bluuebunny/crossref_metadata_2025 huggingface dataset:
Screening for atrial fibrillation by village doctors in rural areas of china: the jiangsu province rural community atrial fibrillation project
Authors: Li M , Chu M , Zhang S M , Shen Y M , Sun X X , Gong J L , Yang G , Shi J J , Ding X W , Gu Z S , Li C Z , Zhang C Q , Wang Z R , Lip G Y H , Chen M L
Published: November 2023

Background

No study has systematically investigated the quality of long-term care delivered to the rural elderly with chronic diseases in China. Since atrial fibrillation (AF) is becoming an increasing burden on healthcare systems worldwide.

Purpose

We conducted an AF screening programme in rural elderly and evaluated healthcare efficiency led by the village doctors in China.

Methods

This cross-sectional study of the rural population aged ≥65 years was conducted from April to June 2019 in our towns of Jiangsu Province. AF was identified using 12-lead electrocardiography in the first-step (government-led health examination) and single-lead electrocardiography in the second-step (in-house AF screening). Questionnaire surveys were designed for the AF patients and their village doctors, respectively.

Results

Among the 31,342 registered subjects, 12,630 (40·3%) declined, 7,956 (25·3%) participated in the first-step and 10,756 (34·3%) in the second-step (Figure 1). The overall AF detection rate was 4·3% (810/18,712). Of the 810 patients with AF (mean age 76·1±5·9 years; 51·4% female), 51·5% had education level below primary school, 2·6% could use smartphone applications, and 8·1% lived with their children. Common risk factors were older age, men, hypertension, diabetes, prior stroke, vascular disease, and congestive heart failure. Among the 402 patients who were aware of AF, there were 367 were at high risk of stroke (CHA2DS2-VASc score ≥3 in women or ≥2 in men) and OAC was currently used in only 10·9% (40/367) of these (Figure 2). Only 17·6% (91/516) of patients with known hypertension had a resting blood pressure level <140/90 mmHg, and 6·0% (8/132) of patients with known diabetes had a fasting blood glucose level ≤6·1 mmol/L. Our questionnaire survey for village doctors showed that only 7·3% (9/122) reported having the knowledge or ability for providing integrated care AF management.

Conclusions

This screening project in rural villages identified AF in 4·3%, but AF management was suboptimal with low use of oral anticoagulation. The current village doctor-dominant rural healthcare system is far from delivering optimal standardized AF management for older patients in rural China. There is a urgent need to support these rural clinics and empower the village doctors in optimising the care of AF patients.The flow chart of this studyThe use of oral anticoagulation
Pesticide exposure an unforseen trigger for atrial fibrillation
Authors: Kishore P , Aid J , Van Wijk S T A N W , Ramos K S , Van Schie M , Knops P , De Groot N A T A S A , Brundel B J J M
Published: November 2023

Background/Introduction

Over the last few decades, the use of pesticides for improving crop yield has continued to soar. Recent evidence shows the residuals of pesticides in many fruits and vegetables in the local supermarket. Although acute exposure to pesticides has been related to various severe illness, including cardiovascular dysfunction, chronic pesticide exposure has been poorly studied. Herein we study the cardiotoxic effect of commonly used pesticides to the most common cardiac arrhythmia, atrial fibrillation (AF).

Purpose

Whether exposure to commonly-used pesticides triggers AF if so, explore the underlying molecular mechanism.

Methods

Ten commonly used pesticides in the Netherlands, including glyphosate, MCPA and boscalid, were used to study cardiotoxicity using experimental Drosophila and rat model systems for AF. Drosophila were exposed to three varying pesticide concentrations, ranging from reported environment concentrations, LD50 and high dose, followed by survival and heart wall measurements (heart rate (HR) and arrhythmicity index). In addition, rats were exposed to four pesticides, paraquat, glyphosate, round-up and MCPA for 16 months followed by AF detection (ECG) and Westernblot and metabolomic analyses of the atrial tissue samples.

Results

A dose dependant survival curve was observed of Drosophila fed with pesticides compared to controls. In prepupae a significant reduction in HR and increase in arrhythmicity index was found for all? utilized pesticides. Furthermore, a significant increase in AF and atrial arrhythmic episodes was observed in rats treated with pesticides (15-70%) compared to non-treated control rats (0%). Metabolomic analyses in rats revealed a significant increase in mitochondrial supercomplexes and 6-phosphoglyconlactate levels in pesticide treated rats compared to controls, suggesting a role for mitochondrial and energy dysfunction to underlie pesticide-induced AF.

Conclusion(s)

This study provides evidence that chronic exposure to commonly-used pesticides in the Netherlands affects longevity, heart wall function in Drosophila and triggers atrial arrhythmia and AF in rats. Likely, the pesticides impair mitochondrial function and energy metabolism.
Direct oral anticoagulation versus warfarin in atrial fibrillation: a nationwide cohort study of effectiveness and safety among frail patients
Authors: Nielsen P B , Ording A G , Skjoeth F , Larsen T B , Soegaard M
Published: November 2023

Background

Frail patients with atrial fibrillation carry a high risk of both stroke and treatment-related bleeding complications, but evidence for the safety and effectiveness of anticoagulation regimens in frail patients remain sparse.

Objectives

To determine the comparative effectiveness and safety of DOAC versus warfarin in frail patients with atrial fibrillation.

Methods

A nationwide registry-based cohort study applying a new-user design including all frail patients with atrial fibrillation who redeemed a prescription for DOAC or warfarin between January 2012 and December 2020. We applied inverse probability of treatment weighting (IPTW) to account for baseline confounding and applied a marginal structural modelling approach with weighted pooled regression to compute hazard ratios (HR) and risk differences for thromboembolic events and major bleeding comparing specific DOAC doses with warfarin.

Results

We identified 32048 anticoagulation naïve frail patients (median age 80 years, 53% female) with atrial fibrillation who started anticoagulation treatment: 6747 (21.1%) patients initiated warfarin therapy, 17076 (50.3%) initiated standard dose DOAC, and 9179 (28.6%) patients with indication for dose reduction initiated reduced dose DOAC. The median CHA2DS2-VASc score was 5. The comparative effectiveness analyses showed a similar risk for thromboembolism with weighted HRs of 0.95 (95% CI 0.80-1.13) for standard dose DOAC versus warfarin, and 0.97 (95% CI 0.77-1.23) for reduced dose DOAC versus warfarin (see Table). The thromboembolic event free survival difference at one year was -0.2% for DOAC regardless of dosing when compared with warfarin. The comparative safety analyses revealed significantly lower risk of major bleeding among patients initiating standard dose (weighted HR 0.69, 95% CI 0.59-0.87) or reduced dose DOAC (weighted HR 0.67, 95% 0.55-0.81) when compared with warfarin. The risk difference of bleeding at one year for DOAC users varied between -1.3% and -3.0%, with the greatest difference for patients with high frailty level initiating reduced dose DOAC.

Conclusion

We observed similar risk of thromboembolism and significantly lower risk of major bleeding associated with both standard and reduced DOAC treatment regimens compared with warfarin in frail patients with atrial fibrillation in routine clinical practice.
10-year trends in oral anticoagulation therapies and ischemic stroke among 157,583 patients with non-valvular atrial fibrillation
Authors: Sun W , Tam T K , Yan B
Published: November 2023

Purpose

Initiation of oral anticoagulation therapy (OAC) for stroke prevention in patients with atrial fibrillation (AF) is often suboptimal in clinical practice. We aimed to describe trends in OAC uptake and incidence of ischemic stroke over the past decade.

Methods

We retrospectively analyzed consecutive patients with non-valvular (NV) AF between January 2012 and July 2022 from 16 public hospitals. Annual incidence of AF was the number of new AF cases as proportion of adult population reported by Census and Statistics Department. Prescription of OAC (vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC)) were recorded. OAC uptake was defined as initiation of OAC within 12 months from AF diagnosis. Incidence of ischemic stroke was calculated for both incident and prevalent AF cohorts over time. Logistic regression was conducted to identify predictors of OAC uptake.

Results

157,583 NVAF patients (mean age 76.6±12.5 and female 49.6%) with mean CHA2DS2VASC 2.6±1.3 were identified. Between 2012 and 2022, incidence of new AF was steady across the years with mean of 0.19%±0.03% (range 0.16% to 0.24%) per year. OAC prescription increased from 15.3% to 46.0% and the incidence of ischemic stroke decreased significantly from 4.0% to 0.6% over the last decade (both p for trend <0.01). DOAC use increased steadily from 6.2% to 41.0% whereas VKA decreased from 9.1% to 3.5% (Figure). Mean time from AF diagnosis to OAC prescription was 0.6±1.6 months. Of all patients prescribed OAC, 40.8% initiated OAC within 1 month after AF diagnosis. CHA2DS2VASC scores ≥4 was associated with higher likelihood of OAC uptake (OR=1.74 (95%CI: 1.69-1.78).

Conclusion

Our real-world data demonstrated steady incidence of new NVAF diagnosis with increasing trend in OAC prescription, predominantly DOAC and decreasing incidence ischemic stroke over the last decade. However, overall utilization of OAC for stroke prevention remains suboptimal.
Comparison of clinical and genetic risk model based on ethnicity for ischemic stroke after atrial fibrillation catheter ablation
Authors: Park J W , Kim D H , Yu H T , Kim T H , Uhm J S , Joung B Y , Lee M H , Pak H N
Published: November 2023

Introduction

CHA₂DS₂-VASc score (CVS) is widely used to estimate the risk of stroke in atrial fibrillation (AF) patients. However, CVS does not include genetic risk, and the risk model for stroke dose not well developed after AF catheter ablation (AFCA). We explored the clinical and genetic risks for ischemic stroke (IS) and compared the difference in prediction power according to ethnicity.

Methods

We used available genome-wide association study (GWAS) data in European (34217 IS, 406111 controls) and Asian (22664 IS, 152022 controls) to develop polygenic risk score (PRS) for IS in 2897 independent Korean AF patients (Median 60 [IQR 52, 67] years, male 74.0%, paroxysmal AF 66.3%, anticoagulation rate 60% in 1367 patients over 2 points of CVS) who underwent the AFCA. The patients with IS within 2 weeks after the AFCA were excluded. In the independent AF cohort during the median 50 [IQR 28-94] months follow-up, 48 experienced the IS after the AFCA. We developed two different PRS derived from European and Asian GWAS data and then two different CVS-combined PRS models in the independent cohort. After including SNPs with p-value <5e-8 in the development cohort, rs635634 and rs671 were used in the CVS-combined European PRS (CVS-EPRS) and CVS-combined Asian PRS (CVS-APRS) model, respectively in the independent cohort. We compared the C index of risk models to investigate the prediction power for the IS.

Results

The CVS was significantly higher in the patients with IS than in their counterparts (3.0 IQR [1.0, 4.0 vs. 1.0 [1.0, 2.0], p<0.001). The overall C index was 0.716 in CVS alone model, 0.711 in the CVS-EPRS model, and 0.725 CVS-APRS model. For predicting 1-year IS after the AFCA, the CVS-APRS model improved the C index as compared to CVS alone model (0.834 vs. 0.813, p=0.037). For predicting 3-year IS after the AFCA, the C-index was higher in the CVS-APRS model as compared to the CVS-EPRS model (0.746 vs. 0.721, p=0.030)

Conclusions

In AF patients with the AFCA, genetic polymorphism with clinical risk factors contributed to predict the 1-year IS. However, ethnicity might be an important factor in adapting genetic contributions to predicting IS.Study flow chartTime dependent ROC curve
Arterial thromboembolism in patients with atrial fibrillation and CHA2DS2-VASc score 1: a nationwide study
Authors: Ostergaard L , Olesen J B O , Petersen J K P , Nielsen L S N , Kristensen S L K , Schou M S , Kober L K , Fosbol E L F
Published: November 2023

Background

Knowledge is sparse on whether rate of stroke differs in patients with atrial fibrillation (AF) and a CHA2DS2-VASc of 1 according to how this point is obtained.

Objectives

To examine the associated rate of thromboembolism according to subgroups with a CHA2DS2-VASc of 1.

Methods

From nationwide registries, patients with incident AF from 2000–2021 and without oral anticoagulants were categorized according to the CHA2DS2-VASc score (CHA2DS2-VASc 0, CHA2DS2-VASc 1: heart failure [HF], hypertension [HT], diabetes mellitus [DM], vascular disease, age 65-74, or CHA2DS2-VASc 2, due to age ≥75 years). Female sex was not considered a risk factor. Outcome was one-year rate of thromboembolism (ischemic stroke, embolism of extremity, or transient cerebral ischemia). Main safety outcome was hospitalization with bleeding. The cumulative incidence of thromboembolism and bleeding were computed for CHA2DS2-VASc 0, the five subgroups of CHA2DS2-VASc 1, and CHA2DS2-VASc 2 (due to age ≥75 years) accounting for death as competing risk. For comparison between study groups crude Cox proportional hazard analysis was used.

Results

We included 29,369 patients with CHA2DS2-VASc 0; 27,845 patients with CHA2DS2-VASc 1: 1,890 (6.8%) patients with HF, 9,649 (34.7%) with HT, 968 (3.5%) with DM, 906 (3.3%) with vascular disease, 14,432 (51.8%) with age 65-74 years; 19,387 patients with CHA2DS2-VASc 2 (age ≥75 years). At one year of follow-up, the cumulative incidence of thromboembolism was 1.1% for CHA2DS2-VASc 1, 2.7% for CHA2DS2-VASc 1 (overall), and 4.9% for CHA2DS2-VASc 2 (age ≥75 years). Within subgroups of CHA2DS2-VASc 1, the cumulative incidence of thromboembolism was 1.7% for HF, 2.6% for HT, 2.2% for DM, 2.7% for vascular disease, and 2.9% for age 65-74 years (Figure 1). Within subgroups of CHA2DS2-VASc 1, age (65-74 years) was associated with the highest rate of thromboembolism, while HF was associated with the lowest rate (Figure 2). The one-year cumulative incidence of hospital admission with bleeding was 0.4%, 1.2%, 1.1%, 1.4%, 1.8%, 1.2%, and 2.2% for CHA2DS2 -VASc 0, CHA2DS2-VASc 1: HF, HT, DM, vascular disease, age 65-74, and CHA2DS2 -VASc 2 (age ≥75), respectively.

Conclusion

Within the spectrum of CHA2DS2-VASc 1, age seemed to be the risk factor with most impact on the rate of thromboembolism, while HF seemed to have the least impact. All subgroups of CHA2DS2-VASc 1 were associated with lower rate of arterial thromboembolism as compared with CHA2DS2-VASc 2 and a higher rate as compared with CHA2DS2-VASc 0.

These findings lay the ground for a better understanding of when to initiate oral anticoagulation in patients with CHA2DS2-VASc 1.
The gender difference in risk factor and incidence rate of hospitalization for heart failure in Japanese atrial fibrillation patients: The Fushimi AF Registry
Authors: Doi K , Nakanishi Y , Minami K , Ishigami K , Ikeda S , Hamatani Y , Yoshizawa T , Ide Y , Fujino A , Ishii M , Iguchi M , Masunaga N , Abe M , Akao M
Published: November 2023

Background

Gender-specific medicine is of concern in cardiovascular medicine. However, the gender difference in risk factor and incidence rate of hospitalization for heart failure (HF) in Japanese atrial fibrillation (AF) patients is little known. The aim of this study is to compare the risk factor and incidence rate of HF hospitalization in male and female.

Method

In the Fushimi AF Registry, we started to enroll patients from March 2011, and follow-up data were available for 4,496 patients by the end of February 2022. In the entire cohort, 2,677 were male and 1,819 were female. We compared clinical characteristics and risk factor and incidence rate of HF hospitalization between the two groups.

Result

Male patients were younger (male vs, female; 71.5 years vs. 76.7 years, p<0.001), greater in body weight (65.0 kg vs. 51.2 kg, p<0.001), had lower pulse rate (77.5 bpm vs. 79.4 bpm, p=0.008), more often persistent/permanent type (52.0% vs. 48.2%, p=0.044), more likely to have previous stroke/systemic embolism (21.1% vs. 18.6%, p=0.039), diabetes mellitus (DM) (26.2% vs. 19.9%, p<0.001), coronary artery disease (CAD) (16.0% vs. 12.3%, p<0.001) and less likely to have prior HF (24.0% vs. 32.3%, p<0.001), chronic kidney disease (CKD) (33.7% vs. 39.3%, p<0.001) and had lower CHADS2 score (1.96 vs. 2.15, p<0.001). In prescription data, male patients more often received oral anticoagulant (58.2% vs. 52.1%, p<0.001) and less in diuretics. Systolic blood pressure, hypertension, prescription of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta blocker were comparable between the two groups.

During the median follow-up of 1,824 days, the incidence rate of HF hospitalization was lower in male than female group (male vs. female: 1.74 vs. 2.09 per 100 person-years, log rank p=0.005). On multivariate Cox regression analysis, age, sustained type of AF, prior HF, DM, CAD and CKD were significantly associated with an increased risk of HF hospitalization in male group. On the other hand, age, prior HF, DM, CKD were significantly associated with an increased risk of HF hospitalization but neither sustained type of AF nor CAD was in female group.

Conclusion

The incidence rate of HF hospitalization was lower in male patients than female patients. The risk factor associated with HF hospitalization were different between male and female in Japanese AF patients.
Prognostic value of monocyte-to-high-density lipoprotein-cholesterol ratio for all-cause mortality and heart failure in new-onset atrial fibrillation: a population-based cohort study
Authors: Tsang C T W , Ren Q W , Huang J Y , Chan Y H , Yiu K H
Published: November 2023

Background

A growing body of evidence suggests that inflammation plays a role in the onset and progression of atrial fibrillation (AF). Monocyte-to-high-density lipoprotein-cholesterol ratio (MHR) has emerged as a novel and accessible biomarker that reflects both inflammation and oxidative stress. Previous studies have demonstrated the predictive value of MHR in several cardiovascular diseases including ischaemic stroke and acute coronary syndrome, but the association between MHR and adverse outcomes of AF remains unclear.

Purpose

With this study, we aimed to investigate the relationship of MHR with all-cause mortality and incident heart failure in patients with new-onset AF.

Methods

Patients with newly diagnosed AF from 1998-2021 (n=80,911) were included in this Hong Kong population-based cohort study. MHR was obtained by dividing fasting monocyte count by high-density lipoprotein-cholesterol, and patients were grouped according to MHR tertiles. We followed up patients until occurrence of outcomes, death or 1st September, 2022. The primary outcome was all-cause mortality, and the secondary outcome was incident heart failure. We evaluated the associations of MHR with all-cause mortality and heart failure both on a continuous scale using restricted cubic spline curves and by categories using multivariate Cox proportional hazards regression model.

Results

The median age of the cohort was 77.9 years old and 41,536 (51.3%) were male. Over a median follow-up of 3.7 years, 43,902 (54.3%) deaths and 14,114 (17.4%) incident heart failure occurred. The restricted cubic spline curves illustrated that MHR had a non-linear association with all-cause mortality and heart failure. Univariate Cox regression indicated that increased MHR at tertiles 2 and 3 were significantly associated with higher risks of all-cause mortality (HR: 1.06 [1.04-1.09], P<0.001, 1.25 [1.22-1.28], P<0.001, respectively) and new onset heart failure (1.07 [1.02-1.11], P=0.002, 1.23 [1.18-1.28], P<0.001, respectively) when compared to those in tertile 1. MHR remained a significant predictor of mortality (tertile 2 HR: 1.06 [1.04-1.09], P<0.001, tertile 3 HR: 1.22 [1.19-1.25], P<0.001) and heart failure (tertile 2 HR: 1.06 [1.02-1.10], P=0.007, tertile 3 HR: 1.21 [1.16-1.26], P<0.001) after multivariable adjustment.

Conclusion

MHR is a promising prognostic biomarker for all-cause mortality and heart failure in patients with new-onset AF.
Biomarkers for the prediction of cognitive decline in atrial fibrillation patients
Authors: Krisai P , Eberl M , Coslovsky M , Rodondi N , Chocano-Bedoya P , Kobza R , Moschovitis G , Rigamonti E , Beer J H , Mueller A , Reichlin T , Conen D , Osswald S , Bonati L , Kuehne M
Published: November 2023

Background

Patients with atrial fibrillation (AF) are at increased risk of cognitive decline. Biomarkers might help to identify the highest risk patients.

Purpose

To investigate associations of a broad panel of biomarkers with cognitive decline in a large population of AF patients.

Methods

We enrolled 1440 AF patients with available baseline biomarkers and cognitive testing by the Montreal Cognitive assessment (MoCA) score at inclusion and at ≥2 yearly follow-ups over three years. Cognition over time was assessed by modelling of a slope over three years. Cognitive decline was defined as a decreasing slope based on 1 standard deviation of the baseline MoCa score. We investigated the associations of biomarkers and age with cognitive decline in univariate logistic regression models by AUCs. We used Lasso modelling to build combined prediction models with biomarkers, clinical variables and both.

Results

Mean age was 72 years, 75% were male, 47% had paroxysmal AF and 90% were anticoagulated. During a follow-up of 3 years, cognitive decline occurred in 93 patients (6.5%). Patients with cognitive decline were older (77 vs 72 years, p=0.001), more often had paroxysmal AF (50 vs 47%, p=0.007) or a history of stroke (24 vs 11%, p=0.001), but there were no differences in anticoagulation (94 vs 90%, p=0.289). The three biomarkers with the highest univariate AUC for cognitive decline were Growth Differentiation Factor (GDF)-15 (0.67 [0.62-0.72]), Cystatin C (0.67 [0.61-0.72]) and high-sensitivity Troponin T (0.65 [0.60-0.70]), while age had the highest overall AUC (0.70 [0.64-0.75]) (Figure). The combined prediction model with the highest AUC of 0.69 (0.67-0.72) included GDF-15, age and baseline cognition.

Conclusion

Over 3 years, 6.5% of AF patients had cognitive decline despite a high rate of anticoagulation. Besides age, GDF-15, Cystatin C and high-sensitivity Troponin T had the highest predictive value for cognitive decline.Univariate AUCs for biomarker/ageFigure legend
Trajectories of walking speed in older adults with atrial fibrillation: a 15 year-follow-up population-based study
Authors: Okoye C , Calderon-Larranaga A , Qiu C , Xia X , Vetrano D
Published: November 2023

Background

Atrial fibrillation (AF), the most common arrhythmia in older adults, has been associated with frailty. However, the role exerted by AF in the long-term trajectories of functional decline still needs to be elucidated.

Purpose

The aim of the present study was to evaluate AF clinical impact on functional decline by tracing the evolution of the walking speed (WS) over 15 years of follow-up in a population-based cohort of older individuals.

Methods

This population-based cohort study included 3141 non-institutionalized participants (age ≥60 years; 63.6% women) from the Swedish National Study on Aging and Care in Kungsholmen (SNAC-K) carried out in Stockholm, who were regularly examined from 2001–2004 to 2016-2019. AF was ascertained from clinical examination, electrocardiogram, and the Swedish National Patient Registry. Physical decline was assessed measuring participants mobility through the WS test (m/s). Participants WS was evaluated at baseline, and then followed up every 6 years (those aged <78 years) or every 3 years (those aged ≥78 years). Incident heart failure, stroke and dementia were also recorded during the follow-up visits. The association between AF and WS trajectories was tested by multivariable joint models accounting for the longitudinal dropouts due to death. Analyses were also stratified by relevant individual characteristics after adjustment for clinically relevant covariates.

Results

At baseline, 285 (9.1%) participants were ascertained to have prevalent AF. Upon accounting for several potential confounders, we observed a faster annual WS decline in AF participants than in non-AF peers (β coefficient per year = −0.013, 95% confidence interval [CI]: −0.017 to −0.007) after multivariable adjustment for age, sex, education, dementia, COPD, diabetes, hypertension, heart failure, stroke, physical activity levels and BMI. The association was stronger in individuals 78+ than those younger than 78 years and in those without stroke, heart failure and higher engagement in physical activity (p per interaction <0.05). In a secondary analysis carried out among participants who were free of heart failure, stroke, and dementia at baseline, controlling by incident heart failure, incident stroke, and incident dementia did not attenuate the association between AF and WS change.

Conclusion

AF is independently associated with a faster physical performance decline in older individuals Incident stroke, heart failure or dementia don’t seem to mediate the relationship between AF and mobility decline over time.
Pulmonary hypertension is an adverse risk factor for peri-procedural complications in patients undergoing cardioversion for atrial fibrillation
Authors: Kodali M , Atluri R , Yalamanchili S , Shoura S , Vardar U
Published: November 2023

Background

Atrial Fibrillation (AF) poses a significant burden on the American Healthcare system. Heart failure and AF commonly coexist in patients. Elevated left ventricular and atrial pressures result in progressive left atrial dilation and remodeling which in turn predisposes to the generation of AF. Many of these patients develop pulmonary hypertension (PHT) due to the remodeling and elevated left-sided pressures. Cardioversion (CV) for non-valvular atrial fibrillation (AF) is commonplace for patients during their initial presentation. Since many who undergo CV for AF could have PHT, we aimed to assess the periprocedural outcomes in this population.

Methods

We utilized the National Inpatient Sample from 2016-2019 to identify roughly 330,820 hospitalized adults who had CV for AF. These hospitalizations were further stratified based on the presence of PHT. A multivariate regression model was used to adjust for confounders and analyze the variables.

Results

Of those who underwent CV for AF, 45,345 (13.7%) had PHT. In-hospital mortality was interestingly lower in those with PHT (9.6% vs 10.37%; p<0.001). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital outcomes when adjusted for patient demographics, comorbidities, and hospital characteristics. When adjusted similarly, patients who underwent CV for AF and PHT had longer length of stay (LOS) by 2.11 days (p<0.001) and had additional hospital costs (HC) of $29,470 (p<0.001).

Conclusion

In this study, patients who underwent CV for AF with co-existing PHT had significantly worse outcomes in terms of LOS, HC, pulmonary embolism, atrial flutter, VT, SVT, AKI, and intubation. Of note, they interestingly had better outcomes in terms of in-hospital mortality, respiratory failure, and strokes. Returning the patient to sinus rhythm likely improved the left heart hemodynamics reducing post capillary pulmonary hypertension explaining the reduced mortality rate in this population. One major limitation of our study is the lack of outpatient follow up and the inability to differentiate between the different groups of PHT. Since several outcomes are worse in the setting of PHT, potential strategies for aggressive rate and volume control for those in AF should be pursued to avoid negative cardiac remodeling that would predispose to the development of PHT. AF patients with co-existing PHT should be aggressively monitored during hospitalizations as they have the potential to have worse outcomes.
Ranolazine is associated with a reduced incidence of atrial fibrillation in patients with chronic coronary syndrome: the results of a real-world analysis of an Italian population
Authors: Fumagalli S , Dovizio M , Mazzoni S , Franci Montorzi R , Santamaria E , Fumagalli C , Degli Esposti L , Marchionni N
Published: November 2023

Background

Ranolazine (Ran) is an anti-anginal drug acting as a late sodium current inhibitor at a cell membrane level. This mechanism of action could be implicated in the control of arrhythmia development. Indeed, some evidence supports the efficacy of Ran as an anti-arrhythmic agent, with a synergistic effect with that of Class III agents, namely amiodarone and dronedarone.

Aims

Aim of this study was to evaluate if the use of Ran in patients with chronic coronary syndrome (CCS) in comparison with other treatments (No-Ran), was associated with a lower incidence of atrial fibrillation (AF) in a real-world clinical setting in Italy.

Methods

Patients included in the database of the National Health System were evaluated (N=6.1 million); the recorded information concerned hospitalizations with the related diseases, clinical events, visits and drug therapy. Patients hospitalized for any cause and discharged with a diagnosis of angina between 2011 and 2020 (ICD-9-CM codes: 413-414) were included in the study provided they had not experienced an AF episode in the 12 preceding months (characterization period). Study population was divided into the Ran (at least one drug prescription) and in the No-Ran cohorts. The mean follow up was 4.3 years for the Ran and 5.0 years for the No-Ran cohorts, respectively.

Results

The study population included N=171,015 patients (mean age: 72 years, men: 66%). Among them, N=148,808 (No-Ran cohort) were treated with other therapies while N=22,207 (Ran cohort) received Ran. After propensity score matching, Ran (N=6,384) and No-Ran (N=25,536) cohorts did not differ for age, Charlson comorbidity index, use of aspirin, beta-blockers, Ca-antagonists and nitrates. The incidence of a new episode of AF during the follow-up period was 5.3% and 9.6% in the Ran and in the No-Ran cohorts, respectively (p<0.001). The Cox-regression analysis showed that independently of age, male gender, heart and renal failure, COPD, use of beta-blockers, Ca-antagonists and nitrates, and of cardiovascular procedures, Ran therapy was associated with a 41% risk reduction to develop AF (HR=0.59, 95%CI: 0.53-0.67, p<0.001).

Conclusions

Our real-world study, performed in a whole subset of the Italian population, showed that Ran use in a long-term follow-up was associated with a lower incidence of AF in patients with CCS.
Impact of diagnosis-to-ablation time on atrial fibrillation recurrence: most pronounced in the first 3 years after diagnosis and clinically irrelevant thereafter
Authors: De Greef Y , Bogaert K , Sofianos D , Buysschaert I
Published: November 2023

Objectives

To assess the impact of the diagnosis-to-ablation time (DAT) on AF recurrence in search of lower and upper DAT thresholds.

Background

DAT is a strong, modifiable predictor of atrial fibrillation (AF) recurrence after ablation. Whether this association holds any lower and/or upper limits is yet unknown.

Methods

A total of 2000 AF patients from two cohorts of 1000 consecutive patients each (69% males, age 62±10 years) undergoing pulmonary vein isolation (PVI) between 2005-2014 and 2017-2019 were followed for 3 years.

Results

Clinical success, defined as freedom of documented AF was achieved in 61.7% of the patients. Median DAT decreased over time from 36 (Q1-Q3: 12-72) months in the first cohort to 12 (Q1-Q3: 5-48) in the second (P<0.001). A multivariable Cox proportional hazards fitted model of AF recurrence rate in relation to DAT (range 0-288 months) demonstrated a steep rise in AF recurrence from 27 to 40% in the first 36 months (d%/dt=0.36), with a first hinge point at 36 months and a less steep rise to 45% until 90 months (d%/dt=0.09), with flattening beyond 90 months (d%/dt=0.026).

Conclusions

The association between DAT and AF recurrence has no lower limit (‘the shorter the better’) while little gain is to be expected beyond a DAT of 36 months (‘the longer the more clinically irrelevant’). Our data advocate for a PVI as early as possible, certainly within 3 years of AF diagnosis.3-year AF recurrence rate versus DAT
Sex-based differences and outcomes in patients undergoing pulmonary vein isolation for atrial fibrillation
Authors: Aguiar Neves A , Sa Carvalho A , Diaz S , Ribeiro Silva M , Santos Silva G , Lopes Fernandes S , Almeida J , Fonseca P , Oliveira M , Goncalves H , Saraiva F , Barros A , Sampaio F , Primo J , Fontes Carvalho R
Published: November 2023

Introduction

Some studies have suggested that the risk of atrial fibrillation (AF) recurrence after catheter ablation (CA) is greater in women than in men, which suggests that sex may be an independent risk factor for AF recurrence. However, the impact of gender on time to AF recurrence after CA is unknown.

Methods

Retrospective, single-centre study including all patients who underwent a first AF ablation procedure between 2017 and 2021. Late recurrence (LR) was defined as any AF recurrence at least 90 days after ablation, while early recurrence (ER) occurred <90 days after ablation. The effect of sex on the cumulative freedom from LR was estimated using the Kaplan-Meier method and compared using the log-rank test and Cox proportional hazards model. In a subgroup of patients, cardiac adipose tissue was quantified using cardiac computerized tomography (CT) scans.

Results

656 patients were included, of whom 32% were women. Average follow-up after ablation was 26 months. In comparison to male patients, women undergoing CA were more likely to be older, have a higher body mass index and were more likely to have comorbid hypertension, thyroid dysfunction and valvular disease.

After model adjustment, women had a greater risk of LR (HR 1.78, 95% CI 1.20-2.62). A reanalysis was conducted using a time-split at one year of follow-up, which showed that risk of LR was greater in women more than 12 months after CA (HR 2.70, 95% CI 1.60-4.57), but not during the first year after CA (HR 1.22, 95% CI 0.74-2.02). Persistent AF was also an independent predictor of LR (HR 2.05, 95% CI 1.45-2.91). In a subgroup of patients who underwent cardiac adipose tissue analysis (n = 348; 37% women), increased epicardial and pericardial adipose tissue volume was associated with an increased risk of LR in univariate analysis, but not after co-variate adjustment.

Conclusions

Women are referred later and less frequently to CA than men. LR after CA is more frequent in women, particularly after one year. Epicardial adipose tissue volume was associated with LR in women, but this effect was not maintained after model adjustment. Further studies are needed to better understand the mechanisms responsible for the increase in LR in women undergoing pulmonary vein isolation.
Does energy matter when performing posterior wall isolation in addition to pulmonary vein isolation at atrial fibrillation ablation: a meta-analysis
Authors: Musat D , Milstein N S , Preminger M , Bhatt A , Habibi M , Sichrovsky T , Shaw R , Mittal S
Published: November 2023

Background

Pulmonary vein isolation (PVI) remains the cornerstone of atrial fibrillation (AF) ablation. Posterior wall isolation (PWI) has been proposed as an adjunct to PVI to improve outcomes. Small series have reported conflicting outcomes. We conducted a meta-analysis of available data to assess the incremental impact of PWI based on whether patients were ablated using a cryoballoon (CB) or radiofrequency (RF) energy.

Objective

To evaluate whether PVI + PWI ablation is a more effective approach for treatment of AF than PVI alone when comparing different ablation energies.

Methods

The online databases (Pubmed, Medline, Embase) were searched using the terms "pulmonary vein isolation", "posterior wall isolation", or "posterior wall ablation". Out of 1917 studies, 11 met our strict criteria (Table). Specifically, patients were undergoing de novo ablation for treatment of AF using either CB or RF energy. Patients had PVI +/- PWI; studies that included additional ablations (except for cavotricuspid isthmus ablation) were excluded. The primary outcome was long-term freedom from recurrence of any atrial tachyarrhythmia (AT).

Results

The cohort consisted of 1905 patients (65 ± 18 years, 74% male); 910 (48%) pts ablated with CB energy and 995 (52%) pts ablated with RF energy (Table). In the CB group, AT recurrence was significantly higher in patients who underwent PVI alone as compared to those who also had PWI (OR 2.47, 95% CI [1.85, 3.31], P < 0.0001, Figure). In contrast, in the RF group, outcome was similar in patients who did and did not undergo PWI in addition to PVI (OR 1.22, 95% CI [0.80, 1.86], P = 0.36, Figure).

Conclusions

PWI in addition to PVI improved outcomes for patients ablated with CB energy. Conversely there was no benefit for patients in whom RF energy was used. Additional randomized studies are needed to determine the role of energy selection for patients undergoing PWI in conjunction with PVI for management of AF.
Clinical efficacy of catheter ablation versus medical rate control among patients with atrial fibrillation across heart failure phenotypes: a meta-analysis of randomized controlled trials
Authors: Dakay D , Junia A , Salces N
Published: November 2023

Background

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. It frequently co-exists with heart failure (HF) with complex dynamic interactions. Trials comparing rate and rhythm control strategies with the latter based on anti-arrhythmic drugs (AADs) failed to show benefit of one strategy over the other. Therefore, it is still unclear what constitutes an ideal AF management, especially in the context of HF.

Objective

To compare the clinical efficacy between catheter ablation and medical rate control among patients with atrial fibrillation and heart failure

Study Selection

Only randomized controlled trials (RCT) comparing catheter ablation and medical rate control in patients with atrial fibrillation and heart failure were selected for review.

Methods

Pubmed, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) reporting clinical outcomes of catheter ablation versus medical rate control for AF in HF patients with > 6 months follow-up. Primary endpoint was change in left ventricular ejection fraction (LVEF). Secondary endpoints were 6-minute walk test (6MWT) distance, quality of life (QoL), BNP levels, and number of adverse events.

Results

Five RCTs with 615 patients were included in the analysis. Patients in the catheter ablation had greater improvement in LVEF (WMD 7.38, 95%CI: p < 0.001), longer 6-min walk distance (WMD 17.41, CI 95%: p < 0.0001), lower Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores (WMD -6.21, CI 95%: p < 0.00001), and lower BNP levels (WMD -113.1 ng/L, CI 95%: p < 0.00001), compared with medical rate control. However, catheter ablation group had higher rates of adverse events mostly from procedural complications (RR 2.2, CI 95%: p = 0.005).

Conclusion

Catheter ablation is superior to medical rate control in terms of LVEF improvement, increase in functional status, reduction in biomarker, and better quality of life among patients with AF and HF.
Results of simultaneous cryoablation of pulmonary veins and left atrium posterior wall in patients with persistent atrial fibrillation
Authors: Baimbetov A , Jukenova A , Bozshagulov T , Bigeldiyev N , Tursunkhanov Z H , Yakupova I
Published: November 2023

Background

Recent studies suggest a clinical benefit associated with posterior wall isolation as an adjunct to the pulmonary vein (PV) isolation in patients with persistent atrial fibrillation (AF). However, data on the safety and efficacy of this cryoballoon ablation approach are limited.

The study aimed to compare the efficacy and safety of catheter treatment of patients with persistent atrial fibrillation using cryoballoon "single shot" technology in two randomized groups.

Materials and methods

Traditional PV cryoballoon isolation was performed in two groups of patients with persistent AF. In the first group of patients (n = 35) underwent only PV cryoballoon isolation. In the second group of patients (n = 33), cryoballoon isolation of the PV and cryoablation of the posterior wall of the left atrium (LA) was performed. Patients after ablation were followed up for 15.6 (2.7–3.5) months for AF recurrence, functional class, and echocardiographic parameters.

Results

The study included 68 patients with persistent AF in the last six months before inclusion, for whom at least two antiarrhythmic drugs of class I-III were ineffective. By random distribution, 35 patients were included in group 1 - (PVI), and they underwent only PV cryoballoon isolation. Group 2 - (PVI+PWA) included 33 patients who underwent PV cryoballoon isolation and additional LA posterior wall cryoablation. The primary efficacy endpoint occurred in 11 patients in group 1 and 6 patients in group 2 (Kaplan-Meier survival, 31.4% and 18.2%, respectively; hazard ratio, 0.96; 95% confidence interval. Undesirable events occurred in 3.8% of each group (p = 1.00). On multivariate analysis, posterior wall ablation and PV isolation using a cryoballoon (PVI+PWA) was an independent predictor of freedom from recurrent atrial fibrillation (odds ratio: 3.57; 95% confidence interval: 1, 39–8.93, p = 0.007).

Conclusions

In patients with persistent AF, posterior wall ablation and PV isolation using a cryoballoon significantly reduce arrhythmia recurrence. Nevertheless, safety is similar compared to patients with only PV isolation.
Temporal trends in the utilization, referral patterns, and complications of catheter ablation for atrial fibrillation in the Netherlands, 2013-2021
Authors: Samuel M , Van Der Stoel M , Blaauw Y
Published: November 2023

Background

Over the past decade, atrial fibrillation (AF) ablation technologies have evolved, operator experience has improved, and indications for referral to AF ablation has expanded. A recent population-level assessment is warranted to assess the impact of these changes on trends in the utilization, referrals, and adverse events (AEs) of AF ablation.

Purpose

Our aim was to describe temporal trends in the population-level incidence, patients referred, and AEs of AF ablation in the Netherlands from 2013 to 2021.

Methods

Temporal trend analyses were conducted using the AF ablation population in the Netherlands Heart Registration and included all consecutive patients treated with catheter ablation for AF between 2013 and 2021 at 16 hospitals in the Netherlands. Annual crude, sex- and age-standardized incidence rates of AF ablation were calculated. Poisson regression models with robust variances were used to evaluate trends in the incidence of AF ablation. Trends in patient characteristics, AEs, and repeat ablations over the study period were evaluated with ANOVA tests.

Results

Between 2013 and 2021, 37,538 AF ablations were performed in the Netherlands, of which 27,027 (72.0%) were index ablations. Repeat ablations (10,511 procedures) were performed within a median time to repeat ablation of 1 (IQR 1-2) year. AF ablation patients were a median age 63 (IQR 56-69) years, 32.8% women, 70.7% had paroxysmal AF, and median CHA2DS2-VASC score was 1 (IQR 1-2). Most patients underwent radiofrequency ablation (55.4%), followed by cryoballoon (33.4%), PVAC (0.6%), pulse-field (0.3%), laser balloon ablation (0.1%), and other (0.1%) (10.1% missing). Over the 9-year period, there was a statistically significant increase in index [incidence rate ratio (IRR) 1.07 (95% CI 1.05-1.08)] and repeat [IRR 1.09 (95% CI 1.05-1.12)] ablations from 2013 to 2021 (Figure 1). The annual sex-standardized incidence rates of AF ablations were approximately double for men compared to women throughout follow-up (Figure 2). In recent years, AF ablation patients had more persistent AF, higher CHA2DS2-VASC scores, and lower LVEF (p<0.05 for all). Minor vascular AEs within 30 days were the most frequent AE of AF ablation (1.1%), followed by phrenic nerve paralysis (0.6%), in-hospital bleeding (0.6%), cardiac tamponade (0.5%), thrombosis (0.3%), major vascular AEs (0.2%) and all-cause mortality (0.1%). Incidence of most AEs remained stable over time (p>0.05 for all).

CONCLUSION

In the Netherlands, the utilization of AF ablation increased by 7% from 2013 to 2021. In recent years, populations referred for AF ablation were increasingly older, had more persistent AF, higher CHA2DS2-VASC scores, and lower LVEF; however, men remained twice as likely to undergo AF ablation compared to women. Reasons for the lower rate of AF ablation among women requires further investigation.
External validation of the Antwerp score: a novel score for predicting responders to catheter ablation of atrial fibrillation in patients with depressed left ventricular function
Authors: Serban T , Du Fay De Lavallaz J , Barker C D , Knecht S , Strebel I , Krisai P , Voellmin G , Osswald S , Sticherling C , Kuehne M , Badertscher P
Published: November 2023

Introduction

Little exists to identify patients with heart failure (HF) and atrial fibrillation (AF), who will benefit from pulmonary vein isolation (PVI). The Antwerp score was proposed as a new prediction model to identify patients with recovery left ventricular ejection fraction (LVEF) after PVI for AF.

Purpose

To externally validate the Antwerp score in a large cohort of patients undergoing PVI.

Methods

Patients with reduced LVEF (< 50%) scheduled to undergo PVI at our hospital were retrospectively analyzed. These were then classified as responders or non-responders to PVI according to the "Universal definition of HF". For each patient, the Antwerp score was calculated, and the performance of the score in predicting LVEF recovery after PVI was evaluated using receiver operating characteristic (ROC) curves and calibration plots.

Results

Between May 2010 and January 2022, 1665 patients underwent CA for AF at our institution. Of these, 208 patients (median age 63 [IQR 54-69] years, 19% women) had reduced LVEF at presentation and were included in the final analysis (27% with paroxysmal and 73% with persistent AF). The median LVEF at baseline was 43% [IQR 38-46]. At 30 [IQR 20-34] months follow-up after the index procedure, 161 patients (77%) were responders, and 47 patients (23%) were non-responders. The median time to LVEF recovery in responders was 8 [IQR 3-22] months. Between responders and non-responders, differences in AF type were not significant (p = 0.99), while QRS width, absence of known HF etiology and LAVI were significant (p<0.001, p<0.001 and p=0.03). After adjusting for difference in baseline characteristics and procedural outcomes between responders and non-responders, only a QRS duration<120 ms (p=0.002) and absence of known etiology (p<0.001) remained statistically significant with LVEF recovery (Figure). The Antwerp score had an area under the curve (AUC) of 0.75 (95% CI 0.67-0.83). A model containing QRS<120 ms and absence of known etiology performed similarly to the complete Antwerp model (Likelihood Ratio p=0.77).

Conclusion

The Antwerp score has a moderate ability to identify patients with the recovery of LVEF after PVI in an external population, showing modest rule-in and rule-out capabilities. QRS width and absence of known HF etiology were confirmed as excellent predictors of LVEF recovery.Figure