J , Valcovo A , Caria R
Published: November 2023

Background and aim

Multielectrode high-density catheters have enabled acquisition of comprehensive and dense maps of electrogram’s amplitude and timing. However, automated activation and voltage mapping are flawed by catheter orientation in relation to the wavefront activation. Omnipolar mapping technology (OT) uses both unipolar and bipolar signals to obtain OT signals and increases the accuracy of automatic point acquisition allowing for a high- density map in a quick and efficient way. The aim of this study was to automatically assess with OT, the left atrium (LA) voltage and wave speed propagation map in sinus rhythm (SR) according to the type of atrial fibrillation (AF).

Methods

We studied 14 consecutive patients referred for ablation of AF, either paroxysmal (PAF) (n=6) or persistent (Pers-AF) (n=8) using catheters with OT. Patients with Pers-AF were cardioverted, and a SR map was obtained before ablation in all patients and voltage and propagation wave speed maps were obtained. The cut-off for low voltage areas (LVAs) was less than 0.1 mV and for low wave speed (LWS) was less than 0.4 mm/ms. Results were compared according to the type of AF.

Results

The results are depicted in the Table. The median duration of AF in Pers-AF was 18 (5-24) months. Patients with Pers-AF had larger LA volumes and displayed presence of LVAs and LWS areas in 100% of cases in comparison with 17% and 33% of cases respectively for PAF patients (p=0.003 and p=0.015). Also, the total LVAs and LWS areas in cm2 were significantly higher, (p=0.001 and p=0.005)). The LVAs and the LWS areas were more frequently located outside the PV-LA junction in Pers-AF than in PAF, respectively 75% vs 0% and 88% vs 0%, p=0.010 and p=0.005 (Figure).

Conclusions

Patients with PAF never presented LVAs or LWS outside the PV-LA junction. On the contrary, patients with Pers-AF had frequently anatomical and electrophysiological abnormalities in the LA body. These findings may suggest the need for a wider ablation strategy in Pers-AF.Normal voltage in purple ; LWS in white
Pulmonary vein isolation versus PVI + adjunctive strategy (substrate modification and renal denervation therapy) for the reduction of 12-month AF recurrence
Authors: Cabrera J , Ozaeta K , Hung P , Tiongco R , Bailon D
Published: November 2023

Background of the Study

This meta-analysis assessed the latest evidence on the use of adjunct ablation strategies to standard pulmonary vein isolation (PVI) for treating atrial fibrillation (AF). Adjunct treatments were further classified as substrate modification (posterior wall isolation, linear ablation and ablation of complex fractionated atrial electrograms) or renal denervation (RDN).

Purpose

While ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, recurrent AF remains common after 12 months, occurring in up to 40-60% of patients undergoing standard PVI ablation. Treatment strategies have diversified in a response to these challenges. These include reduction of the arrhythmogenic substrate, modulation of autonomic inputs and improvement of risk factors, such as hypertension.

Methods

A systematic literature search from MEDLINE and PubMed electronic databases was performed until November 2022. The primary outcome was 12-month AF recurrence defined as AF lasting ≥30 seconds on follow-up. The secondary outcome was incidence of procedure-related major adverse events (MAEs), defined as death, clinical strokes, acute heart failure decompensation, pericardial effusion causing tamponade, arteriovenous fistulas, and atrioesophageal fistulas.

Results

Nine studies comprising 1686 patients were included in the final analysis. AF recurrence was 487/1082 (45%) in the PVI + Adjunct group and 204/604 (33.8%) in PVI Alone. Pooled analysis showed that PVI + adjunct was inconclusively associated with less incidence of 12-month AF recurrence (RR 0.79, 95% CI 0.60–1.04, I2 = 70%, p-value 0.09). Subgroup analyses of six RCTs under the PVI with substrate modification arm showed non-significant increase in 12-month AF recurrence in PVI + substrate modification (RR 0.85, 95% CI 0.6-1.21, p-value 0.38). Subgroup analyses of the 3 RCTs on hypertensive AF patients showed strong evidence of decreased 12-month AF recurrence in PVI + RDN compared to PVI alone (RR 0.65, 95% CI 0.48-0.89, p-value 0.007). Secondary outcome of major adverse procedure-related events in overall pooled analysis showed 8 events in 604 patients undergoing PVI alone, and 23 events in 1082 patients undergoing PVI + adjunct ablation. There is no significant difference in the number of reported MAE in PVI alone over PVI + adjunct (RR 1.16 [0.49-2.75], p = 0.73).

Conclusion

Overall, PVI with adjunctive strategies did not significantly reduce 12-month AF recurrence after ablation. Among these strategies, RDN demonstrated a significant reduction in the primary endpoint, whereas substrate modification did not. There was no significant difference in MAEs reported between standard therapy versus those with adjunctive treatment. We conclude that PVI ablation strategies should be individualized, and modification of both triggers and risk factors for AF show better rhythm control on follow-up.
Efficiency and safety in AF ablation using a novel loop-shaped cryoablation catheter
Authors: Hovhannisyan G , Hamann J , Dawid M , Payo A L , Quick S , Ibrahim K , Christoph M
Published: November 2023

Background

Different single shot ablation systems are under development to improve the efficiency and safety of pulmonary vein isolation for the treatment of atrial fibrillation (AF).

Purpose

Evaluation of effectiveness and safety of a novel cryoloop catheter (figure 1) for pulmonary vein isolation.

Methods

In a single centre prospective registry, patients with drug-refactory AF underwent pulmonary vein isolation (PVI) using a novel loop-shaped cryoablation catheter. For efficiency assessment the following parameters were registered: 1: the number of successfully isolated pulmonary veins (PV) confirmed by entrance- and exit block; 2: total procedure time, left atrial dwell time, total cryoablation time and applications as well as total fluoroscopy time; 3: freedom from atrial arrhythmia after 6 months. For safety assessment the following parameters were studied: 1: periinterventional adverse events like pericardial effusion, thromboembolic events and bleedings according to BARC classification; 2: endoscopic detected esophageal lesions (EDEL); 3: phrenic nerve palsy; 4: computed tomography angiography (CTA) detected PV stenosis until 6 months after PVI.

Results

In total, 25 subjects were enrolled in the current registry and received PVI with the loop-shaped cryoablation catheter. In terms of efficiency, successful acute PVI could be achieved in 91/100 treated PVs. Total procedure, atrial dwell, cryoablation and total fluoroscopy times were 130.5 ± 24.2 min, 101.4 ± 19.8 min, 40.8 ± 11.0 min and 22.5 ± 5.5 min, respectively. On average, 4.5 cryoenergy applications per PV were required for acute PVI. Out of the blanking period of 3 months, after 6 months 18/25 subjects (72%) were free from any atrial arrhythmia. With respect to safety, no pericardial effusion, thromboembolic event or bleeding complication occurred. 2/25 subjects experienced a transient phrenic nerve palsy. Additionally, no EDEL or PV stenosis could be detected.

Conclusion

The present single centre registry confirmed the effectiveness and safety of the novel loop-shaped cryoablation catheter for the treatment of atrial fibrillation.Figure 1: cryoloop catheter
Improvement in post-ablation chest pain and same-day discharge with the use of active esophageal cooling
Authors: Cooper J , Joseph C , Turer R , Mcdonald S , Kulstad E , Daniels J
Published: November 2023

Background

Active esophageal cooling is a common method of esophageal protection during radiofrequency (RF) ablation for the treatment of atrial fibrillation (AF). Compared to the main alternative, luminal esophageal temperature (LET) monitoring, active esophageal cooling reduces esophageal injury. Recent findings in the community hospital setting indicate that procedure time and post-ablation chest pain may also be reduced, leading to greater same-day patient discharge.

Objective

We aimed to compare the differences in same-day discharge rates and patient-reported post-ablation chest pain between patients treated with either LET monitoring or active esophageal cooling while undergoing RF ablation in a large academic medical center.

Methods

We reviewed data from RF ablations performed between January 2020 and October 2022 by five attending electrophysiologists and four electrophysiology fellows. These data were extracted from Epic’s Clarity database by two clinical informaticists. Extracted data points were paired with a manual chart review of inbound phone calls, electronic messages, follow-up visits, and readmissions within 30 days of the procedure.

Results

A total of 175 patients underwent RF ablation between January 2020 and October 2022, with 63 (36%) patients treated with LET monitoring and 112 (64%) treated with active esophageal cooling. Chest pain was reported by 11 patients (18%) in the LET monitored group and 7 patients (6%) in the actively cooled group (P=<0.001). Of the patients treated with LET monitoring, 13 (20.6%) were discharged within 12 hours of admission compared to 44 (39.3%) of the patients treated with active esophageal cooling (P=0.016).

Conclusions

The adoption of active esophageal cooling during RF ablation was associated with less postoperative chest pain and increased same-day discharge rates.
Catheter ablation in general anesthesia reduces atrial fibrillation recurrence regardless of atrial fibrillation type
Authors: Riis-Vestergaard L
Published: November 2023

Background

Treatment with catheter ablation (CA) as rhythm control is increasingly used in atrial fibrillation (AF). Short-term AF recurrence after first-time CA varies from 10-30% in paroxysmal AF (PAF) and up to 50% in persistent AF (PeAF). Strategies to optimize outcome is still an ongoing challenge. Whether the sedation strategy, conscious sedation (CS) or general anesthesia (GA), has any impact on AF recurrence has yet to be determined. Currently no guidelines are available regarding sedation strategy.

Objective

To investigate the impact of sedation strategy in CA for PAF and PeAF on AF recurrence.

Method

This nationwide retrospective registry study was conducted using large real-life data from Danish mandatory registries. All patients above 18 years, that underwent CA for AF from January 1st 2010 to December 31st 2018, were identified and included at the date of ablation. Exposure of interest was type of anesthesia, and patients were stratified into CS or GA. Primary endpoint was recurrent AF after a 3-months blanking period, defined by a composite endpoint of first-reached endpoint of either use of antiarrhythmic drugs (AAD), AF-admission, electrical cardioversions or AF re-ablation.

5-year risk of recurrent AF was examined by the Aalen-Johansen estimator, taking the competing risk of death into account. Subgroup analysis of PAF and PeAF was performed.

Results

The study cohort consisted of 6,423 patients with first-time CA. 3,958 patients with PAF and 2,465 patients with PeAF. 5,058 patients underwent the procedure in CS, and 1,365 in GA.

5-year cumulative incidence of recurrent AF was higher in the CS group for both PAF and PeAF with 49,3% and 58,9% respectively, compared to 39,0% for PAF and 46,2% for PeAF in the GA group (Figure 1).

A total of 3,242 patients reached the primary endpoint. Admissions for AF was the predominant endpoint for both CS and GA (1323, 42,0%). When subdivided into PAF and PeAF, admission for AF was still the predominant endpoint (Table 1).

Conclusion

Reduction of AF recurrence after CA is a continuing challenge. This study shows that the sedation strategy is important, and that the risk of recurrence is significantly lower for CA performed in GA. Subgroup analysis of PAF and PeAF, shows that regardless of AF type, recurrence rates are significantly lower in the GA group.Figure 1Table 1
Population rates and contemporary outcomes of atrial fibrillation ablation among older adults: a nationwide cohort study
Authors: Ferro E G , Reynolds M R , Xu J , Song Y , Cohen D J , D'avila A , Zimetbaum P J , Yeh R W , Kramer D B
Published: November 2023

Background

Atrial fibrillation (AF) is the most common sustained arrhythmia, with pulmonary vein isolation (PVI) increasingly recommended as first-line therapy. Limited data suggest increasing use of PVI as well as increasing rates of post-PVI complications, but contemporary real-world outcomes among older adults remain unclear.

Purpose

To evaluate patient characteristics, population rates and 30-day clinical outcomes for PVI in a nationwide sample of adults aged >65 in the United States.

Methods

First-time PVIs were identified among US Medicare fee-for-service beneficiaries using CPT procedural codes, and comorbidities were ascertained using ICD-10 diagnosis codes associated with each procedural claim. Study outcomes included rates of PVI use, procedural complications, all-cause re-hospitalizations, and all-cause mortality at 30 days.

Results

From January 2017 through December 2020, 156,601 patients underwent first-time PVI performed by 2,791 unique operators. The mean patient age was 72.5 ± 5.2 years, 42.6% were female and the majority (92.7%) Caucasian. The rate of PVI increased from 2.48 per 100,000 beneficiaries in the first quarter of 2017 (performed by 2,113 operators) to 3.01 per 100,000 beneficiaries in the last quarter of 2020 (performed by 2,415 operators) – a 4.8% relative increase per year (p=0.02). This growth was driven primarily by outpatient elective procedures, which represented the majority (85.0%) of all PVIs. Concurrent with this increase in PVI use, there was a significant decrease in complication rates (3.9% in 2017 vs 3.1% in 2020, p<.0001) and re-hospitalizations (8.8% vs 7.1%, p<0.001) at 30 days, with no significant change in mortality at 30 days (0.36% vs 0.40%, p=0.38). Bleeding was the most common peri-procedural complication (1.4%), followed by pericardial effusion requiring intervention (1.2%) and access site vascular complications (0.55%).

Conclusions

This large nationwide cohort study shows that the use of PVI has steadily increased in contemporary clinical practice. Despite the widespread adoption of this procedure by a growing number of operators, cumulative complication and re-hospitalization rates at 30 days have decreased over time, with stable and very low rates of short-term mortality – even among older patients, who are ordinarily considered to be at higher risk. These findings contrast with those from previously published studies of non-representative cohorts. Results from our study should reassure both patients and providers on the overall safety of PVI as an increasingly common first-line procedure for rhythm control. Forthcoming analyses will be finalized by the time of presentation to evaluate whether hospital and operator volume further influence procedural outcomes.Central Figure: PVI Trends and Outcomes
Permanent pacemaker implantations among patients with spinal cord injury in the United States
Authors: Margolis G , Kobo O , Kazatsker M , Roguin A , Shapira A , Behrbalk E , Leshem E
Published: November 2023

Background

Acute spinal cord injury (SCI) is associated with severe cardiovascular complications. Information regarding the need for permanent cardiac pacing in SCI patients is scarce and based on case reports and small case series. We aimed to investigate the extent of permanent pacemaker (PPM) implantation procedures as well as to identify predictors for PPM insertion among SCI patients in a U.S contemporary, nationwide, all-comer registry.

Methods

Using the National Inpatient Sample (NIS) database, patients hospitalized with a primary diagnosis of SCI in the US between 2016-2019 and underwent PPM implantation were identified. Patients with cardiac implantable electronic device in-situ were excluded. Baseline demographics, clinical characteristics, injury type, in-hospital procedures and outcomes including time to PPM implantation, length of stay and mortality were collected. Outcome analysis performed after propensity score matching (PSM). Predictors of PPM implantation were identified via a multivariable logistic regression model.

Results

A total of 35880 patients, were hospitalized with a primary diagnosis of SCI during the study period, and 240 (0.7%) received a PPM. Median age of patients receiving PPM was 69 years, 75% were males, and 67% had high level SCI injury (level C1-5). Time to PPM implantation was 9 days (IQR 4-19). PPM implantation was associated with higher rates of cervical spine injuries, traumatic brain injury (TBI), chest and upper limbs injuries, respiratory failure and other signs of severe illness. Longer hospital stay and higher in-hospital mortality rate was observed in patients receiving a PPM.

Multivariate analysis identified the following independent risk factors for PPM implantation: cervical SCI [OR 77.07 (11.13-553.42), p<0.001], TBI [OR 3.84(1.59-9.28), p=0.003] and tracheostomy/respiratory ventilation> 96 h [OR 31.766(7.91-127.54), p=<0.001].

Conclusion

Cervical SCI, need for tracheostomy and prolonged mechanical ventilation were the strongest predictors for PPM implantation in patients hospitalized for SCI in a nationwide registry.
Lower risk of atrial fibrillation development associated with SGLT-2 inhibitors in type 2 diabetic patients compared to DPP-4 inhibitors: a nationwide cohort study
Authors: Lee J , Kim M , Bae J W , Cho M C
Published: November 2023

Background

Accumulating evidence shows that sodium-glucose co-transporter-2 (SGLT-2) inhibitors reduce cardiovascular outcomes. However, this favorable effect is unclear for newly atrial fibrillation (AF) development compared to other anti-diabetic drugs.

Purpose

We investigated the association of SGLT-2 inhibitor for newly AF development compared to dipeptidyl peptidase-4 (DPP-4) inhibitors in patients with type 2 diabetes.

Methods

Using the Korean National Health Insurance Service database, among 2,160,911 type 2 diabetes patients (age ≥20 years) between 1 May 2016 and 31 December 2018, we studied 42,806 patients with SGLT-2 inhibitors and 448,715 patients with DPP-4 inhibitors who had not prior AF diagnosis. Propensity score-matching (1:1 ratio) was used to correct for differences between the groups.

Results

During a median follow-up of 1.3 years, after propensity score matching, compared with patients with DPP-4 inhibitors (n=42,786), patients with SGLT-2 inhibitors (n=42,786) have shown lower incidence and risk of AF (2.7 and 3.3 per 1000 person-years; hazard ratio 0.73, 95% confidence interval 0.55-0.97; p=0.028) aand an absolute rate difference of −0.7 [95% confidence interval (CI) −1.3 to −0.1, p=0.034] per 1000 person-years by on-treatment analysis. In intention-to-treat analysis, these results were consistent (2.6 and 3.2 per 1000 person-years; hazard ratio 0.83, 95% confidence interval 0.66-1.03; p=0.092) with an absolute rate difference of −0.5 [95% confidence interval (CI) −1.2 to −0.1, p=0.093] per 1000 person-years . In subgroup analysis, SGLT-2 inhibitors were associated with lower risks of AF in heart failure compared to their counterparts in intention-to-treat analysis (p for interaction=0.036).

Conclusion

Based on this nationwide cohort of type 2 diabetes patients treated with SGLT-2 inhibitors or DPP-4 inhibitors, SGLT-2 inhibitors were associated with protection against newly AF development after adjusting for clinical confounders.Incidence rates and adjusted HR
Biomarker BMP10 profiles suggest an association of female and age with atrial endomysial fibrosis: Results from the ISOLATION AF ablation registry
Authors: Habibi Z , Verhaert D V M , Hermans B J M , Philippens S , Westra S W , Chaldoupi S M , Maesen B A E , Isaacs A J , Zeemering S , Linz D , Vernooy K , Schotten U
Published: November 2023

Background/Introduction

Atrial fibrillation has a complex pathophysiology such as inflammation, myocyte injury, collagen and lipid infiltration. Different biomarkers reflect these pathophysiological pathways. The biomarker Bone Morphogenetic Protein 10 (BMP10) is a secreted protein, expressed by myocytes, and is required for myocyte growth and development. BMP10 is associated with PITX2 and endomysial fibrosis. We recently demonstrated that BMP10 is independently associated with left atrial andomysial fibrosis.

Purpose

To analyze the correlation between the blood-based biomarker BMP10 with sex and age in patients with atrial fibrillation.

Methods

A cross-sectional analysis was conducted of atrial fibrillation patients scheduled for catheter ablation included from July 2020 through May 2022 in the prospective multicenter ISOLATION cohort study (NCT04342312). Clinical characteristics and routine tests were collected before ablation. Blood samples were taken before ablation and were analyzed for BMP10 among other known and novel cardiovascular biomarkers.

We investigated the correlation between BMP10 and age in a univariate analysis and in a multivariate analysis including differences in clinical traits. In addition, we investigated the difference in BMP10 levels between males and females.

Results

Blood samples from 509 patients were analyzed. Their mean age was 64±9 years, and 31.2% were female. 352 patients (69.2%) had paroxysmal AF and 152 patients (29.9%) had persistent AF. Heart failure was reported in 77 patients (15%). 357 (70%) patients were in sinus rhythm at the time the blood was drawn (table 1).

Univariate analysis showed that BMP10 levels increased with age (figure 1). After adjusting for sex, type of AF, heart failure and rhythm at blood drawing, BMP10 remained higher in older patients (Beta coefficient 0.77, standard error 0.14, p-value <0.001). In addition, univariate analysis showed that BMP10 was significantly higher in women than in men (2.16 ng/L versus 1.95 ng/l, P< 0.001). After adjusting for age, BMP10 remained higher in women than in men.

Conclusion

Elevated BMP10 levels suggest that in older patients possibly more atrial fibrosis is present and thus more substrate for AF. In addition, the different biomarker profile suggests that AF in women may more often be associated with atrial fibroses than in men.
Invasively diagnosed HFpEF in AF associated with functional remodelling of the left atrial appendage: implications for stroke risk
Authors: Ariyaratnam J , Mishima R S , Kadhim K , Emami M , Gallagher C , Lau D H , Sanders P , Elliott A D
Published: November 2023

Background

HFpEF commonly coexists with atrial fibrillation (AF). The influence of coexisting HFpEF on function of the left atrial appendage (LAA) and risk of stroke remains unknown.

Objective

To use invasive hemodynamic assessment and multi-modality imaging to evaluate the influence of underlying HFpEF on LAA function in patients with symptomatic AF.

Methods

Patients with AF and preserved ejection fraction undergoing AF ablation were prospectively recruited. All participants underwent invasive diagnosis of HFpEF using established hemodynamic criteria. Participants were classified as ‘HFpEF’ when mean left atrial pressure (mLAP) was >15mmHg and ‘early HFpEF’ when mLAP rose to above 15mmHG after infusion of 500mls saline. For LAA assessment, participants underwent 1) contrast-enhanced cardiac CT to evaluate LAA volume, 2) transesophageal echocardiography to investigate emptying velocities (LAAEV), filling velocities (LAAFV) and LAA ejection fraction (LAAEF) and 3) high-density electroanatomic mapping to assess LAA bipolar voltages.

Results

Of 115 participants recruited, 55 had ‘HFpEF’, whilst 29 had ‘early HFpEF’ and 31 had ‘no HFpEF’. Table 1 demonstrates the baseline characteristics and LAA structural and functional parameters across the three groups. The HFpEF group was characterized by higher BMI (p=0.008) and higher prevalence of hypertension (p=0.023) but there was no significant difference in age (p=0.194) or gender (p=0.376). LAA volume was not significantly different across the three groups (p=0.509). However, the HFpEF group demonstrated reduced LAAEV (p=0.021) and LAAFV (p=0.015) compared to early HFpEF and no HFpEF. HFpEF was also associated with reduced LAAEF (p=0.015) and reduced LAA bipolar voltages in sinus rhythm (p=0.028) compared to no HFpEF. In a multivariable analysis HFpEF group was the only independent predictor of reduced LAAEV (p=0.015).

Conclusions

Invasively diagnosed HFpEF in AF is common and associated with significantly reduced LAA function. The coexistence of HFpEF may therefore be a determinant of future stroke risk in patients with AF.
Oral anticoagulant use and outcomes in Asian patients with atrial fibrillation in the GLORIA-AF Registry
Authors: Romiti G F , Corica B , Proietti M , Mei D A , Frydenlund J , Bisson A , Boriani G , Olshansky B , Chan Y H , Huisman M V , Chao T F , Lip G Y H
Published: November 2023

Background

Ethnic differences in the management and outcomes of patients with atrial fibrillation (AF) have been shown in previous studies, but available data is still limited, although urgently needed.

Purpose

to analyse oral anticoagulant (OAC) prescription, OAC discontinuation, and long-term risk of major outcomes in Asian patients with AF, using data from a global prospective cohort study.

Methods

Using data from the GLORIA-AF Registry Phase II and III, we analysed patients according to their self-reported ethnicity (Asian vs. Non-Asian), and according to Asian ethnic subgroup (i.e. Chinese, Japanese, Korean and other Asian). Odds of OAC prescription were analysed through multivariable logistic regression, while the risk of OAC discontinuation and adverse outcomes were analysed through multivariable Cox-regression model. Primary outcome of this analysis was defined as the composite of all-cause death and major adverse cardiovascular events (MACE).

Results

34,421 AF patients were included (70.0±10.5 years, 45.1% females, 6,900 (20.0%) Asian). Compared to Non-Asian subjects, prescription of OAC and non-vitamin K antagonist oral anticoagulant (NOAC) was lower in Asian subjects (Odds Ratio [OR] and 95% Confidence Intervals (CI): 0.23 [0.22-0.25] and 0.66 [0.61-0.71], respectively; Figure 1), but higher in the Japanese subgroup. Asian ethnicity was also associated with OAC discontinuation (Hazard Ratio [HR] and [95%CI]: 1.79 [1.67-1.92]), and lower risk of the primary composite outcome (HR [95%CI]: 0.86 [0.76-0.96]; Figure 2). Among the secondary outcomes, Asian patients had also higher risk of thromboembolism and intracranial haemorrhage, and lower risk of major bleeding events.

Conclusions

In this large, contemporary cohort of patients with AF, Asian subjects received suboptimal management of thromboembolic risk, and showed a peculiar long-term risk of adverse outcomes. Integrated and appropriate treatment of these patients is crucial to improve their prognosis.Figure 1Figure 2
The current and future total health care costs of atrial fibrillation
Authors: Sandhu R , Qureshi H , Dover D , Hawkins M N , Kaul P
Published: November 2023

Background

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, yet detailed information on the cost burden remains sparse. These data are essential for determining resource allocation, benchmarking care, identifying areas for more efficient healthcare delivery and to measure effects of alternative treatment strategies.

Purpose

We sought to examine costs for inpatient, ambulatory, physician, and drugs for AF and model future costs.

Methods

In this retrospective population-based cohort study, we used linked administrative databases to identify all adult patients presenting to any healthcare setting with nonvalvular AF (NVAF) as the most responsible diagnosis in our city, Canada, from fiscal years 2010-2018.

Costs for inpatient, ambulatory, physician, and drugs were estimated, in 2019 Canadian dollars, by using Statistics Canada Consumer Price Index. A two-part cost model with logit and gamma generalized linear model was developed to predict costs from 2019 to 2030.

Results

There were 48,854 NVAF patients. The median age was 70 [59.0,80.0] years, 55% were male, and median CHADS-Vasc score = 3.0 [1.0,4.0]. NVAF-related costs were $1.4 billion dollars (inpatient $1.1 billion, ambulatory $107.0 million, physician $59.6 million, drugs $140.1 million) and represented 36.8% of total costs (Figure 1). The per patient cost of NVAF was $30.1 thousand. Over the study period, costs increased by 2.2% for inpatient, 40.5% for ambulatory, 67.1% for physician, and 214.2% for drugs. By 2030, we estimate there will be 54,523 NVAF patients. NVAF-related costs from 2019 to 2030 are estimated to be $3.6 billion (inpatient $2.5 billion, ambulatory $310.5.0 million, physician $197.5 million, drugs $610.4 million) and will represent 32.1% of total costs (Figure 1).

Conclusions

Costs for AF are on the rise and the distribution of costs are changing. Although inpatient costs represent the highest proportion of total AF costs, they are projected to decrease while costs due to ambulatory, physician and drug costs are increasing.
Trends in clinical outcomes of patients with incident atrial fibrillation; results from a nationwide registry
Authors: Tsaban G , Golan Ben Baruch Y , Kazerle L , Alnsasra H , Barrett O , Henkin Y , Eisen A , Weisband Y , Schliamser J , Zahger D , Haim M
Published: November 2023

Background

Atrial fibrillation (AF) is associated with the risk of stroke and death. Advancements in patient care, such as direct oral anticoagulant (DOAC) use, are expected to improve AF patients' outcomes. However, real-world data examining this expectation are sparse.

Methods

We performed a historical population-based study among patients of Israel's largest health-maintenance-organization among patients aged>21 years diagnosed with AF between 01/01/2010 and 01/01/2020. The study population was divided into early-era (2010-2014) and late-era (2015-2020). We compared the time-dependent 5-year risk of stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), or death.

Results

Of 98,241 patients (median-age:76, 51.3% women), 48,852 were in the early-era, and 49,389 were in the late-era. The late-era group had higher rates of OAC than the early-era group (51.3% vs. 33.5%, p<0.001). The predominant OACs were warfarin (28.4%) in the early-era and DOACs (45.1%) in the late-era.

Five-year death rates were 17,226 (35.3%) and 14,702 (29.8%) in the early-era and late-era groups, respectively (p<0.001), and 5-year stroke rates were 1,997 (4.1%) and 1,474 (3.0%) in the early-era and late-era groups, respectively (p<0.001). In multivariate models, era-related death risk was mediated by between-group OAC changes (p-for-interaction<0.001). OAC was associated with lower death risk (aHR 0.93, 95%CI(0.89,0.96),p<0.001). The late-era group had a lower stroke risk (aHR 0.90 95%CI(0.82,0.99),p=0.037), which was associated with between-group OAC changes (p-for-interaction=0.002). OAC was associated with reduced stroke risk in the late-era only (aHR 0.87, 95%CI(0.78,0.97),p=0.012). The risk of ICH was similar across study groups (p=0.40). GIB risk was lower in the late-era (aHR 0.85 95%CI(0.78,0.93),p<0.001). OAC was associated with increased GIB risk in the early-era (aHR 1.32, 95%CI(1.21,1.43),p<0.001) but not in the late-era (aHR 1.06 95%CI(0.96,1.17),p=0.24).

Conclusions

Contemporary AF management is associated with lower stroke, death, and significant bleeding risks. The pendulum shift from warfarin to DOACs was associated with improved clinical benefits.Survival curves of the outcome
Impact of diabetes mellitus severity, treatment regimen and glycaemic control on atrial fibrillation prevalence. A report from the NOMED-AF prospective cross-sectional observational study
Authors: Gumprecht J , Lip G Y H , Sokal A , Sredniawa B , Stokwiszewski J , Zdrojewski T , Grodzicki T , Kazmierczak J , Opolski G , Kalarus Z
Published: November 2023

Introduction

Diabetes mellitus (DM) is a well-known risk factor for atrial fibrillation (AF), but the mechanism(s) by which DM affects AF prevalence remains unclear. The pathophysiological background underlying the frequent coexistence of diabetes and AF seems to be multifactorial, involving changes in left atrial size, abnormal proinflammatory mediators and endothelial dysfunction.

Purpose

This study aims to evaluate the impact of diabetes mellitus severity, expressed as its known duration, antihyperglycemic treatment regimen and glycaemic control reflected by HbA1c level on AF and its silent, asymptomatic form (SAF) prevalence.

Methods

The cross-sectional NOMED-AF trial schedule comprised multistage, stratified and clustered population sampling with subsequent clinical evaluation and long-term non-invasive AF screening. AF was screened using a telemonitoring vest for a mean of 21.9± 9.1 days. From the representative sample of 3014 participants (mean age 77.5, 49.1% female), 881 participants (mean age 77.6 ± 0.25, 46.4% female) with concomitant DM were involved in the analysis.

Results

The mean DM duration was 12 ± 0.35 years, but no significant impact of DM timespan on AF and SAF prevalence was observed. There were also no differences in the course of DM treatment pattern (oral medication vs insulin vs both - oral + insulin) among the study population with and without concomitant AF (p=0.106). From the study population 72% (95% CI: 68.7-75.1) received only oral hypoglycaemic medication; 12.9% (95% CI: 10.7-15.5) was taking both oral treatment + insulin injections; and 15.1% (95% CI: 12.7-17.8) were administered with insulin only. Metabolic control reflected by HbA1c levels showed no significant association with AF prevalence (p=0.635; p=0.094).

On multivariate analyses, age (Odds Ratio (OR) 1.35, 95%CI: 1.18-1.53, p<0.001), p=0.042), body mass index (BMI; OR 1.043, 95%CI: 1.01-1.08, p=0.027) and LDL<100 mg/dl (OR 0.64, 95%CI: 0.42-0.97, p=0.037) were independent risk factors for AF prevalence, while age (OR 1.45, 95%CI: 1.20-1.75, p<0.001), LDL<100 mg/dl (OR 0.43, 95%CI 0.23-0.82, p=0.011), use of statins (OR 0.51, 95%CI: 0.28-0.94, p=0.031) and HbA1c ≤6.5 (OR 0.46, 95%CI: 0.25-0.85, p=0.013) were associated with silent AF prevalence.

Conclusions

Diabetes duration, diabetic treatment pattern or metabolic control per se did not significantly impact the prevalence of AF, including silent AF detected by prospective continuous monitoring. Independent predictors of AF were age, BMI and low LDL levels, with statins and HbA1c ≤6.5 being additional independent predictors for SAF.
Associations of adding salt to foods with incident atrial fibrillation in the UK biobank study
Authors: Park Y , Yang P S , Jang E S , Yu H T , Kim T H , Sung J H , Pak H N , Lee M H , Joung B Y
Published: November 2023

Background/Introduction

Recent studies documented that the frequency of adding salt to foods was significantly related with cardiovascular disease and premature death.

Purpose

We aimed to investigate the relationship between frequency of adding salt to food and incident atrial fibrillation (AF).

Methods

The UK Biobank cohort study enrolled more than 500 000 participants aged 40 to 70 years across the United Kingdom from 2006 to 2010. We excluded participants with AF, coronary artery disease, heart failure or stroke. This study included 395,682 participants who completed the questionnaire of the frequency of adding salt to foods at baseline.

Results

Compared with participants with a higher frequency of adding salt to foods, participants with a lower frequency were more women and had lower waist and Townsend deprivation index (TDI). During follow-up, 19212 (4.9%) developed AF. Compared with the group of always adding salt to foods, lower frequency of adding salt to foods was significantly associated with lower risk of incident AF after adjustment for age, sex, body mass index, TDI and other clinical variables (Hazard ratio[HR] 0.88 [95% confidence interval[CI] 0.82-0.95] in the group of usually, HR 0.85 [95% CI 0.80-0.91] in the group of sometimes and HR 0.82 [95% CI 0.77-0.88] in the group of never/rarely, respectively). In the multivariate Cox regression analysis, the lowest frequency of adding salt to food had lower risk of incident AF (HR 0.77 [95% CI 0.63-0.93]) compared with the highest frequency group after adjustment for total energy intake.

Conclusion

Our study indicates that lower frequency of adding salt to foods was associated with lower risk of incident AF.Baseline characteristicsRisk of incident atrial fibrillation
Validation of novel electrocardiographic classification for stroke prediction in patients with atrial fibrillation undergoing cardioversion
Authors: Relander A , Kaaria J , Jaakkola S , Vasankari T , Nuotio I , Airaksinen K E J , Kiviniemi T
Published: November 2023

Introduction

Atrial cardiomyopathy (aCM) is an electromechanical entity reflecting abnormal conduction, structure and function of the myocardium predisposing to stroke and atrial fibrillation (AF), however, its electrocardiographic (ECG) definition is poorly characterized. We systematically assessed potential ECG markers of aCM in an attempt to identify those at risk for stroke and systemic embolism (SSE) or a combination of SSE, heart failure and death (major adverse events, MAE).

Methods and Results

We manually reviewed 1591 ECGs from patients with AF undergoing an acute cardioversion from the Finnish Cardioversion study (FIN-CV). Using post-CV 30d follow-up data as the derivation cohort, we determined the predictive performance of various P-wave indices including P-wave duration, morphology, and P-terminal force (PTF) for SSE prediction. The best predictive performance was found using a combination of prolonged P-wave (≥180ms), deflected P-wave morphology in lead II, biphasic P-waves in all inferior leads or increased PTF (≥80mm*ms) as markers for extensive aCM. We validated the findings using the long-term follow-up in patients with no anticoagulation of whom 219/874 (25.1%) had extensive aCM. During the median follow-up of 4.9 years, there was 51 (5.8%) new SSE and 152 (17.4%) MAE in total. At 3 years, 9 (4.1%), 4 (1.2%) and 1 (0.3%) patients with extensive, moderate or no aCM had suffered from SSE, respectively (p=0.002). At 5 years, the rates were 16 (7.3%), 8 (2.5%) and 5 (1.5%) (p<0.001). Extensive aCM remained an independent predictor for SSE (HR 4.5, 95%CI 2.1-9.5, p<0.001) and MAE (HR 1.7, 95%CI 1.1-2.6, p=0.01) after adjusting for CHA2DS2-VASc score (Figure 1).

Conclusion

Novel electrocardiographic markers of extensive aCM provided additional prognostic insight on risk for stroke in atrial fibrillation patients.Figure 1Graphical Abstract
Atrial fibrillation burden and timing of anticoagulation therapy in patients with screen-detected and clinically-diagnosed AF
Authors: Sun W , Tam T K , Yan B
Published: November 2023

Purpose

We evaluated the impact of atrial fibrillation (AF) burden and timing of oral anticoagulation (OAC) therapy initiation on stroke risk in patients with screen-detected and clinically-diagnosed AF.

Methods

Consecutive patients aged ≥65 years attending medical outpatient clinics with or without known AF were prospectively enrolled for AF-screening using handheld single-lead ECG (AliveCor) from 12/2014 to 12/2017 (NCT02409654). Repeated screening was performed in patients with >1 visit during this period. Patients who participated in repeat screening were included in final analysis. Patients with previously known AF who were in AF in the initial screening and those with repeat screen-positivity were considered probably persistent AF, otherwise paroxysmal AF (single screen-positivity) or no AF (never screen-positive). Time from AF detection to initiation of OAC (Dx-to-Rx) was divided into two exposure levels, Dx-to-Rx ≤ 1 and >1 month. Ischemic stroke risk was estimated using adjusted sub-distribution hazard ratios (aSHR) derived from Fine and Gray regression models, accounting for death as competing risk, adjusting for components of CHA2DS2VASC score and chronic renal disease, with no AF as reference and stratified according to AF burden and Dx-to-Rx.

Results

Of 11,972 patients enrolled, 3,853(32.2%) received repeated screening (mean age 76.7±7.3, female 47.5%), of which 3.7% (n=144) had screened-detected AF, 25.2% (n=972) previously known AF, 5.9% (n=226) clinically-diagnosed AF during follow-up, and 65.2% (n=2,511) no AF. Persistent AF was identified in 16.7% (n=644/3,853). Of patients with all AF categories, 55.1% (n=739/1,342) initiated OAC within 1 month after AF diagnosis. During a median follow-up period of 7.2(IQR: 6.1-7.5) years, compared to no AF, patients with paroxysmal AF and Dx-to-Rx ≤ 1m (aSHR=1.40, 95%CI:0.80-2.47) had similar low risk of ischemic stroke, while aSHR was highest for persistent AF and Dx-to-Rx >1m (aSHR=2.42, 95%CI:1.38-4.26), followed by persistent AF with Dx-to-Rx≤ 1m (aSHR=2.19,95%:1.47-3.28), and paroxysmal AF with Dx-to-Rx >1m (aSHR=2.00,95%CI:1.32-3.02) (Figure). Subgroup analysis revealed the effect of early initiation of OAC (P for interaction=0.936) and higher AF burden (P for interaction=0. 863) were consistent across screen-detected and clinically-diagnosed AF.

Conclusion

Among patients with screen-detected AF or clinically-diagnosed AF, lower AF burden and immediate initiation of OAC therapy were associated with reduction in risk of ischemic stroke. Early detection of AF by screening facilitating early OAC prophylaxis might improve clinical outcomes.Cumulative risk of ischemic stroke
Heart failure after left atrial appendage occlusion: insights from the LAAOS-III randomized trial
Authors: Krisai P , Belley-Cote E P , Mcintyre W F , Tsiplova K , Paparella D , Whitlock R P , Healey J S
Published: November 2023

Background

Left atrial appendage removal or occlusion (LAAO) might increase the risk for heart failure (HF) due to the loss of the LAA`s reservoir function, active contraction and neuroendocrine function.

Purpose

To investigate the incidence of HF hospitalizations and/or HF related death after LAAO in the Left Atrial Appendage Occlusion Study (LAAOS III).

Methods

In LAAOS III, 4811 patients with atrial fibrillation (AF) and a CHA2DS2-VASc score ≥2 were randomized to undergo or not undergo surgical LAAO during cardiac surgery for another indication. We compared the incidence of a composite endpoint of HF hospitalizations and HF related death between the two randomized groups (LAAO vs no-LAAO). We also pre-specified subgroups including: sex, age, BMI, surgery type, concomitant AF ablation, prior history of HF, history of hypertension, diabetes, prior myocardial infarction, left ventricular ejection fraction, sinus rhythm and occlusion method.

Results

We included 2379 patients in the LAAO and 2391 patients in the no-LAAO group. Overall, mean age was 71 years, 67% were male and 57% had prior HF. Baseline characteristics including drug treatment were balanced between the groups. Over a mean follow-up of 3.8 years, 395 (8.3%) patients met the primary HF endpoint: 209 (8.8%) in the LAAO group and 186 (7.8%) in the no-LAAO group. We did not find a significant difference for the primary endpoint between the randomized groups (Hazard ratio [95% confidence intervals] 1.13 [0.93-1.37], p=0.233) (Figure). The only significant subgroup interaction was for concomitant AF ablation (p for interaction = 0.004). Patients in the LAAO group without concomitant AF ablation had a higher risk for the primary endpoint (HR [95% CI] 1.37 [1.08-1.74], p=0.009) than patients with ablation (HR [95% CI] 0.74 [0.51-1.06], p=0.097).

Conclusion

LAAO did not increase the risk for a combined endpoint of HF hospitalizations and HF related death in patients with AF. Patients with concomitant AF ablation might have lower risk for the combined endpoint.Figure
Dementia risk among patients with atrial fibrillation treated with non-vitamin K vs. vitamin-K oral anticoagulants
Authors: Sagris D , Ntaios G , Harrison S , Buckley B , Underhill P , Lane D , Lip G Y H
Published: November 2023

Background

Atrial fibrillation (AF) is associated with increased risk of dementia. Whether the use of direct oral anticoagulats (DOAC) is associated with lower risk of dementia compared to vitamin-K antagonist (VKA) is unclear.

Purpose

The purpose of this study was to assess the risk of new all-cause dementia and vascular dementia in AF patients, treated with either DOAC or VKAs.

Methods

Anonymized electronic medical records from the TriNetX federated research network were used. AF patients treated with DOACs within 1 month of AF diagnosis, were 1:1 propensity score- matched with those treated with a VKA. Patients were followed up to 10 years for all-cause dementia and vascular dementia. Logistic regression and Cox proportional hazard models were used to calculate odds ratios (OR) and hazard ratios (HR), respectively with 95% confidence intervals (CIs).

Results

Among 321,282 patients included in the propensity-scored cohort [mean (SD) age 69.7 (±13.5) years; 138,593 (43.1%) female], dementia was diagnosed among 15,050 (4.7%) patients. Among patients treated with DOACs, all-cause dementia was diagnosed in 6,337 (3.9%) and 8,713 (5.4%) among those treated with VKA (OR:0.72, 95%CI:0.69-0.74). Vascular dementia was diagnosed in 1,188 (0.7%) patients treated with DOACs and 1,766 (1.1%) among the VKA-treated (OR:0.67, 95%CI:0.62-0.72). DOACs were associated with lower risk of all-cause dementia and vascular dementia compared to VKA (HR:0.85, 95%CI:0.82-0.88 and HR:0.82, 95%CI:0.76-0.88, respectively).

Conclusions

In this large propensity-score matched analysis, AF patients treated with a DOACs had significantly lower risk of all-cause dementia and vascular dementia compared to those treated with VKA. This finding requires confirmation in ongoing randomised controlled trials.