bluuebunny/crossref_metadata_2025 huggingface dataset:
Atrial high-rate episodes detected by cardiac implantable electronic devices: arrhythmic burden and progression towards de-novo clinical atrial fibrillation
Authors: Imberti J F , Tosetti A , Mei D A , Gerra L , Golle' A , Martella A , Bonini N , Mauro E , Turco V , Casali E , Vitolo M , Boriani G
Published: May 2024

Background

Atrial high rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) are associated with a higher risk of thromboembolic events, but whether oral anticoagulants (OACs) improve patient outcomes is still debated. On the other hand, OACs benefits in patients with clinical atrial fibrillation (AF) are well established. Therefore, the potential progression of AHRE towards clinical AF should be promptly recognized.

Purpose

To evaluate the incidence of de-novo clinical AF and its potential predictors.

Methods

Consecutive CIED patients presenting AHRE (with confirmation of an arrhythmia lasting 5 min–23 h 59 min, atrial rate 175/min, with no AF at 12-lead ECG and no prior clinical AF) were retrospectively enrolled. Potential predictors of incident clinical AF were investigated by building six different multivariable Cox’s regression analyses, and the duration of the single longest AHRE episode during follow-up was used as a time-dependent covariate.

Results

126 patients (median age 79.7 (73.8-84.6), 34.1% female) had available follow-up data. Detailed patients' characteristics are provided in Figure 1. Over a median follow-up of 1128 (580-1646) days, 41/126 (32.5%) patients developed incident clinical AF. A single longest AHRE episode lasting ≥ 6 hours (h) was found associated with a higher risk of incident clinical AF after adjusting for HATCH score, female sex, and coronary artery disease (CAD) (Hazard ratio (HR) 2.82; 95%CI 1.32-6.04) and also in the model adjusting for CHA2DS2-VASc score and CKD (HR 3.13; 95%CI 11.57-6.25). Similar results were found for a single longest AHRE episode lasting ≥ 12 hours (HR 4.91; 95%CI 2.31-10.42 and HR 4.90; 95%CI 2.50-9.60, respectively), and lasting ≥ 24h (HR 4.40; 95%CI 1.82-10.60 and HR 4.56; 95%CI 2.05-10.14, respectively) (Figure 2). On the other hand, HATCH score and CHA2DS2-VASc score were independently associated with a higher risk of incident clinical AF only in multivariable models adjusting for episodes of AHRE lasting ≥6 h (HR 1.42; 95%CI 1.02-1.97 and HR 1.37; 95%CI 1.03-1.83, respectively) but this association was not confirmed after adjusting for AHRE of longer duration.

Conclusions

In patients with AHRE, the incidence of de-novo clinical AF is high in a three-year follow-up. Baseline patients’ characteristics (HATCH and CHA2DS2-VASc scores) and AHRE duration during follow-up may help to intensify monitoring and decision-making, being independently associated with incident clinical AF at follow-up.Baseline characteristicsMultivariate Cox's regression analysis
Biomarkers to predict improvement of left ventricular ejection fraction after atrial fibrillation ablation
Authors: Serban T , Hennings E , Strebel I , Knecht S , Du Fay De Lavallaz J , Krisai P , Arnet R , Voellmin G , Osswald S , Sticherling C , Kuehne M , Badertscher P
Published: May 2024

Background

Atrial fibrillation (AF) and heart failure (HF) frequently coexist. Catheter ablation (CA) of AF is increasingly used in patients with AF and HF. However, prediction of improvement of HF after CA is challenging.

Aim

We aimed to evaluate the value of biomarkers, alone and in conjunction with a clinical tool (Antwerp score) to predict left ventricular ejection fraction (LVEF) recovery after CA in patients with AF and HF.

Methods

Patients undergoing CA for AF with depressed LVEF (<50%) were included. Plasma levels of 13 biomarkers were measured immediately prior to CA. Patients were categorized into "responders" (LVEF normalisation after CA in case of HFmrEF and at least 10% LVEF improvement and LVEF > 40% at follow-up in case of HFrEF) and "non-responders" (no LVEF recovery after CA). Models were constructed by comparing the plasma levels of the various biomarkers in responders and non-responders and by adjusting for age, sex, and Antwerp score and subsequent biomarkers were then combined according based on likelihood-ratios. The predictive power of the biomarkers alone and combined in outcome prediction, as well as improvement of the Antwerp score was then evaluated.

Results

Out of 1665 patients undergoing CA of AF, we included 208 patients with depressed LVEF (median age 63 years, 19% female, median LAVI 42 ml/m2, median LVEF 43%). The median follow-up time was 30 months [IQR 20-34] and the median time to LVEF recovery was 8 months [IQR 3-22]. Of these, 161 (77%) were responders and 47 (23%) were non-responders. Out of 13 biomarkers, four biomarkers (ANG2, GDF15, FGF23 and MyBPC3) were significantly different between responders and non-responders (p ≤0.001). A biomarker panel using these four biomarkers could predict LVEF recovery after CA for AF with an AUC of 0.72 (95%CI 0.64-0.81) overall, 0.69 (95%CI 0.59-0.78) in HFmrEF and 0.88 (95%CI 0.77-0.98) in HFrEF (Figure, A). Only ANG2 and GDF15 remained significantly associated with LVEF recovery after adjustment for age, sex, and the Antwerp score. The AUC of the Antwerp score for prediction of LVEF recovery improved from 0.75 (95% CI 0.67-0.83, Figure, B) to 0.78 (95% CI 0.70-0.86, Figure, C) in the overall population, from 0.71 (95% CI 0.61-0.81) to 0.74 (95% CI 0.64-0.84) in case of HFmrEF and from 0.87 (95% CI 0.78-0.97) to 0.92 (95% CI 0.85-0.99) in case of HFrEF when ANG2 and GDF15 were included in the model.

Conclusion

A biomarker panel using ANG2, GDF15, FGF23 and MyBPC3 performs similarly for prediction of LVEF recovery after CA in AF compared to the Antwerp score. The biomarkers ANG2 and GDF15 slightly improve the predictive value of the Antwerp score.Figure
Timing of detection of atrial fibrillation recurrence in patients with transient new-onset atrial fibrillation detected during hospitalization for noncardiac surgery or medical illness
Authors: Mcintyre W F , Johnson L S , Vadakken M E , Latendresse N R , Kribo F , Ramasundarahettige C , Wong J A , Healey J S
Published: May 2024

Background

Approximately one third of patients who experience transient new-onset atrial fibrillation (AF) during a hospitalization for noncardiac surgery or medical illness will have recurrent AF within 1 year.

Purpose

To estimate the expected rate of detection of AF recurrence using different durations of continuous ECG monitoring during follow-up of patients who have had AF occurring transiently during physiologic stress.

Methods

We used continuous ECG data from participants enrolled in the AFOTS Follow-up Study. Participants had transient new-onset AF while hospitalized for noncardiac surgery or medical illness and were discharged from hospital in sinus rhythm. We calculated the median time to detection of the first recurrent AF episode and the proportion of recurrent AF events that would be captured with an ECG monitor worn for 24 h, 48 h, 7 days and 14 days, and with a repeated 14-day monitor worn approximately 6 months after the first monitor.

Results

A total of 139 participants (41.0% female, median CHA2DS2-VaSC Score 3.0 (Interquartile Range [IQR] 2.0- 4.0)) wore at least one ECG monitor for a median of 13.5 days (IQR 11.7-13.8). A second ECG monitor was worn by 83 (59.7%) participants for a median of 12.9 days (IQR 10.0-13.9); the second monitor was worn a median of 175.0 days (IQR 153.0-216.0) after the first monitor.

Among the study participants in whom recurrent AF was detected (n = 40, 28.8%), the median time to AF lasting at least 30 seconds was 128.0 hours (IQR 32.5-232.5). The proportion of AF recurrences detected after more than 24 hours of monitoring was 75.0% (n = 30).

The yield of AF detection increased with longer monitoring times (Figure 1). AF was detected in 5.0% of participants at 24 hours, 5.8% at 48 hours, 6.5% at 72 hours, 12.2% at 7 days, 21.6% at 14 days and in 28.8% of participants by the end of the second 14-day monitor.

Conclusions

In patients who have experienced transient new-onset AF during a hospitalization for noncardiac surgery or medical illness, the rate of capture of AF recurrence in follow-up increases with longer monitoring durations. 14-day monitors capture nearly 4 times as many AF events as 48 h monitors.
Sex differences at diagnosis and in one-year outcomes in patients with early atrial fibrillation
Authors: Trinks-Roerdink E M , Seelig J , Chu G , Van Der Horst S F B , Voorhout L , De Vries T A C , Van Gelder I C , Huisman M V , Rutten F H , Hemels M , Geersing G J
Published: May 2024

Background

Little is known about differences in clinical phenotype between men and women with atrial fibrillation (AF). Our aim was to explore phenotypical sex differences at diagnosis and at one-year follow-up, in patients with early AF.

Methods

We used data from 5,469 participants of the DUTCH-AF registry; a nationwide prospective registry of patients with early AF or atrial flutter (diagnosis ≤ 6 months before inclusion) in the Netherlands, aged ≥ 18 years. We describe sex differences in clinical phenotype at diagnosis and at one-year follow-up, including the following outcomes: i) ischemic and bleeding events, ii) all-cause mortality, iii) AF-related hospital admissions, including ablation and cardioversion, and iv) AF progression patterns.

Results

At inclusion, women were older than men (median 73 vs. 69 years, p<0.001), had more often paroxysmal AF (66% vs. 55%, p<0.001), and less often persistent AF (27% vs. 37%, p<0.001). They also had hypertension more often (59% vs. 53%, p<0.001), and less often vascular disease (12% vs. 21%, p<0.001, and reported more often symptoms at inclusion and in the month before follow-up; 56% vs. 46%, p<0.001, and 31% vs. 23%, p<0.001, respectively. Women underwent cardioversion and ablation procedures less often than men (14% vs. 21% p<0.001 and 3% vs. 5%, p<0.001, respectively). Moreover, for the combined rhythm control intervention cardioversion and ablation, women also underwent this rhythm control outcome less often than men (unadjusted odds ratio was 0.63 95% CI (0.55-0.73)), regardless of age, and the type of AF (i.e., paroxysmal or persistent AF) at inclusion (adjusted odds ratio 0.77 95% CI (0.62-0.92)). No differences were observed for ischemic and bleeding events, all-cause mortality, or AF progression patterns, but the number of these events was small.

Conclusion

Men and women with early AF differ in age, comorbidities, symptoms, and management. These findings are building blocks for individualized sex-specific AF care and research.
Time-trends of sex differences in stroke risk in atrial fibrillation: Are female patients still at higher risk today? A nationwide cohort study
Authors: Nielsen P B , Broendum R F , Noehr A K , Overvad T F , Lip G Y H
Published: May 2024

Background

Female sex is associated with higher risk of stroke in patients with atrial fibrillation (AF), particularly in the presence of other stroke risk factors. This has implications for oral anticoagulant treatment (OAC) decision-making, based on points of the CHA2DS2-VASc score. However, stroke rates have declined over recent years, and management has evolved over time towards a holistic approach that may have diminished the sex differences in AF-related stroke.

Purpose

To examine the changes in stroke risk over time in relation to risk differences between males and females not treated with oral anticoagulants in a nationwide cohort study.

Methods

This was an observational cohort study including patients with a hospital diagnosis of AF between 2007 and 2021. Data were obtained from the Danish nationwide registries. We identified a cohort of adult patients who were not receiving OAC treatment for up to 30 days after their AF diagnosis. Patients were followed up for thromboembolic events within one year after the AF diagnosis. Survival analysis was applied to describe the yearly rate of events and to estimate the risk ratio for females vs males of thromboembolism according to baseline risk levels, i.e., the CHA2DS2-VA score level (leaving out the ‘Sc’ sex criterion).

Results

A total of 188,704 AF patients (median age 75 years (IQR: 64 to 84); 49.7% female) who did not receive OAC treatment were included. The risk of thromboembolism during the entire study period was overall higher in females (3.5% in males vs. 4.7% among females). The overall one-year thromboembolic risk declined over time from 4.9% between 1997-2000 to 3.3% between 2017-2020, with male-female risk differences less evident in recent years (Figure 1a). The relative risk of stroke diminished from 1.22 (95%CI 1.10-1.34) in years 1997-2000 to 1.02 (95%CI 0.85-1.19) in years 2017-2020 for patients with a CHA2DS2-VA score of ≥2 (Figure 1b). For patients with a score of <2, the relative risk was lowest between 2005-2008 (1.02 (95%CI 0.63-1.42)) and was 1.18 (95%CI 0.54-1.83) in the latest time period. Formal statistical test for time trends according to score level revealed non-significant results (p-value=0.10 for score 0-1; p-value=0.17 for score levels of ≥2).

Conclusion

The risk of stroke among patients with AF has been declining over the last two decades. The excess stroke risk observed among females relative to males has also diminished, most evident among AF patients with ≥2 prevalent stroke risk factors.
New-onset atrial fibrillation in patients with ST-elevation myocardial infarction
Authors: Minder J , Mannhart D , Katic J , Knecht S , Krisai P , Nestelberger T , Leibundgut G , Sticherling C , Kuehne M , Badertscher P
Published: May 2024

Background

New-onset atrial fibrillation (NOAF) complicating ST-elevation myocardial infarction (STEMI) remains clinically challenging. Little is known regarding the long-term clinical impact of NOAF in the acute STEMI phase compared to a prior diagnosis of AF before the onset of STEMI.

Methods

We retrospectively reviewed consecutive patients undergoing percutaneous coronary intervention (PCI) for STEMI between May 2015 and September 2023. Patients were stratified based on NOAF diagnosis during the index-hospitalization vs. preexisting AF prior to the onset of STEMI. Long-term follow-up was obtained for stroke, major bleeding, or death.

Results

We analyzed 1327 consecutive patients undergoing PCI for STEMI. NOAF was detected in 117 patients (9%) and 69 patients (5%) had prior AF. Patients with NOAF and prior AF had similar baseline characteristics. NOAF patients were 65% males, with a mean age of 69 ± 13 years. All patients were treated with enoxaparin, but only 30% of patients with NOAF and 65% with prior AF were discharged with triple therapy, p<0.05. During a median follow-up of 696 days, the rates of stroke were 11% in patients with NOAF compared to 6% (p= 0.03) in patients with prior AF. Major bleeding occurred in 7% vs. 9%, p= 0.59, and death in 19% vs. 22%, p= 0.25 of patients with NOAF vs. prior AF.

Conclusion

NOAF was detected in almost 1 out of 10 STEMI patients and was associated with a similar rate of major bleeding and death as in patients with prior AF. The risk of NOAF for stroke might be higher than that of prior AF. These finding warrant confirmation in larger data sets.Central illustration
Post-operative atrial fibrillation after noncardiac surgery: diagnostic role of ambulatory rhythm monitoring for recurrent arrhythmia after hospital discharge
Authors: De Melo Junior J , Naser J , Chamberlain A , Gersh B , Noseworthy P , Siontis K
Published: May 2024

Introduction

Postoperative atrial fibrillation (POAF) after noncardiac surgery constitutes 10-15% of all cases of incident atrial fibrillation (AF) in the community and has been associated with an increased risk of stroke. The risk of subsequent AF among patients with POAF is not well defined.

Purpose

To evaluate the role of systematic 30-day electrocardiographic (ECG) monitoring in the detection of AF recurrence after POAF.

Methods

In a prospective interventional study, patients who underwent major noncardiac surgeries and had new AF documented by ECG in the post-operative period between May 2022 and April 2023 were identified. For these patients, a 30-day ambulatory ECG monitor was recommended upon discharge, with final ordering deferred to the primary inpatient teams. Rates of recurrent AF of any duration detected by 30-day monitoring plus routine care versus routine care alone after the surgery were compared.

Results

Eighty-five patients with new-onset POAF were included (mean age 72 years, male 67%). Of these, 35 (41%) patients underwent up to 30 days [median 23 (IQR 6-27) days] of continuous ECG monitoring after hospital discharge. There were no significant differences in baseline characteristics between patients who did or did not undergo monitoring (Table 1). During median 281 (IQR 197-385) days of follow-up, recurrent AF was documented in 14/35 (40%) patients in the monitoring group as opposed to 7/50 (14%) patients in the usual care group (log-rank p=0.003, Figure 1). The median time from day of surgery until documented AF recurrence was 25 (IQR 6-53) days in the monitoring group and 66 (IQR 25-145) in the usual care group. Overall, 81% of recurrent AF events in both groups were detected in the first 3 months after surgery. The median burden of AF in the cardiac monitoring group was 7% (IQR 1-15), with the longest AF event lasting a median of 6 (IQR 2-18) hours. Anticoagulation for AF was prescribed in 24/64 (37%) patients with POAF without recurrence and in 16/21 (76%) patients with recurrent AF.

Conclusion

Recurrent AF following POAF is common and detected most frequently in the first 3 months after noncardiac surgery. Systematic ambulatory rhythm monitoring is associated with a higher rate of AF detection following hospital discharge and may identify a patient subgroup who might benefit from anticoagulation therapy.Table 1Figure 1
Effectiveness of a stepwise approach for screening of atrial fibrillation after stroke: insights from the SAFAS study
Authors: Guenancia C , Benali K , Garnier L , Duloquin G , Didier R , Pommier T , Laurent G , Vergely C , Bejot Y
Published: May 2024

Background

Detection of atrial fibrillation (AF) is critical after ischemic stroke, providing information regarding the mechanism of the event and leading to modification in the antithrombotic strategy. While most guidelines recommend screening patients for AF with 12-lead ECG, telemetry, long-duration Holter monitoring and implantable cardiac monitor (ICM), the optimal timing and combination of such screening tools remain unclear.

Objective

This study aimed at investigating the suitability of a sequential combination of screening techniques (12-lead ECG, telemetry, in hospital long-lasting Holter monitoring, and ICM in the detection of AF after stroke.

Methods

Patients without previously known AF admitted to the Dijon University Hospital stroke unit for acute ischemic stroke were prospectively enrolled. After a stepwise screening approach for AF based on admission ECG, telemetry monitoring during the stroke unit stay and long-duration Holter monitoring during hospital stay, cryptogenic stroke patients were implanted of an ICM. Primary endpoint was the presence of AF detected during the 3-year period after stroke based on this sequential screening approach.

Results

A total of 240 patients were included. Among them, 104 (43.3%) patients had a documented cause of stroke non-related to AF. Among the remaining 136 patients (53.7% male, 70.8±13.7 yo), AF was detected in 82 (60%) patients over the acute screening phase or the 3-year follow-up with ICM. AF was diagnosed using 12-lead ECG, in-hospital telemetry, and in hospital long-lasting Holter monitoring in 17 (13%), 25 (18%), and 18 (13%) patients, respectively. AF was detected after the first 24 hours on the long-lasting Holter monitoring in 66% of patients. Among the 76 (56%) patients classified as cryptogenic after the complete stroke work-up and implanted from an ICM, AF was detected in 22 (29%) patients. AF occurred during the first, second, and third years of implantable monitoring in 14 (18.4%), 5 (6.6%), and 3 (3.9%) patients, respectively (Figure 1). Mean time from ICM implantation to AF diagnosis was 308+/-279 days. Finally, among all AF detected, 72% (60/83) were found during the initial intensive in-hospital screening.

Conclusion

A stepwise approach for AF screening after ischemic stroke allows the early detection of AF in a substantial number of patients during hospital stay. Even with such proactive initial monitoring strategy, invasive monitoring remains complementary to non-invasive screening tools not to overlook more distant AF episodes. Studies focusing on the relative risk of ischemic stroke recurrence according to AF timing and burden are needed.Figure 1
Genetic and clinical risk factors for stroke recurrence with different impact by assessment age: data from the UK Biobank
Authors: Chung S , Yang P S , Jang E , Kim D , Yu H T , Kim T H , Uhm J S , Sung J H , Pak H N , Lee M H , Joung B
Published: May 2024

Background

The predictive utility of genetic risk factors added to clinical risk factors for stroke recurrence is unclear. Furthermore, whether those predictive utility change in different age groups is uncertain. This study aimed to compare the association of genetic and clinical risk factors with recurrent stroke.

Methods

Data were collected from 5,378 patients with a history of stroke from the UK Biobank. Cox proportional hazards regression models were used to assess the associations of genetic, demographic, lifestyle, and comorbidity risk factors with stroke recurrence, both in overall and three age-based groups.

Results

Over a median follow-up of 11.5 (interquartile range [IQR] 10.6–12.3) years, 417 patients had recurrent stroke. The hazard ratio (HR) for recurrent stroke was most pronounced for diabetes mellitus (HR 2.28, 95% confidence interval [CI] 1.83-2.86). Additionally, current smoking, hypertension, age, and polygenic risk score for ischemic stroke (stroke PRS) were also significantly associated with recurrent stroke. Based on concordance index (C-index, 95% CI), the strongest predictors were diabetes mellitus (0.578, 0.556-0.599) followed by age, hypertension and stroke PRS. However, the stroke PRS (0.577, 0.527-0.627) was the strongest predictor in the younger 1/3 patient group (median age 54, IQR 50-57). In addition to demographic, lifestyle, and comorbidity risk factors, genetic risk factor improved C-index of the prediction model from 0.640 (0.592-0.688) to 0.652 (0.602-0.703) in the younger group.

Conclusions

Recurrent stroke is significantly associated with genetic and clinical risk factors. Genetic risk factor enhances the predictive model`s accuracy, particularly in younger patients.Prediction of stroke recurrence
Temporal trends of ischemic stroke rates in atrial fibrillation without anticoagulation: a nationwide cohort study from 2007 to 2018
Authors: Teppo K , Airaksinen K E J , Halminen O , Jaakkola J , Salmela B , Kouki E , Haukka J , Luojus A , Putaala J , Linna M , Aro A , Mustonen M , Hartikainen J , Lehto M
Published: May 2024

Background

Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS), but whether the magnitude of this risk has changed over time is unknown.

Purpose

To evaluate temporal trends in IS rates in patients with AF who have not initiated oral anticoagulant (OAC) therapy.

Methods

The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study covers all patients with incident AF in Finland from 2007 to 2018. A four-week quarantine period from AF diagnosis was applied and only follow-up time without OAC therapy was included. IS incidence rates were computed in four-year intervals.

Results

In total, 129 789 patients with new-onset AF (49.2% women; mean age 71.4 years) were identified. The IS incidence rate trends according to sex and the CHA2DS2-VA score are depicted in the Figure, along with the previously estimated treatment thresholds for direct oral anticoagulants (red broken line) and warfarin therapy (blue broken line). Between the calendar year intervals of 2007-2010 and 2015-2018, their mean CHA2DS2-VA score increased from 2.5 to 3.0, while concurrently the overall IS rate decreased by 25% from 36.7 (95% CI 34.5-39.0) to 27.6 (95% CI 26.1-29.0) events per 1000 patient years. This trend was driven by a 32% decrease in women, particularly among those with high CHA2DS2-VA scores. The overall IS rate in patients with a CHA2DS2-VA score of 1 was 8.2 (95% CI 7.2-9.4) events per 1000 patient years and it remained stable across the study period.

Conclusions

The IS rates in AF patients without OAC therapy have decreased by 25% between 2007 and 2018, despite their rising stroke risk scores. In patients with a CHA2DS2-VA score of 1 the IS rate appears to be lower than previously assumed and approximately at the threshold at which the potential benefits and harms of OAC therapy have been estimated to overlap.
Prediction of atrial fibrillation in patients with stroke: a systematic review with meta-analysis
Authors: Helbitz A , Haris M , Younsi T , Romer E , Raveendra K , Hayward C , Shuweihdi F , Larvin H , Wu J , Gale C P , Nadarajah R
Published: May 2024

Background

Atrial fibrillation-related strokes have a high rate of recurrence,1 and are associated with substantial morbidity, long-term disability, and mortality.2,3 Detection of AF at the time of stroke may require extended cardiac rhythm monitoring,4-6 which is costly.7 Identifying patients with stroke at high risk for AF can be challenging but important for preventing recurrent strokes.

Purpose

To provide an overview of prediction tools for AF in patients with an acute stroke, and to determine suitability for clinical use by synthesising discriminatory abilities.

Methods

We performed a systematic review of prediction tools (including multivariable scores and individual parameters) derived, validated and/or augmented for AF prediction in patients with strokes using Medline and Embase through 25 October 2023. Discrimination measures for tools with c-statistic data from ≥3 cohorts were pooled by Bayesian meta-analysis, with heterogeneity assessed through a 95% prediction interval (PI). Summary discrimination values of <0.60, 0.60-0.70, 0.70-0.80, and >0.80 were defined a priori as inadequate, adequate, good and excellent.1

Results

From 8125 unique records we included 71 studies from 135 cohorts with a mean age and percentage of women ranging from 43.0 years to 77.5 years, and 25.2% to 55.3%, respectively. We identified 99 prediction tools for incident AF after a stroke. 33 predictive tools used clinical variables, 13 only used Echocardiographic data, 14 only used electrocardiogram (ECG) data, and 39 used combinations of the above modalities.

87 tools were developed with Cox or logistic regression and 12 tools through machine learning approaches. 36 had undergone external validation, with 27 demonstrating a c-statistic >0.75 on external validation.

Nine multivariable prediction models and two predictive factors (B-type natriuretic peptide and age) were eligible for meta-analysis. Of multivariable prediction models, 4 showed good summary discrimination with wide heterogeneity (Figure 1): LADS (n = 1286, summary c-statistic 0.713, 95% CI 0.534-0.882 95% PI 0.379 -0.979), CHASE-LESS (n = 22747 summary c-statistic 0.726, 95% CI 0.667-0.785 95% PI 0.608-0.836), AS5F (n = 31517, summary c-statistic 0.726, 95% CI 0.693-0.754 95% PI 0.645-0.808), STAF (n = 3759, summary c-statistic 0.771, 95% CI 0.679-0.859 95% PI 0.456-0.973). BNP showed excellent summary discrimination with acceptable heterogeneity (Figure 2), (n = 1343 summary c-statistic 0.832, 95% CI 0.776-0.886 95% PI 0.718-0.927).

Conclusions

Five prediction tools externally validated for prediction of risk of AF in those who have had an acute stroke demonstrate good predictive ability. In meta-analysis, BNP performed the best out of all the models and variables tested.
NT-proBNP in severe aortic valve stenosis: necessity for higher cut-off values regarding congestive heart failure detection in atrial fibrillation
Authors: Schober A , Heidel C , Roth N , Xu C , Schober A , Schober M , Hubauer U , Lehn P , Burkhardt R , Luchner A , Maier L , Debl C , Jungbauer C
Published: May 2024

Background

NT-proBNP is an established biomarker for the determination of fluid overload. Patients suffering from atrial fibrillation seem to have higher serum levels of NT-proBNP than patients in sinus rhythm, independent from fluid overload. However, there is no established alternative cut-off for patients with atrial fibrillation, especially in patients with severe aortic valve stenosis.

Aim

The aim of the current study was to evaluate the levels of serum NT-proBNP for patients with atrial fibrillation (AF) and sinus rhythm (SR) for the determination of fluid overload in patients with severe aortic valve stenosis.

Methods

167 Patient suffering from severe aortic valve stenosis undergoing evaluation for TAVR at our hospital were included in this study. Upon recruitment blood samples from every patient were collected and an ECG was documented for each patient. Serum NT-proBNP was measured and volume overload was objectivated by calculation of plasma volume status (PVS), an already published method to estimate fluid overload or depletion by using a formula including weight and haematocrit.

Results

37 patients (22.2%) suffered from AF upon recruitment. 47 patients (28.1%) showed fluid overload, indicated by increased PVS (PVS > 0, SR n=37, AF n=10). 94 patients (56.3%) were male and mean age was 80 years. Patients with and without AF showed no significant difference in age, sex or prevalence of cardiovascular diseases, except for gradients across the aortic valve (SR 47mmHg vs. AF 38mmHg; p<0.05) and left ventricular ejection fractions (SR 57% vs. AF 55%; p<0.05).

Patients suffering from atrial fibrillation showed significantly higher serum levels of NT-proBNP (4843 ng/L vs. 1226 ng/L, p<0.001). ROC-analyses in patients with SR and severe aortic valve stenosis, showed satisfying results for NT-proBNP (AUC 0.72; sensitivity 0.81; specificity 0.58) to detect fluid overload. Comparable results were evident in patients with AF (AUC 0.77; sensitivity 0.70; specificity 0.78), but cut-off-values in patients suffering from atrial fibrillation were more than six times as much as in patients with sinus rhythm (6575 ng/L vs. 1053 ng/L).

Conclusion

NT-proBNP proved itself as a sufficient marker to determine volume overload in patients with severe aortic valve stenosis. Cut-offs for accurate determination of fluid overload deviate greatly in patients with sinus rhythm and atrial fibrillation, therefore different cut-offs might be required.
Screening for atrial fibrillation in patients with symptoms of cognitive impairment
Authors: Hygrell T , Henckel J , Rosenqvist M
Published: May 2024

Introduction

A diagnosis of atrial fibrillation increases the risk for dementia (1). Large register studies including approximately 400,000 patients with atrial fibrillation, have suggested that oral anti-coagulation treatment is associated with a 30-50% reduction of dementia development (2). Still, there are no studies investigating the true prevalence of atrial fibrillation in patients with cognitive problems.

Purpose

We studied the incidence of silent atrial fibrillation in patients with symptoms of cognitive impairment, participation rate in atrial fibrillation screening and the tolerance of the screening method in this specific population.

Method

Patients ≥70 years of age, referred from primary care for cognitive investigation at a specialised memory clinic, were invited to undergo a long-term ECG recording using an ECG-patch for two weeks. Patients with a known diagnosis of atrial fibrillation or who already were prescribed oral anti-coagulation treatment were excluded. Participants with detected atrial fibrillation (>30 seconds) were referred to a cardiologist for follow-up and oral anti-coagulation treatment was initiated according to clinical guidelines.

Results

During the inclusion period n=734 patients were examined for symptoms of cognitive impairment at a memory clinic. Of those, n=191 (26%) had already known atrial fibrillation and n=2 (0.3%) had oral anti-coagulation treatment for other reasons. Of the patients eligible for inclusion n=255/541 (47%) agreed to participate in screening for atrial fibrillation. Participants had a median age of 77 (IQR 74-82) years and median CHA2DS2-VASc score 3 (IQR 3-5). Long-term ECG was recorded for a median of 13.7 (IQR 12.6-14.0) days. Among the 255 participants n=14 (6%) had new atrial fibrillation detected. Total prevalence of atrial fibrillation in the population undergoing cognitive investigation increased with two percent units after screening to 28%.

Conclusion

The incidence of atrial fibrillation is remarkably high in patients with symptoms of cognitive impairment. Participation rate in screening is high in the selected population and the screening method is well-tolerated.
Comparison between Novel and Conventional Electrocardiographic Markers of Atrial Cardiomyopathy for identification of Persons at Risk for Ischemic Stroke
Authors: Huang T , Aldaoud S A , Mueller-Edendorn B M E , Pilia N P , Eichenlaub M E , Allgeier J A , Keyl C K , Neumann F J N , Trenk D T , Westermann D W , Arentz T A , Jadidi A J
Published: May 2024

Background

Atrial cardiomyopathy is associated with increased risk for future atrial fibrillation (AF) and ischemic stroke. Several ECG-derived parameters have been reported to assess the risk for future ischemic stroke.

Purpose

To predict risk of future ischemic stroke by comparison of the novel parameter duration of the amplified digital sinus-p-wave (APWD; 80mm/mV; 175mm/sec) vs previously described p-wave indices and clinical risk factors (cerebrovascular disease (CVD), CHADS-VASc-score).

Methods

P-wave-derived parameters were measured on digital 12-lead-sinus-ECGs (recorded +/- 6 months from the clinical stroke event) using the software "ECG-Precision-Analysis V-1-2023".

and clinical CHA2DS2-VASc Score was assessed in 80 patients with ischemic stroke (no history of AF, no oral anticoagulation (OAC)) and compared to 80 control patients (without OAC, AF or ischemic stroke within the next five years).

Results

Patients with ischemic stroke vs control patients presented a higher CHA2DS2-VASc Score (3.7 vs 3.2, p=0.04), had more frequently heart failure (25% vs 13%, p=0.04) and cerebrovascular atherosclerotic disease with stenosis >40% ((22.5% vs 10%, p=0.032).

P-wave indices were as follows in patients who developed ischemic stroke within the next 12 months versus patients without stroke within a follow-up period of five years, respectively: APWD (144 vs 128ms, p<0.0001), non-amplified SPWD (118 vs 116ms, p=0.081), A-PTF-V1 (-4660 vs -3860µV*ms, p=0.005), durations and amplitudes of terminal-p-wave in V1 (A-Duration-V1 (83 vs 79ms, p=0.119), A-Amplitude-V1 (-50µV vs -50µV, p=0.028), and advanced interatrial block (aIAB in 25% vs 3.8% of patients; p<0.0001.

The novel ECG-derived parameter (duration of the amplified sinus-P-wave >140ms) was the best predictor for future ischemic stroke (accuracy: 74%, sensitivity and specificity: 61% and 86%, respectively; PPV: 82%; area under ROC: 0.776). Sensitivity and specificity of the SPWD, aPTFV1 and aIAB were significantly lower (SPWD>120ms: sensitivity 35% and specificity 78%, PPV: 61%; aPTFV1 ≤-5000µV*ms, accuracy: 61%, sensitivity 46%% and specificity 75%, PPV: 65%; aIAB: accuracy: 61%, sensitivity 25% and specificity 96%, PPV: 87%).

Conclusions

Among the currently identified ECG markers of atrial cardiomyopathy, the novel APWD and advanced interatrial block have the best predictive performances for diagnosis of persons at risk for ischemic stroke.Comparison between ECG ParametersPredictive Accuracy of Parameters
Left atrial strain measurement in patients with heart failure and atrial fibrillation compared to a control group
Authors: Herzer L , Duckwitz N , Kirsch K , Mettke F , Hamadanchi A , Schulze P C , Surber R , Grosse A
Published: May 2024

Background

Left atrial (LA)-strain measurement is a non-invasive and widely available echocardiographic method to detect atrial cardiomyopathy as a process of structural and functional remodeling. The aim of this study is to measure LA-strain in patients with heart failure (HF) and atrial fibrillation (AF), compared to patients without structural heart disease and to evaluate whether or not LA-Strain could be part of a multi-modality assessment that influences therapy strategies and prognosis in patients suffering AF.

Methods

This study includes 18 patients with HF in sinus rhythm who underwent CRT implantation (HF group), 25 patients with persistent AF and preserved ejection fraction (EF) who underwent left atrial catheter ablation (AF group) and 22 patients without structural heart disease or AF who underwent electrophysiological study (control group). All subjects received measurement of reservoir (LASr), conduit (LAScd) and contraction (LASct) LA strain imaging using two-dimensional speckle tracking echocardiography (2D-STE).

Results

Patient characteristics in the HF-group showed mean age 68y (SD 10,6), mean EF 29% (SD 6,8), 66% male compared to the AF-group with mean age 66y (SD 8.0), mean EF 60% (SD 5.1), 68% male. The control-group showed mean age 55y (SD 13.8), mean EF 60% (SD 5.4), 55% male.

For LASr we found normal values in the control groups and reduced values in the HF und AF group (HF: mean 20% [9 – 45%], AF: mean 24% [7 – 52%], control: mean 42% [30 – 67%]). In LASr, LAScd and LASct there was a statistically significant difference between the HF and the control group (p < 0.001) as well as the AF and control group (p < 0.001), whereas there was no difference between AF and HF group (p = 0.444).

Discussion

Patients with persistent AF show similar LA-strain compared to patients with HF and patients without structural heart disease present significant better LA strains. The findings of this study suggest, that LA strain analysis might contribute to comprehensive assessment of patients with AF especially as a simple imaging method. A limitation of our results could be the significant younger age of our control group (p = 0.004) as fibrotic remodeling increases in advanced age. It remains to be analyzed whether early AF treatment could prevent further fibrotic remodeling and whether measuring LA strain could provide further information for risk stratification and the definition of therapeutic intervention strategies.
Validation of CT in comparison to TEE in routine workflow for detection of LAA thrombus in patients under oral anticoagulation presenting for left atrial ablation
Authors: Stolterfoht H , Graeger S T , Hamadanchi A , Schulze P C , Grosse A
Published: May 2024

Background

Left atrial (LA) thrombus in patients (pts) presenting for LA ablation is an absolute contraindication to ablation. Although thrombi can still form despite the use of oral anticoagulation (OAC) in advance of the procedure. Transesophageal echocardiography (TEE) has been considered the gold standard for LAA thrombus detection. Additional cardiac computer tomography (CT) is often performed in pts with persistent atrial fibrillation (AF) or atrial tachycardia (AT). The aim of the study was in routine workflow 1) to identify the incidence of LAA thrombi in TEE and CT, 2) to search for an association in detecting LAA thrombi in the 2 methods and 3) to find out if the LAA flow velocity/ LA volume influences the thrombus detection.

Methods

Between 05/2018 and 10/2023 patients with AF/AT under OAC which were scheduled for a LA ablation were included. TEE and CT searching for LAA thrombus were carried out at intervals of up to 7 days. LAA flow velocity measured in the TEE. The LA volume which included LAA and excluded the pulmonary veins were obtained from the CT at the end-systole.

Results

Patients characteristics: 283 pts were included, mean age of 66y (+9y), 182 male, mean CHA2DS2-VASc score 3 [0-7]. All patients, mostly on NOACs (n=265), were orally anticoagulated. Mean LA volume (LA + LAA) was 158 ml (+45ml), LAA flow velocity was reduced (< 40 cm/s) in 119 pts (42%). In the majority of cases (73%), TEE and CT were performed at the same day or with an interval of 1 day. In 16 pts a LAA thrombus was detected using TEE,42 pts had SEC/Sludge but no solid thrombus. An LAA thrombus in the CT was described in 26 pts (10%), 6% couldn't definitively diagnose thrombi due to contrast recesses/flow phenomena in 16 pts. In 8 out of 34 events (23%) TEE and CT agreed on the diagnosis of a thrombus, in 6 cases during same-day examinations. 18 pts: LAA thrombus on CT, not on TEE (mean interval: 2d). 8 pts: LAA thrombus on TEE, not on CT (mean interval: 1.5d). In 71% (200 out of 283) of cases, CT and TEE agreed in ruling out a thrombus (p=0.358). LAA flow velocity and thrombus verification by TEE showed a significant correlation (p < 0.001). No correlation was found between the presence of a thrombus on CT and LA volume (p= 0.964).

Discussion

In 12% of the patients, all treated with OAC, a thrombus was described in at least one of the examinations or in both. Only in one out of four pts TEE and CT agreed on the diagnosis of a thrombus. It was notable that both examinations excluded thrombi in 70%. LAA flow velocity and thrombus verification in the TEE are significant correlated. LA volume and thrombus notification in CT are not related.

Conclusion

Routine diagnosis of LAA thrombus remains challenging, with frequent discrepancies between TEE, the gold standard, and CT. TEE results depend on the examining physician, while CT is limited by flow phenomena and scan timing.
The potentially underestimated influence of atrial fibrillation on NT-proBNP in chest pain
Authors: Lang F , Schlossbauer M , Staudner S , Leininger S , Vogel M , Lehn P , Burckhard R , Zimmermann C , Hupf J , Hubauer U , Maier L , Jungbauer C
Published: May 2024

Introduction/Purpose

NT-proBNP is a widely used diagnostic marker in the emergency department (ED). The main objective of the current study was to determine the association of NT-proBNP in patients with chest pain presenting with sinus rhythm (SR) compared to atrial fibrillation (AFib). Hereby, a focus was the evaluation of serum NT-proBNP head-to-head to urinary NT-proBNP.

Methods

In this study, urinary as well as blood concentrations of NT-proBNP were measured in a total of 601 patients, who presented with acute chest pain in the ED (mean age = 61.1 y, SD = 16.9 y). In the initial ECG 68 patients suffered from AFib and 533 showed SR.

The participants were categorized according to their diagnosis into acute coronary syndrome (ACS, AFib n = 28, SR n = 261), acute decompensated heart failure (ADHF, AFib n= 16, SR n = 21), non-ischemic chest pain without congestion (NICP, AFib n = 24, SR n = 96) or chest-wall syndrome (CWS, SR n = 155).

Results

In the overall study cohort, patients with AFib showed significantly higher concentrations of urinary as well as blood NT-proBNP compared to those in sinus rhythm (each p < 0.001). Additionally, among patients with acute coronary syndrome (ACS), there were significantly increased biomarker concentrations in patients presenting with AFib compared to sinus rhythm (each p < 0.001, AUCblood = 0.801, AUCurine = 0.701), similarly for patients categorized into NICP (each p < 0.001, AUCblood = 0.833, AUCurine = 0.756). The same pattern was observed among the ACS subcategories (each p < 0.001). Regarding ROC analysis, promising predictive values were shown for detection of AFib: STEMI (AUCblood = 0.902, AUCurine = 0.867), NSTEMI (AUCblood = 0.757, AUCurine = 0.696) and UA (AUCblood = 0.821, AUCurine = 0.681). Comparing ROC curves, significant differences were noted in UA (p < 0.001), opposite to STEMI as well as NSTEMI (each p = n. s.). Regarding ADHF, paradoxically higher NT-proBNP concentrations were noted among patients showing sinus rhythms compared to AFib. Furthermore, a multivariate binary regression analysis showed blood NT-proBNP and age as independent predictors of atrial fibrillation (p < 0.05), opposite to urinary NT-proBNP, high-sensitivity troponin T and diabetes (each p = n. s.).

Conclusion

Urinary and to a larger extent blood NT-proBNP showed significantly higher concentrations in AFib. In conclusion, in ED patients elevated NT-proBNP may potentially be frequently caused by a coexisting AFib. Regarding ADHF patients, the effect of AFib might be consumed by other conditions that have a greater impact on NT-proBNP.
Single center experience of efficacy and safety of atrioventricular node ablation after left bundle branch area pacing for the management of atrial fibrillation
Authors: Jacobs M , Bodin A , Spiesser P , Babuty D , Clementy N , Bisson A
Published: May 2024

Introduction

Atrioventricular node ablation (AVNA) with permanent pacing is an effective treatment of symptomatic atrial fibrillation (AF). Permanent right ventricular pacing is associated with cardiac dyssynchrony, which can worsen heart failure (HF) symptoms. Left bundle branch area pacing (LBBAP) is a recent pacing technique, more physiologic and less associated with cardiac dyssynchrony.

Purpose

To evaluate feasibility, safety and outcomes at 6 months of AVNA associated with LBBAP in patients with symptomatic AF.

Methods

In this retrospective monocentric study, we included all consecutive patients treated with AVNA procedure and LBBAP. Procedures characteristics, clinical follow-up, electrical and echographic data at baseline and 6 months were studied and compared to the data of a matched cohort (1:1) of patients who received an AVNA procedure with conventional pacing between March 2010 and February 2023.

Results

75 AVNA procedures and LBBAP were studied. The success rate of AVNA was 98.7% at first ablation without any complications, especially no lead dislodgement or threshold rise. Pacing electrical parameters at implant were good, and stable at 6 months follow-up, with no threshold rise. At 6 months, 4 (5%) patients were hospitalized for heart failure and 1 (1.3%) was deceased. Patients had a significative improvement in NYHA class, palpitations symptoms, and left ventricular ejection fraction (LVEF) (p ≤ 0.0001 for all). After matching with a cohort of patients with AVNA and conventional pacing (n=68), patients with LBBAP had a significantly better improvement of LVEF (+5.27±9.62% versus -0.48±14%; p = 0.01), and a lower rate of a composite endpoint (all cause death and hospitalization for HF) (HR 0.34, 95%CI: 0.1-1.06; p = 0.064).

Conclusions

AVNA with LBBAP in patients with symptomatic AF was feasible and safe. Complication rate and adverse outcomes at 6 months were similar to AVNA with conventional pacing, and LVEF improvement was significantly greater.Matched populationsOutcomes at 6 months
Long-term anti-arrhythmic is effective than no anti-arrhythmic in patients with first developed paroxysmal atrial fibrillation
Authors: Park Y M , Cha M S , Kang W C , Shim J , Choi I S
Published: May 2024

Background

There is no detailed guideline recommendation of AAD treatment for the firstly developed paroxysmal atrial fibrillation (AF). Anti-arrhythmic drugs (AAD) prevent recurrence of AF and short-term AAD treatment would increase drug safety by reducing treatment duration.

Introduction

We designed the prospective, randomized trial to evaluate the efficacy of short- and long-term AAD (flecainide) compared with no treatment in maintaining sinus rhythm in patients with firstly developed paroxysmal atrial fibrillation (PAF).

Methods

Definition of the firstly developed PAF was the patients with firstly developed symptomatic PAF without history of palpitation. Sixty patients were randomly assigned into no AAD treatment (Group I; N=21), short-term AAD treatment (flecainide 100mg bid for 4 weeks, Group II; N=20) or long-term AAD treatment (flecainide 100mg bid for 6 months, Group III; N=19). All patients were in sinus rhythm at randomization. Patients received clinical follow up with serial evaluation of rhythm status.

Results

There were no significant differences in age, gender, cardiovascular comorbidities and echocardiographic parameters. Among the total population, AF recurred in 16 patients (26.7%) during the follow up period. AF free survival was significantly different among groups (p=0.038) (Fig 1).

Conclusions

Long-term AAD at least 6 months is beneficial in maintaining sinus rhythm than no or shot-term AAD in patients with firstly developed PAF.