bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiotrophin-1 and components of metabolic syndrome: what is the role in the development of atrial fibrillation?
Authors: Ionin V , Zaslavskaya EL , Barashkova EI , Skuridin DS , Baranova EI , Shlyakhto EV
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Pavlov University

Introduction. The cardiotrophin-1 (CT-1) is a cytokine from the interleukin-6 family associated with pathology of the cardiovascular system, contributing to myocardial remodeling and the development of fibrosis in patients with hypertension. CT-1 is involved in the regulation of energy processes and the metabolism of adipose tissue, as well as in the regulation of lipid and carbohydrate metabolism. Revealed an increase in the deposition of type I collagen in the atrial myocardium against the background of dilatation of the left atrium and an increase in the expression of CT-1. The role of CT-1 in the development of AF is currently being actively studied.

Purpose. To determine the concentration of cardiotrophin-1 (CT-1) in patients with metabolic syndrome (MS) and atrial fibrillation (AF) with an assessment of the relationship with the parameters of obesity and metabolic disorders.

Methods. In a one-stage case-control study, 352 patients aged 35 to 65 years were included: patients with MS (n = 223), of which 107 patients with AF, and comparison groups consisted of patients with AF without MS (n = 69) and practically healthy examined without cardiovascular diseases and metabolic disorders (n = 60).

Results. It was found that the concentration of CT-1 in serum in patients with AF is higher than in patients with MS without AF (766,2 (539,2-1032,3) and 590,2 (480,1-922,3) pg/ml, p = 0,005) and higher than in healthy subjects (780,2 (550,2-1050,3) and 410,1 (290,2-549,2) pg/ml, p < 0,0001). It was found that in patients with AF and MS, the concentration of CT-1 in the blood serum is higher than in patients with AF without MS (851,2 (589,1-1146,3) and 681,1 (480,1-823,2) pg/ml, p = 0,004). CT-1 positively correlates with the concentration of glucose in blood plasma (r = 0,423, p = 0.002) and triglycerides (r = 0,207, p = 0,003), as well as with the waist circumference (r = 0,265, p < 0.001) and the thickness of epicardial fat (r = 0,351, p < 0,001). Using ROC analysis, it was found that with an increase in the concentration of CT-1 in blood serum more than 638,1 pg/ml, the probability of AF increased by 4 times (OR = 4.0, 95%CI 2,31-6,94, p < 0,0001).

Conclusion. An increase of serum CT-1 concentration is associated with heart remodeling and obesity in patients with MS and probably has a pathogenetic role in increasing the risk of AF in this cohort of patients.
Atrial fibrillation detected at screening is not a benign condition - a comparison of clinical outcomes in screen-detected vs. hospital-detected atrial fibrillation
Authors: Zwartkruis VW , Geelhoed B , Suthahar N , Gansevoort RT , Bakker SJL , Van Gelder IC , De Boer RA , Rienstra M
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation

Background

Screening for atrial fibrillation (AF) improves detection of AF. However, it is unknown whether AF detected at screening carries risks similar to clinically detected AF, and if it should be treated similarly.

Purpose

We aimed to compare clinical outcomes in individuals with screen-detected vs. hospital-detected incident AF.

Methods

We studied 8265 individuals (mean age 49 ± 13 years, 50% women) without prevalent AF from the population-based PREVEND (Prevention of Renal and Vascular End-Stage Disease) cohort study. By design, 70% of PREVEND participants had urinary albumin concentration ≥10 mg/l. AF was considered screen-detected when first detected on a 12-lead electrocardiogram (ECG) during one of the PREVEND study visits, and hospital-detected when first detected on a hospital ECG. Using Cox regression models with screen-detected and hospital-detected AF as time-varying covariates, we studied the association of screen-detected vs. hospital-detected AF with mortality, incident heart failure (HF), and incident cardiovascular (CV) events.

Results

During a mean follow-up of 9.7 years, 265 participants (3.2%) developed incident AF (mean age 62 ± 9 years, 30% women, 65% hypertension, 23% obesity, 9% diabetes, 15% history of myocardial infarction, 3% history of stroke, 2% prevalent HF). Of all incident AF cases, 60 (23%) were screen-detected and 205 (77%) hospital-detected. Baseline characteristics were generally comparable between participants with screen-detected and hospital-detected AF. A larger proportion of incident AF was screen-detected in men (26%) compared to women (15%). In univariabe analysis, both screen-detected and hospital-detected AF were strongly associated with death, incident HF, and incident CV events. After multivariable adjustment, hospital-detected AF was significantly associated with death (HR 2.95, 95% CI 2.18-4.00), incident HF (HR 3.98, 95% CI 2.49-6.34), and incident CV events (HR 1.92, 95% CI 1.21-3.06). Screen-detected AF was significantly associated with death (HR 2.21, 95% CI 1.09-4.47) and incident HF (HR 4.90, 95% CI 2.28-10.57), but not with incident CV events (HR 1.12, 95% CI 0.46-2.71).

Conclusions

In a population-based cohort enriched for microalbuminuria, almost a quarter of incident AF cases was first detected through ECG screening. Compared to hospital-detected AF, screen-detected AF was similarly associated with adverse outcomes. Although randomised trials are needed, this study highlights that AF screening may help decrease the general burden of CV disease.
Prevalence of new onset atrial fibrillation and associated outcomes in patients with sepsis: a systematic review and meta-analysis
Authors: Romiti GF , Corica B , Proietti M
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

New-onset Atrial Fibrillation (neoAF) is a common complication in patients with sepsis and septic shock, imposing major challenges in management and worse prognosis; however, the actual prevalence of neoAF, as well as its impact on outcomes are still unclear. The aim of this study is to provide a comprehensive systematic review and meta-analysis on the prevalence of neoAF in patients with sepsis, and its impact on in-hospital mortality and intensive care unit (ICU) mortality.

Methods

Pubmed and EMBASE were systematically searched through 23th December 2020. Studies reporting on prevalence of neoAF and/or impact on in-hospital mortality or ICU mortality in patients with sepsis or septic shock were selected and included. Pooled prevalence and 95% Confidence Intervals (CI) were calculated, as well as Odds Ratios (OR), 95%CI and 95% Prediction Intervals (PI) for outcomes. Subgroup analysis and meta-regressions were performed to account for potential sources of heterogeneity; sensitivity analysis according to the "leave-one-out" approach were also performed.

Results

Among 4249 records retrieved from the literature search, 21 articles were identified and included in the systematic review. Across 207599 patients with sepsis or septic shock, prevalence of neoAF was found as high as 14% (95%CI: 9%-21%), with high heterogeneity between studies; significant subgroup differences were observed according to geographical location (with lower prevalences reported in North-American studies compared to European/Middle-East and Asian cohorts), study design and number of sepsis patients included in the original studies. A multivariate meta-regression model including sample size and geographical location was able to explain most part of the heterogeneity. Patients with sepsis showed an increased risk of both in-hospital mortality (OR: 2.31, 95%CI: 1.92-2.79, 95%PI: 1.52-3.53, Figure 1 panel A) and ICU mortality (OR: 2.66, 95%CI: 2.21-3.21, 95%PI: 1.77-4.00, Figure 1 panel B), with low to no heterogeneity detected between studies included. The "leave-one-out" sensitivity analysis confirmed the results of the main analysis.

Conclusions

Among patients with sepsis, neoAF is a common complication, being present in 1 out of 7 individuals. Patients with neoAF are at higher risk of mortality during sepsis, and may need specific therapeutical interventions. Abstract Figure.
Novel tool for predicting residual stroke risk in atrial fibrillation: mCARS
Authors: Ding WY , Rivera-Caravaca JM , Marin F , Torp-Pedersen C , Roldan V , Lip GYH
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Recently, CARS was proposed to predict 1-year absolute stroke risk in non-anticoagulated patients with atrial fibrillation (AF). We aimed to determine whether a modified CARS (mCARS) may be used to assess the residual stroke risk in anticoagulated AF patients.

Methods

We studied patient-level data of anticoagulated AF patients from the real-world Murcia AF Project and AMADEUS clinical trial. Individual mCARS was estimated for each patient using an estimated 64% risk reduction with anticoagulation.

Results

3,503 patients were included (2,205 [62.9%] clinical trial and 1,298 [37.1%] real-world). In the clinical trial cohort, the median age was 71 (IQR 65-77) and CHA2DS2-VASc score 3 (IQR 2-4). In the real-world cohort, the median age was 76 (IQR 70-81) and CHA2DS2-VASc score 4 (IQR 3-5).

At 1-year, there were 40 and 31 stroke events in the clinical trial and real-world cohorts, respectively. Average predicted residual stroke risk by mCARS was identical to actual stroke risk (1.8 [±1.8%] vs. 1.8% [95% CI, 1.3-2.4]) in the clinical trial, and broadly similar in the real-world (2.1 [±1.9%] vs. 2.4% [95% CI, 1.6-3.4]). Additionally, these values were comparable across the subgroups stratified by CHA2DS2-VASc score in both cohorts.

AUCs of mCARS for prediction of stroke events in the clinical trial and real-world were 0.678 (95% CI, 0.598-0.758) and 0.712 (95% CI, 0.618-0.805), respectively. In an exploratory analysis, we found that mCARS was able to refine stroke risk estimation for each point of the CHA2DS2-VASc score in both cohorts.

Conclusion

Personalised residual 1-year absolute stroke risk in anticoagulated AF patients may be estimated using mCARS. Such patients with high residual stroke risk may benefit from more aggressive interventions and follow-up. Absolute 1-year stroke risk Clinical Trial Real-World Median (IQR) Range Median (IQR) Range CHA2DS2-VASc score 0 NA 0.9 (0.6 - 1.3) 0.2 - 1.4 CHA2DS2-VASc score 1 1.1 (0.7 - 1.4) 0.2 - 2.0 1.4 (0.9 - 1.7) 0.2 - 13.0 CHA2DS2-VASc score 2 2.0 (1.5 - 2.4) 0.3 - 10.8 2.1 (1.5 - 2.6) 0.3 - 10.8 CHA2DS2-VASc score 3 2.6 (2.1 - 3.4) 0.4 - 13.3 2.8 (2.5 - 3.4) 0.9 - 13.3 CHA2DS2-VASc score 4 3.6 (2.8 - 5.6) 0.3 - 18.1 3.9 (3.3 - 5.0) 1.1 - 21.0 CHA2DS2-VASc score 5 6.7 (3.6 - 14.0) 1.9 - 20.9 4.8 (3.9 - 12.2) 1.2 - 21.0 CHA2DS2-VASc score 6 13.6 (5.5 - 15.8) 2.4 - 21.8 12.8 (4.8 - 16.7) 2.2 - 21.8 CHA2DS2-VASc score 7 15.7 (14.5 - 17.4) 4.5 - 21.9 15.6 (5.9 - 17.5) 4.1 - 23.5 CHA2DS2-VASc score 8 16.5 (14.0 - 18.5) 13.1 - 20.3 16.9 (15.7 - 19.5) 13.6 - 21.0 IQR, interquartile range; NA, not applicable.
Abutting left atrial appendage and left superior pulmonary vein predicts recurrence of atrial fibrillation after point-by-point pulmonary vein isolation
Authors: Szegedi N , Simon J , Szilveszter B , Sallo Z , Herczeg S , Nagy VK , Szeplaki G , Tahin T , Merkely B , Geller L
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation is the cornerstone for rhythm control in patients with drug-refractory atrial fibrillation (AF). Baseline predictors of AF recurrence after catheter ablation are well established, such as female gender and left atrial enlargement. The role of the spatial relationship between the left superior pulmonary vein (LSPV) and left atrial appendage (LAA) is unknown.

Purpose

We sought to evaluate whether juxtaposed LSPV and LAA plays a role in AF recurrence after catheter ablation for paroxysmal AF.

Methods

Consecutive patients, who underwent point-by-point radiofrequency catheter ablation for paroxysmal AF at our hospital between January of 2014 and December of 2017, were enrolled in the study. All patients underwent pre-procedural cardiac CT-angiography (CTA) for the assessment of left atrial (LA) and pulmonary vein (PV) anatomy. Abutting LAA-LSPV was defined as cases when LSPV touched the posterior aspect of LAA (distance less than 2 mm).

Results

We included 428 patients (60.7 ± 10.8 years, 35.5% female). AF recurrence rate was 33.4% with a median recurrence-free time of 21.2 (IQR = 8.8-43.0) months. In the univariate analysis, female sex (HR = 1.45; 95%CI = 1.04-2.01; p = 0.028), LA volume (HR = 1.01; 95%CI = 1.00-1.01; p = 0.042), and cases when LSPV touched the posterior wall of LAA (HR = 1.53; 95%CI = 1.09-2.14; p = 0.013) were associated with AF recurrence. In the multivariate analysis, female sex (adjusted HR = 1.55; 95%CI = 1.06-2.28; p = 0.024), LA volume (adjusted HR = 1.01; 95%CI = 1.00-1.02; p = 0.028), and abutting LAA-LSPV (adjusted HR = 1.60; 95%CI = 1.13-2.50; p = 0.008) remained significant predictors of AF recurrence.

Conclusion

Female gender, higher LA volume, and abutting LSPV and LAA predispose patients to have a higher chance for arrhythmia recurrence after catheter ablation for paroxysmal AF.
Novel cryo-balloon ablation technology for pulmonary vein isolation in patients with atrial fibrillation: preliminary experience from a multicenter clinical practice
Authors: Tondo C , Stabile G , Filannino P , Moltrasio M , De Simone A , Artale P , Fassini G , La Rocca V , Bianchi S , Perna F , Tundo F , Colella J , Iuliano A , Malacrida M , Iacopino S
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Complete electrical pulmonary vein isolation (PVI) by cryo-balloon approach is a well-established ablation strategy of atrial fibrillation (AF). Recently, a new cryoablation system (POLARx) with unique features has been made available for clinical use. To date, no data exist on procedural characteristics of this system in a multicentric clinical practice.

Purpose

We aimed to characterize the initial experience of this technology in the Italian clinical practice.

Methods

Consecutive patients (pts) undergoing AF ablation from the CHARISMA registry at 5 Italian centres were included. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred >60 sec or when time to isolation (TTI) was not available. The ablation endpoint was PV isolation as assessed by entrance and exit block.

Results

Two-hundred sixty-two cryoapplications from 49 pts (194 PVs) were analyzed. PVI was achieved with cryoablation only in all pts. The mean number of freeze applications per pt was 5.3 ± 1.5 (1.3 ± 0.6 for LIPV, LSPV and RSPV, 1.6 ± 1.3 for RIPV), with 143 (73.7%) PVs treated in a single-shot fashion (38, 19.6% with 2 shots; 13, 6.7% with more than 2 shots). Sixteen (33%) pts were treated with a single freeze to each of the PVs. The mean nadir temperature was -55.5 ± 6.9 °C and was colder than -50°C in 83% of the PVs. TTI information was evaluable in 120 (46%) cryoapplications with a median TTI of 47 [32-75] sec (median temperature at TTI = -49 [-53 to -42] °C). The mean time to target -40 °C (TTT) was 30.1 ± 6.9 sec with a TTT < 60 sec achieved in 99.2% of the cryoapplications; the mean thaw time to 0 °C was 18.6 ± 5.8 sec (thaw time >15 sec in 70.3% of the cryoapplications). The mean PV occlusion grade (rank 1-4) was 3.6 ± 0.6 (grade 2 in 5.2% of the cases, grade 3 in 25.6% and grade 4 in 69.2%). No complications were observed at 30 days post-procedure.

Conclusion

In this first multicentric experience in a clinical practice setting, the novel cryo-balloon system proved to be safe and effective and resulted in a high proportion of successful single-freeze isolation. Cooling parameters seem to be slightly different from reference cryo-balloon technology.
Very high-power short-duration temperature-controlled ablation for pulmonary vein isolation: The Fast-and-Furious study
Authors: Heeger CH , Sano MS , Meyer-Saraei RMS , Eitel CE , Phan HL , Hatahet SH , Traub AT , Delgado Lopez LDL , Vogler JV , Kuck KH , Tilz RRT
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation for atrial fibrillation (AF) treatment provides effective and durable PVI associated with encouraging clinical outcome. The novel QDot ablation catheter with Qmode + ablation mode (90W/4sec, Figure 1) offers the ability to possibly improve safety and decrease ablation procedure times.

Aims

We aim to evaluate safety and efficacy of the very high-power short-duration (vHP-SD) temperature-controlled radiofrequency (RF) ablation Qmode + mode for pulmonary vein isolation (PVI) utilizing the novel QDot micro ablation catheter. The data was compared to conventional power-controlled ablation index (AI) guided PVI.

Methods

Twenty-five consecutive patients with paroxysmal or persistent AF were prospectively enrolled, underwent vHP-SD based PVI (vHP-SD group) and were compared to 25 consecutive patients treated with conventional CF-sensing catheters (control).

Results

All PVs were successfully isolated utilizing Qmode +. The total median RF ablation time was vHP-SD: 334 (282, 369) sec. vs control: 1567 (1250, 1756) sec. (p < 0.0001), the median procedure time was vHP-SD: 56 (48-62) vs. control: 104 (92-122) min (p < 0.0001). No differences in periprocedural complications were observed.

Conclusions

The novel Qmode + provides safe and effective PVI with impressive short RF time and short procedures times. Procedure time and RF time were substantial lower in the vHP-SD group. Abstract Figure 1
Predictive value of ten risk scores for outcomes of atrial fibrillation patients undergoing radiofrequency pulmonary vein isolation
Authors: Mulder MJ , Kemme MJB , Hopman LHGA , Kusgozoglu E , Gulcicek H , Van De Ven PM , Hauer HA , Tahapary GJM , Van Rossum AC , Allaart CP
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction:

A significant number of patients experience recurrent atrial fibrillation (AF) after ablation. Predicting who will or will not benefit from AF ablation is challenging. Although various risk scores have been designed to predict outcomes after AF ablation, comparative data are sparse and external risk score validation is often lacking.

Purpose

In this study, we aimed to compare ten previously described risk scores with regard to their predictive value for post-ablation AF recurrence and procedural complications.

Methods

A total of 482 AF patients (37% non-paroxysmal AF, 66% male, mean age 62 ± 9 years) undergoing initial radiofrequency pulmonary vein isolation (RF-PVI) were included in the present analysis. Prior to ablation, all patients underwent both transthoracic echocardiography and either cardiac computed tomography imaging or cardiac magnetic resonance imaging. The following risk scores were calculated for each patient: APPLE, ATLAS, BASE-AF2, CAAP-AF, CHADS2, CHA2DS2-VASc, DR-FLASH, HATCH, LAGO and MB-LATER. The predictive performance of the risk scores for AF recurrence and complications were assessed separately by receiver operating characteristic (ROC) curves.

Results

Median follow-up was 16 (12-31) months. AF recurrence after the 90-day blanking period was observed in 199 patients (41%), occurring after a median of 183 (124-360) days after ablation. Overall procedural adverse event rate was 6%. The HATCH score was the only score without predictive value for recurrent AF after ablation (area under curve [AUC] 0.545). All other investigated scores demonstrated statistically significant but poor predictive value for recurrent AF after ablation (AUC 0.553-0.669). CHA2DS2-VASc and CAAP-AF were the only risk scores with predictive value for procedural complications (AUC 0.616, p = 0.043; AUC 0.615, p = 0.044; respectively). ROC curve analyses of the studied risk scores for the prediction of AF recurrence and complications are shown in Figure.

Conclusion

Currently available risk scores perform poorly in predicting outcomes after RF-PVI. These data suggest that the utility of these scores for clinical decision-making is limited. Abstract Figure. ROC curve analyses of risk scores
Efficacy and safety of a high power short duration ablation-index guided protocol for pulmonary vein isolation using a single catheter
Authors: Badertscher P , Knecht S , Madaffari A , Spies F , Osswald S , Schaer B , Sticherling C , Kuehne M
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation for atrial fibrillation (AF) is the most common performed electrophysiological procedure. The cost of this procedure remains high.

Purpose

To improve health care utilization, we aimed to compare the efficacy and safety of a minimalistic, streamlined single radiofrequency catheter ablation approach using high power short duration ablation-index guided protocol (HPSD) vs. a standard single catheter protocol.

Methods

A circular mapping catheter free PVI with a single transseptal puncture was performed in 91 patients. A CARTO fast anatomical map was performed with the ablation catheter. Pacing maneuvers were used to confirm exit block. Procedural characteristics and success rates were compared using HPSD- vs. a standard ablation-protocol. Freedom from recurrence was defined as a 1-year absence of AF episodes > 30 s, beyond the 3-month-blanking-period.

Results

Using the HPSD-protocol the median procedure, map and RF ablation time were significantly shorter in the HPSD group compared to the standard group, 84 (IQR 76-100) vs. 118 minutes (IQR 104-141), 12 (IQR 10-16) vs. 18 minutes (IQR 15-21) and 1036 (898-1184) vs. 1949 seconds (IQR 1693-2261), respectively, P < .001 for all. First-pass-PVI was achieved using the HPSD-protocol in 23 patients (74%) and the standard-protocol in 30 patients (53%), p = 0.08. Localization of conduction gaps are illustrated for the HPSD-protocol and the standard-protocol in Figure 1. The residual gap was identified using the ablation catheter only in all patients. No procedural complication were observed. At 12 months follow-up, 60 (89.6%) patients remained free from AF with no differences between groups.

Conclusions

A minimalistic, CMC-free HPSD-guided PVI approach is very efficient, safe, likely cost-saving, and associated with excellent clinical outcomes at 1 year. Abstract Figure 1
Effects of pulse field and radiofrequency pulmonary vein isolation on parasympathetic cardiac innervation
Authors: Peichl P , Wichterle D , Stojadinovic P , Cihak R , Nakagawa H , Kautzner J
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): IKEM

Background

Pulmonary vein isolation (PVI) is an established treatment modality for patients with atrial fibrillation (AF). PVI performed by radiofrequency (RF) energy results in parasympathetic denervation of the heart by collateral ganglionic plexi ablation. Pulse field (PF) is a novel nonthermal energy source for PVI that selectively ablates atrial myocardium while preserving cardiac autonomic nerves, which may affect the outcome after PVI.

Purpose

The study compared the effect of PVI between RF and PF ablation on cardiac autonomic function and a short-term AF recurrence rate. The resting heart rate (HR) was evaluated as a simple index of sinus nodal parasympathetic innervation.

Methods

We investigated 45 patients (aged 64 ± 7 years, 4 women) who underwent PVI by novel three-dimensional electroanatomical mapping/ablation system (lattice electrode ablation system). PVI was performed by either high-energy RF (n = 21) or PF (n = 24) energy using the identical ablation catheter. Resting HR assessed by standard ECG was recorded the day before the procedure and at the 3-month visit. Arrhythmia recurrences were analysed by 24-Holter at the 3-month visit.

Results

All PVs were acutely isolated in all patients. The HR data are shown in the Table. The baseline HR did not differ between both groups. A significant increase in HR was observed only in the RF ablation subgroup. The between-group difference remained significant even after adjustment for age, gender, and baseline HR. There was no difference in arrhythmia recurrences at the 3-month visit between study groups.

Conclusions

  Parasympathetic denervation effects on HR after the PF ablation are virtually absent. Comparable AF recurrence rate at 3-month visit after RF and PF ablation suggests that preservation of autonomic innervation has no impact on AF recurrence during short-term follow-up. Table RF PVI (n = 21) PF PVI (n = 24) P Baseline HR (bpm) 60.0 ± 7.1 63.8 ± 9.4 n.s. HR change - 3-month visit (bpm) 14.4 ± 6.9 0.3 ± 8.6 P <0.001 Arrhythmia recurrences 3/21 (14%) 2/24 (8%) n.s.
Defining the blanking period duration after cryoballoon pulmonary vein isolation in patients taking an antiarrhythmic drug
Authors: Musat D , Milstein NS , Saberito M , Bhatt A , Habibi M , Preminger MW , Sichrovsky T , Shaw R , Mittal S
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon pulmonary vein isolation (CB) is an accepted method for ablation in patients with atrial fibrillation (AF). A three-month blanking period (BP) is commonly used in clinical trials and practice. However, the actual BP duration in patients (pts) on an antiarrhythmic drug (AAD) at time of ablation remains undefined.

Objective

To objectively define the BP duration in pts undergoing CB while taking an AAD.

Methods

We enrolled consecutive pts with AF who had CB PVI while on an AAD. All pts had an implantable loop recorder (ILR). We prospectively followed all pts and determined the time to last AF episode during the 90-day post-PVI BP. This was then correlated with likelihood of having an AF recurrence between 3-12 months post-PVI.

Results

The cohort included 92 pts (66 ± 10 years; 62 [67%] male; 33 [36%] PAF; CHA2DS2-VASc 2.6 ± 1.7). AADs used included dofetilide (42), dronedarone (14), amiodarone (25), sotalol and propafenone (3 each), and flecainide (5). The AAD was stopped at a median of 80 [36, 105] days post-PVI.  We defined 4 distinct groups: (1) no AF in 90-day BP (n = 45 [49%]); (2) last AF within 30 days of PVI (n = 17 [18%]); (3) last AF within 60 days of PVI (n = 13 [15%]); and (4) last AF within 90 days of PVI (n = 17 [18%]). Following the 90-day BP, 47 (51%) pts had a recurrence of AF. Once recurrent AF was observed > 30 days post-ablation, patients had high likelihood of having a long term AF recurrence (p = 0.037, Figure).

Conclusion

Our data suggest that the optimal BP duration in AF patients undergoing CB PVI while taking an AAD is 30 days. An AF recurrence after 30 days is associated with a very high likelihood of recurrent AF during longer-term follow-up. Abstract Figure.
Does cardiac arrhythmia surgery improve a patient"s quality of life? a systematic review and meta-analysis
Authors: Van Der Heijden CAJ , Bidar E , Vos R , Maessen J , Athanasiou T , Maesen B
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Although one-year success of arrhythmia surgery for atrial fibrillation (AF) has long been defined as freedom from supraventricular tachyarrhythmia, patient-reported quality of life (QOL) has become increasingly important.

Purpose

We aimed to analyze current evidence of QOL following both concomitant and stand-alone arrhythmia surgery for AF.

Methods

Studies reporting on QOL of patients undergoing arrhythmia surgery for AF, stand-alone or concomitant, who provided essential data for the analysis, were included in this systematic review. A meta-analysis was performed on inter-study heterogeneity of changes in QOL in 9 of 12 included studies who used the Short-Form (SF) 36 tool. The metric standardized mean difference (SMD) was used to compare one year outcomes with baseline scores per variable of the SF-36 QOL questionnaire (total patients n = 545). Finally, meta-regression based on rhythm outcome after one year and add-on arrhythmia surgery as covariate were performed.

Results

QOL scores improved one year after surgical ablation for AF, evaluated by several questionnaires. In standalone arrhythmia procedures, meta-regression showed a significant improvement between the QOL and the procedural effectiveness after one year (Physical Functioning p = 0.015, Role Physical p = 0.006, General Health p = 0.002, Social Functioning p = 0.043. Forest plot Physical Functioning: SMD = 1.105; heterogeneity: I²=90.6%, p < 0.001). While this association was also suggested in concomitant procedures, only the variable Physical Role demonstrated a significant improvement when comparing QOL of cardiac surgery with and without add-on surgical AF ablation (p = 0.037).

Conclusion

Arrhythmia surgery for AF improves QOL. Both in standalone and concomitant procedures, the improvement in QOL seems to be related to the procedural effectiveness to maintain sinus rhythm after 12 months. Abstract Figure. SF-36 variable Physical Functioning
Non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in (morbidly) obese or low body weight patients with atrial fibrillation: a meta-analysis
Authors: Grymonprez M , De Backer TL , Steurbaut S , Boussery K , Lahousse L
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fund for Scientific Research Flanders (FWO)

Background

Oral anticoagulants are crucial for preventing systemic thromboembolism in atrial fibrillation (AF), with guidelines preferring non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) in the general AF population. However, as NOACs are administered in fixed doses, concerns of unintentional underdosing in morbidly obese patients and unintentional overdosing in underweight patients have emerged. Moreover, VKAs are still recommended in morbidly obese patients (body mass index (BMI) ≥40 kg/m², body weight >120 kg) due to lack of data for NOACs in these patients.

Purpose

A critical appraisal of the benefit-risk profile of NOACs in AF patients across the body weight spectrum. 

Methods

After searching the Medline database, phase III randomized controlled trials (RCTs) and longitudinal observational cohort studies on the effectiveness and safety of NOACs versus VKAs in obese (BMI ≥30 kg/m²), and class III obese (BMI ≥40 kg/m²) non-valvular AF patients, and in low body weight (≤60 kg) AF patients during a mean/median follow-up of ≥6 months were included. The meta-analyses were performed using a random effects model with the Mantel-Haenszel method.

Results

A meta-analysis based on 4 phase III RCTS and 3 longitudinal observational cohort studies demonstrated that NOAC use in obese and class III obese AF patients was associated with significantly lower stroke/systemic embolism (stroke/SE) risks (RR 0.82, 95%CI [0.71-0.96]; and RR 0.75, 95%CI [0.64-0.87], respectively), similar to lower major bleeding risks (RR 0.83, 95%CI [0.69-1.00]; and RR 0.74, 95%CI [0.57-0.95], respectively), and similar mortality risks (RR 0.92, 95%CI [0.73-1.15]; and RR 1.17, 95%CI [0.83-1.64], respectively) as compared to VKAs. In AF patients ≤60 kg, significantly lower stroke/SE (RR 0.63, 95%CI [0.56-0.71]) and major bleeding risks (RR 0.71, 95%CI [0.62-0.80]), and similar mortality risks (RR 0.68, 95%CI [0.42-1.10]) were observed for NOAC- versus VKA-treated patients in a meta-analysis based on 4 phase III RCTs and 2 longitudinal observational cohort studies.

Conclusions

The benefit-risk profile of NOACs seems preserved in (morbidly) obese AF patients and patients with low body weight of ≤60 kg. However, more data are needed in underweight AF patients (BMI <18.5 kg/m²) and on differences between NOACs to further optimize management in these patient subgroups.
Kidney, limb and ophthalmic complications and death in patients with nonvalvular atrial fibrillation and type 2 diabetes prescribed rivaroxaban or warfarin: an electronic health record analysis
Authors: Costa O , Brescia CW , Vardar B , Abdelgawwad K , Sood N , Coleman CI
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Bayer AG, Berlin, Germany

INTRODUCTION

Patients with nonvalvular atrial fibrillation (NVAF) and type 2 diabetes (T2D) have a higher risk of kidney, limb, and ophthalmic complications than those without T2D.

PURPOSE

We sought to evaluate these complications and death in patients with NVAF and T2D prescribed rivaroxaban or warfarin.

METHODS

We analyzed Optum® de-Identified electronic health record (EHR) data from 11/2010-12/2019. We included adults with NVAF and T2D newly initiated on rivaroxaban or warfarin with ≥12 months of prior EHR activity. Patients with another indication for anticoagulation, valve disease, history of end-stage renal disease, major adverse limb events (MALE), diabetic retinopathy or pregnancy were excluded. We evaluated the incidence rate of developing a composite outcome of >40% decrease in estimated glomerular filtration incidence rate (eGFR) from baseline, eGFR < 15 mL/minute/1.73 m2, need for dialysis or kidney transplant, MALE, diabetic retinopathy or death. Overlap weighting was used to balance baseline characteristics between cohorts while preserving sample size.  Hazard ratios with 95% confidence intervals were calculated using propensity score-overlap weighted Cox regression.

RESULTS

We included 24912 rivaroxaban and 58270 warfarin users. Rivaroxaban was associated with a significant reduction in the composite endpoint versus warfarin (-19.7 events per 1000 person years) driven mostly by an >40% decrease in eGFR from baseline, need for dialysis or renal transplant, MALE and death (Figure 1).

CONCLUSIONS

Rivaroxaban was associated with reduced incidence rates of kidney and limb complications, and death in NVAF patients with T2D.

FUNDING

 Funding for this study was provided by Bayer AG, Berlin, Germany Abstract Figure 1. Outcomes
Role of long-term continuous cardiac monitoring in oral anticoagulation management of patients with known atrial fibrillation
Authors: Natale A , Kasner SE , Diener HC , Verma A , Amin A , Beinart SC , Del Greco M , Kusano K , Pouliot E , Franco NC , Mittal S
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Medtronic

OnBehalf

Reveal LINQ Registry Investigators

Background

Monitoring atrial fibrillation (AF) with an insertable cardiac monitor (ICM) provides objective data for clinicians to make decisions on oral anticoagulation (OAC) management, based on individual risk profiles. Whether ICM data is being used for that purpose has not been widely explored.

Purpose

To show the impact of AF burden measured by an ICM on OAC treatment initiation and discontinuation in patients with known AF.

Methods

Patients from the prospective, ongoing, multi-center Reveal LINQ Registry monitored for AF management, or pre- or post-ablation monitoring were eligible. Follow-up was scheduled every 6 months for up to 3 years. Patients were excluded if they had no AF data available within the last 6 months of follow-up (FU), or less than 6 months of FU and no change to their OAC treatment compared to baseline. AF burden was defined as the percentage of time in AF 6 months prior to last FU, excluding the first 3 months post-ablation for patients who had an ablation.

Results

The analysis included 225 patients (65 ± 10 years, 72% male, mean CHA2DS2-VASc score 2.1 ± 1.4) monitored with an ICM for 21.8 ± 7.9 months. At baseline, 164 (73%) were taking OAC therapy, 147 (65%) had a history of paroxysmal AF and 79 (35%) had persistent AF. Forty percent of patients had a history of atrial ablation prior to ICM insertion and 37% had ≥1 AF ablation procedure after ICM. Patients were grouped according to OAC status at baseline, CHA2DS2-VASc score and AF burden (Figure: bars show percentage of patients with a change in OAC status during monitoring). Patients at high risk of stroke and AF burden >0.5% were more likely to initiate OAC therapy, whereas patients with higher AF burden were less likely to discontinue OAC, regardless of their risk score. Among those with no AF burden detected during the last 6 months of follow-up and on OAC at baseline, approximately half discontinued OAC, whereas 1/3 of patients with high risk score had initiated OAC, despite having no AF detected.

Conclusion

Our results derived from real-world practice show that AF detected and quantified by an ICM influences OAC therapy management in patients with known AF. Many patients with a low CHA2DS2-VASc score and no AF or low AF burden have had OAC therapy discontinuation, whereas a high proportion of patients with high AF burden have initiated OAC, regardless of their risk score. Abstract Figure. OAC according to risk and AF burden
Safety and effectiveness of edoxaban in a real-world clinical setting: Two-year follow-up of the ETNA-AF-Europe study
Authors: De Caterina R , De Groot JR , Weiss TW , Kelly P , Monteiro P , Deharo JC , De Asmundis C , Lopez-De-Sa E , Waltenberger J , Steffel J , Levy P , Bakhai A , Kirchhof P
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe

OnBehalf

ETNA-AF-Europe investigators

Background

Oral anticoagulation (OAC) for stroke prevention is essential in the management of patients with atrial fibrillation (AF). The assessment of OAC use in routine clinical care and the effects of this therapy on outcomes and safety are important.  Purpose: We analysed two-year outcome data with adjudicated follow-up results in 13,417 patients with AF treated with edoxaban. Methods: ETNA-AF-Europe (Clinicaltrials.gov: NCT02944019) enrolled 13,417 consecutive patients with AF treated with edoxaban in 825 centres in 10 European countries and 2-year prospectively collected, real world data is presented. Results: Edoxaban was prescribed according to licence recommendations in 83.1% (n = 11,146) of patients (Table). Whilst three quarters of patients were prescribed edoxaban 60 mg (n = 10,248, 76.4%), the quarter prescribed edoxaban 30 mg were older (79.5 versus 71.8 years), had a higher stroke risk (CHA2DS2-VASc score: 3.9 versus 3.0) and a higher bleeding risk (HAS-BLED score: 2.9 versus 2.4). Thromboembolic and bleeding events were more common in patients receiving edoxaban 30 mg OD without differences in intracranial haemorrhage (ICH) (Figure). Patients prescribed a non-recommended dose of edoxaban had a numerically higher stroke risk (CHA2DS2-VASc score: 3.6 versus 3.1) with subsequent higher rates of ischemic stroke and mortality, however they also had higher bleeding rates, with the exception of ICH (table) despite a similar initial bleeding risk (HAS-BLED score: 2.7 versus 2.5). Conclusions: In this large, European data set reporting two-year outcomes on edoxaban therapy, no additional safety signals were observed and event rates were in line with those observed in ETNA-AF after 1 year and in ENGAGE AF-TIMI 48, re-affirming the safety and effectiveness of edoxaban licence recommendations in a real world setting of patients with AF. All key events of interest, other than intracranial haemorrhage, were numerically lower in patients prescribed the licenced recommended dose. Outcomes with rec. vs non-rec. dosesn (%/year [95%CI])Recommended dose (n = 11,146; 83.1%)Non-recommended dose (n = 2271; 16.9%)Any stroke/SEE138 (0.68 [0.57;0.80])31 (0.76 [0.51;1.07])Ischaemic stroke99 (0.48 [0.39;0.59])26 (0.63 [0.41; 0.93])Major bleeding189 (0.93 [0.80;1.07])49 (1.20 [0.89;1.59])Intracranial haemorrhage43 (0.21 [0.15;0.28])7 (0.17 [0.07;0.35])All-cause mortality729 (3.55 [3.30;3.82])208 (5.04 [4.38;5.78])CV mortality405 (1.97 [1.79;2.18])113 (2.74 [2.26;3.30])CI, confidence interval; CV, cardiovascular; rec., recommended; SEE, systemic embolic event.Abstract Figure. Annualised event rates at 2-year FU
The Atrial Fibrillation Better Care (ABC) pathway in atrial fibrillation: a systematic review and meta-analysis of 285,000 patients
Authors: Romiti GF , Pastori D , Rivera-Caravaca JM , Ding WY , Gue YX , Menichelli D , Gumprecht J , Koziel M , Yang PS , Guo Y , Lip GYH , Proietti M
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The ‘Atrial Fibrillation Better Care’ (ABC) pathway has been recently proposed as a holistic approach for the comprehensive management of patients with Atrial Fibrillation (AF), standing on three main pillars: ‘A’ Avoid stroke (with Anticoagulants); ‘B’ Better symptom management; ‘C’ Cardiovascular and Comorbidity management. The ABC pathway is now recommended in several clinical guidelines, including the recent European Society of Cardiology (ESC) AF management guidelines. We performed a systematic review of the current evidence for use of the ABC pathway on clinical outcomes.

Methods

We performed a systematic review and meta-analysis according to PRISMA Guidelines. Pubmed and EMBASE were searched for studies reporting the prevalence of ABC pathway adherent management in AF patients, and its impact on clinical outcomes (all-cause death, cardiovascular death, stroke, and major bleeding). Metanalysis of odds ratio (OR) was performed with random-effect models; subgroup analysis and meta-regression were performed to account for heterogeneity; a CHA2DS2-VASc-stratified sensitivity analysis was also performed.

Results

Among 2862 records retrieved from the literature search, 8 studies were included. The pooled prevalence of ABC adherent management was 21% (95% confidence intervals (CI), 13-34%), with a high grade of heterogeneity; in a multivariable meta-regression model, adherence to each criteria of the ABC pathway explained most part of the heterogeneity (R2 = 98.9%). Patients treated according to the ABC pathway showed a lower risk of all-cause death (OR:0.42, 95%CI 0.31-0.56), cardiovascular death (OR:0.37, 95%CI 0.23-0.58), stroke (OR:0.55, 95%CI 0.37-0.82) and major bleeding (OR:0.69, 95%CI 0.51-0.94), with moderate heterogeneity. Meta-regressions showed that the increasing prevalence of diabetes mellitus, coronary artery disease, chronic heart failure and history of stroke were associated with a reduced effectiveness of the ABC pathway for all-cause and cardiovascular death; each comorbidity was able to explain a significant proportion of heterogeneity at univariate meta-regression. Conversely, longer follow-up time was associated with more effectiveness of the ABC pathway for all outcomes. Adherence to ABC pathway was associated with a progressively greater reduction of the all-cause death risk amongst patients with higher CHA2DS2-VASc scores; no difference in ABC pathway effectiveness was found across CHA2DS2-VASc strata for CV death and stroke occurrence.

Conclusions

Adherence to the ABC pathway was suboptimal, being adopted in 1 in every 5 patients. Adherence to the ABC pathway was associated with a reduction in the risk of major adverse outcomes. Our data supports extensive application of the ABC pathway for the management of AF. Abstract Figure.
Risks of thromboembolism, mortality and bleeding in 2,435,541 atrial fibrillation patients with and without cancer: a nationwide cohort study
Authors: Pastori D , Marang A , Bisson A , Menichelli D , Herbert J , Lip GYH , Fauchier L
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background. Atrial fibrillation (AF) and cancer are frequently coexisting in clinical practice. The impact of cancer on outcomes in AF patients is unclear as well as the performance of HAS-BLED and CHA2DS2-VASc scores.

Purpose. To investigate the incidence rate (IR) of all-cause and cardiovascular mortality, ischemic stroke (IS), major bleeding and intracranial haemorrhage (ICH) according to the presence of cancer and cancer types.

Methods

Observational retrospective cohort study including 2,435,541 AF patients.

Results. Overall, 399,344 (16.4%) had cancer, the most common being metastatic, prostatic, colorectal, lung, breast, and bladder (figure). The table shows the IR of bleeding and ischemic outcomes according to the cancer type. During 2 years follow-up, the IS was higher with pancreas, uterine and breast cancers.

Cancer increased major bleeding (HR 1.27, 95%CI 1.26-1.28) and ICH (HR 1.07, 95%1.05-1.10), which progressively increased by HAS-BLED score, which showed generally good predictivity (c indexes >0.70). The CHA2DS2-VASc score showed slightly lower predictivity in AF cancer patients.

Conclusions. Cancer increased all-cause and cardiovascular mortality, major bleeding and ICH risk in AF patients. The association between cancer and IS differed among cancer types. All-cause deathCardiovascular deathISMajor bleedingICHNo Cancer10.8 (10.8-10.8)3.8 (3.8-3.8)2.4 (2.3-2.4)5.0 (5.0-5.1)1.2 (1.1-1.2)Cancer27.0 (26.8-27.1)4.4 (4.4-4.5)2.3 (2.2-2.3)8.4 (8.3-8.5)1.3 (1.3-1.4)Breast20.4 (20.1-20.8)4.2 (4.1-4.4)2.6 (2.5-2.8)5.5 (5.3-5.7)1.3 (1.2-1.4)Ovarian40.4 (38.7-42.2)3.8 (3.3-4.4)2.2 (1.8-2.6)8.6 (7.8-9.5)0.9 (0.7-1.2)Uterine27.0 (26.0-28.1)4.2 (3.8-4.7)2.6 (2.3-2.9)9.0 (8.4-9.6)1.1 (0.9-1.3)Prostatic20.4 (20.1-20.7)4.2 (4.1-4.3)2.2 (2.1-2.3)9.1 (8.9-9.3)1.4 (1.3-1.5)Renal24.2 (23.5-24.9)4.1 (3.8-4.4)2.1 (1.9-2.3)9.6 (9.1-10.1)1.5 (1.3-1.7)Bladder23.7 (23.3-24.1)3.9 (3.7-4.1)2.2 (2.1-2.4)11.7 (11.4-12.0)1.2 (1.1-1.3)Gastric41.2 (40.0-42.5)3.6 (3.3-4.0)2.2 (1.9-2.5)11.0 (10.3-11.7)0.9 (0.7-1.1)Colorectal22.5 (22.2-22.8)3.2 (3.1-3.4)2.1 (2.0-2.2)8.4 (8.2-8.6)1.1 (1.0-1.2)Liver59.8 (58.2-61.4)5.9 (5.4-6.5)1.9 (1.7-2.3)12.7 (11.9-13.5)1.5 (1.2-1.7)Pancreas72.4 (70.4-74.5)5.7 (5.2-6.3)2.8 (2.4-3.3)11.7 (10.9-12.6)1.4 (1.2-1.7)Lung60.7 (60.0-61.4)5.6 (5.4-5.9)1.9 (1.8-2.0)8.2 (7.9-8.5)1.0 (0.9-1.1)Leukaemia38.1 (37.3-38.9)6.1 (5.8-6.4)2.0 (1.8-2.2)12.4 (11.9-12.9)1.9 (1.7-2.1)Myeloma33.3 (32.4-34.1)5.1 (4.8-5.5)2.0 (1.8-2.2)11.6 (11.1-12.2)1.5 (1.4-1.7)Metastatic66.9 (66.3-67.4)6.0 (5.8-6.2)2.2 (2.1-2.3)10.4 (10.2-10.6)1.3 (1.2-1.4)Abstract Figure 1