Health-related quality of life in patients with atrial fibrillation: The role of symptoms, comorbidities, and the type of atrial fibrillation

Aims

This study aimed to analyse health related quality of life (HRQoL) for patients with different atrial fibrillation (AF) types and to identify patient characteristics, symptoms and comorbidities that influence HRQoL.

Methods

We used baseline data from the Swiss Atrial Fibrillation (Swiss-AF) study, a prospective multicentre observational cohort study conducted in 13 clinical centres in Switzerland. Between April 2014 and August 2017, 2415 AF patients were recruited. Patients were included in this analysis if they had baseline HRQoL data as assessed with EQ-5D-based utilities and visual analogue scale (VAS) scores. Patient characteristics and HRQoL were described stratified by AF type. The impact of symptoms, comorbidities and socio-economic factors on HRQoL was analysed using multivariable regression analysis.

Results

Based on 2412 patients with available baseline HRQoL data, the lowest unadjusted mean HRQoL was found in patients with permanent AF regardless of whether measured with utilities (paroxysmal: 0.83, persistent: 0.84, permanent: 0.80, p<0.001) or VAS score (paroxysmal: 73.6, persistent: 72.8, permanent: 69.2, p<0.001). In multivariable analysis of utilities and VAS scores, higher European Heart Rhythm Association (EHRA) score, recurrent falls and several comorbidities showed a strong negative impact on HRQoL while AF type was no longer associated with HRQoL.

Conclusions

Multiple factors turned out to influence HRQoL in AF patients. After controlling for several comorbidities, the EHRA score was one of the strongest predictors independent of AF type. The results may be valuable for better patient assessment and provide a reference point for further QoL and health economic analyses in AF populations.

Effect of a Strategy of Comprehensive Vasodilation vs Usual Care on Mortality and Heart Failure Rehospitalization Among Patients With Acute Heart Failure: The GALACTIC Randomized Clinical Trial

IMPORTANCE

Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF).

OBJECTIVE

To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019.

INTERVENTIONS

Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan.

MAIN OUTCOMES AND MEASURES

The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days.

RESULTS

Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%).

CONCLUSIONS AND RELEVANCE

Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00512759.

Clinical Predictors and Prognostic Impact of Recovery of Wall Motion Abnormalities in Takotsubo Syndrome: Results From the International Takotsubo Registry

Background

Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide‐ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients.

Methods and Results

TTS patients from the International Takotsubo Registry were included in this study. Cut‐off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In‐hospital outcomes and 1‐year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P=0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P=0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1‐year outcome compared with patients with early recovery (P=0.003). On multiple logistic regression, male sex, LV ejection fraction <45%, and acute neurologic disorders were associated with the absence of early recovery.

Conclusions

TTS patients without early LV recovery have different clinical characteristics and less favorable 1‐year outcome compared with patients with early recovery. The factors associated with the absence of early recovery included male sex, reduced LV ejection fraction, and acute neurologic events.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.

Incidence and Predictors of Atrial Fibrillation Progression

Background The incidence and predictors of atrial fibrillation (AF) progression are currently not well defined, and clinical AF progression partly overlaps with rhythm control interventions (RCIs). Methods and Results We assessed AF type and intercurrent RCIs during yearly follow-ups in 2869 prospectively followed patients with paroxysmal or persistent AF. Clinical AF progression was defined as progression from paroxysmal to nonparoxysmal or from persistent to permanent AF. An RCI was defined as pulmonary vein isolation, electrical cardioversion, or new treatment with amiodarone. During a median follow-up of 3 years, the incidence of clinical AF progression was 5.2 per 100 patient-years, and 10.9 per 100 patient-years for any RCI. Significant predictors for AF progression were body mass index (hazard ratio [HR], 1.03; 95% CI, 1.01-1.05), heart rate (HR per 5 beats/min increase, 1.05; 95% CI, 1.02-1.08), age (HR per 5-year increase 1.19; 95% CI, 1.13-1.27), systolic blood pressure (HR per 5 mm Hg increase, 1.03; 95% CI, 1.00-1.05), history of hyperthyroidism (HR, 1.71; 95% CI, 1.16-2.52), stroke (HR, 1.50; 95% CI, 1.19-1.88), and heart failure (HR, 1.69; 95% CI, 1.34-2.13). Regular physical activity (HR, 0.80; 95% CI, 0.66-0.98) and previous pulmonary vein isolation (HR, 0.69; 95% CI, 0.53-0.90) showed an inverse association. Significant predictive factors for RCIs were physical activity (HR, 1.42; 95% CI, 1.20-1.68), AF-related symptoms (HR, 1.84; 95% CI, 1.47-2.30), age (HR per 5-year increase, 0.88; 95% CI, 0.85-0.92), and paroxysmal AF (HR, 0.61; 95% CI, 0.51-0.73). Conclusions Cardiovascular risk factors and comorbidities were key predictors of clinical AF progression. A healthy lifestyle may therefore reduce the risk of AF progression.

P1894Serum light-chain neurofilament is associated with brain atrophy in patients with atrial fibrillation

Background and aims

There is emerging evidence that atrial fibrillation (AF) is associated with cognitive dysfunction, increased risk for dementia and reduced brain volume independent of stroke, but the underlying mechanisms of these associations remain unclear. Here, we investigated the association of serum light-chain neurofilament (sNfL), a neuroaxonal injury biomarker, with brain atrophy in AF patients.

Methods

Explorative analysis from the Swiss-AF cohort study, a multicenter prospective observationalstudy which recruited patients aged ≥45 years with documented AF (NCT02105844). In baseline blood samples, sNfL concentrations were measured in duplicates using a single-molecule array assay. Brain MRI was obtained at baseline and at two years using a standardized protocol including a 3D T1-weighted MPRAGE sequence, on which Structural Image Evaluation using Normalization of Atrophy (SIENA) with optimized parameters for brain extraction was applied to calculate the two-year percentage whole brain volume change (PBVC).

Results

We included 245 Swiss-AF patients (median age 73, 73% male). Two-year PBVC was significantly associated with baseline sNfL in linear regression, with a 0.09% whole brain volume decrease per 10 pg/ml sNfL increase (95% CI [0.05–0.13], p<0.001). This association remained significant after adjustment for age, history of stroke and other vascular risk factors.

Neurofilament and brain atrophy

Conclusion

Increasing baseline sNfL was predictive of higher two-year brain atrophy rates independent of stroke history in AF patients. This association might reflect a chronic neurodegenerative process in AF.

Acknowledgement/Funding

Swiss National Science Foundation

P1876Atrial fibrillation related symptoms and cardiovascular outcomes

Background

Comprehensive information on the impact of atrial fibrillation (AF)-related symptoms and quality of life (QoL) on adverse outcomes is sparse.

Purpose

We aimed to investigate whether AF-related symptoms and/or QoL are associated with cardiovascular outcomes in a large cohort of AF patients.

Methods

A total of 3902 participants with documented AF from two nationwide prospective cohort studies in Switzerland were included. Information on AF-related symptoms was assessed yearly by standardized questionnaires, QoL was quantified using a visual analog scale (0–100, with higher scores indicating better QoL). The primary endpoint was a composite of stroke and systemic embolism. The secondary endpoint was a composite of cardiovascular death, hospitalization for heart failure and myocardial infarction. We assessed associations using multivariable, time-updated Cox proportional-hazards models including age, sex, study cohort, history of heart failure, hypertension, diabetes, prior stroke, prior myocardial infarction, vascular disease and prior catheter ablation for AF as covariates.

Results

Mean age was 72 years, and 72% were male. The median QoL score was 75 points, and 2572 (66%) participants had AF-related symptoms. Symptomatic individuals were younger (71 vs 75 years) and had more often paroxysmal AF (29 vs 23%) (p for both <0.001). The most frequent symptoms were palpitations (42%), dyspnea (25%) and fatigue (18%). In multivariable, time-updated models, the hazard ratio (HR) was 1.24 (95% confidence intervals (CI) 0.72; 2.11, p=0.43) for the primary endpoint and HR 0.83 (95% CI 0.65; 1.06, p=0.14) for the secondary endpoint in symptomatic vs non-symptomatic individuals. There was a significant, inverse association for a 5-point increase in the QoL score with both the primary (HR 0.94 (95% CI 0.88; 0.99), p=0.04) and secondary (HR 0.91 (95% CI 0.88; 0.93), p<0.0001) endpoints.

Conclusions

AF-related symptoms are not associated with adverse cardiovascular events in AF patients. In contrast, QoL is inversely associated with to adverse cardiovascular outcomes.

Pulmonary vein isolation using ablation index vs. CLOSE protocol with a surround flow ablation catheter

Aims

Pulmonary vein isolation (PVI) using ablation index (AI) incorporates stability, contact force (CF), time, and power. The CLOSE protocol combines AI and ≤6 mm interlesion distance. Safety concerns are raised about surround flow ablation catheters (STSF). To compare safety and effectiveness of an atrial fibrillation (AF) ablation strategy using AI vs. CLOSE protocol using STSF.

Methods and results

First cluster was treated using AI and second cluster using CLOSE. Procedural data, safety, and recurrence of any atrial tachycardia (AT) or AF &gt;30 s were collected prospectively. All Classes 1c and III anti-arrhythmic drugs (AAD) were stopped after the blanking period. In total, all 215 consecutive patients [AI: 121 (paroxysmal: n = 97), CLOSE: n = 94 (paroxysmal: n = 74)] were included. Pulmonary vein isolation was reached in all in similar procedure duration (CLOSE: 107 ± 25 vs. AI: 102 ± 24 min; P = 0.1) and similar radiofrequency time (CLOSE: 36 ± 11 vs. AI: 37 ± 8 min; P = 0.4) but first pass isolation was higher in CLOSE vs. AI [left veins: 90% vs. 80%; P &lt; 0.05 and right veins: 84% vs. 73%; P &lt; 0.05]. Twelve-month off-AAD freedom of AF/AT was higher in CLOSE vs. AI [79% (paroxysmal: 85%) vs. 64% (paroxysmal: 68%); P &lt; 0.05]. Only four patients (2%) without recurrence were on AAD during follow-up. Major complications were similar (CLOSE: 2.1% vs. AI: 2.5%; P = 0.87).

Conclusion

The CLOSE protocol is more effective than a PVI approach solely using AI, especially in paroxysmal AF. In this off-AAD study, 79% of patients were free from AF/AT during 12-month follow-up. The STSF catheter appears to be safe using conventional CLOSE targets.

Long-Term Prognosis of Patients With Takotsubo Syndrome

BACKGROUND

Prognosis of Takotsubo syndrome (TTS) remains controversial due to scarcity of available data. Additionally, the effect of the triggering factors remains elusive.

OBJECTIVES

This study compared prognosis between TTS and acute coronary syndrome (ACS) patients and investigated short- and long-term outcomes in TTS based on different triggers.

METHODS

Patients with TTS were enrolled from the International Takotsubo Registry. Long-term mortality of patients with TTS was compared to an age- and sex-matched cohort of patients with ACS. In addition, short- and long-term outcomes were compared between different groups according to triggering conditions.

RESULTS

Overall, TTS patients had a comparable long-term mortality risk with ACS patients. Of 1,613 TTS patients, an emotional trigger was detected in 485 patients (30%). Of 630 patients (39%) related to physical triggers, 98 patients (6%) had acute neurologic disorders, while in the other 532 patients (33%), physical activities, medical conditions, or procedures were the triggering conditions. The remaining 498 patients (31%) had no identifiable trigger. TTS patients related to physical stress showed higher mortality rates than ACS patients during long-term follow-up, whereas patients related to emotional stress had better outcomes compared with ACS patients.

CONCLUSIONS

Overall, TTS patients had long-term outcomes comparable to age- and sex-matched ACS patients. Also, we demonstrated that TTS can either be benign or a life-threating condition depending on the inciting stress factor. We propose a new classification based on triggers, which can serve as a clinical tool to predict short- and long-term outcomes of TTS. (International Takotsubo Registry [InterTAK Registry]; NCT01947621).

First-in-man implantation of the Tricento transcatheter heart valve for the treatment of severe tricuspid regurgitation

Here we describe the first implantation of the novel bicavally anchored Tricento transcatheter heart valve via the transvenous transfemoral access in a 74-year-old woman with severe tricuspid regurgitation and holosystolic hepatic vein backflow. Following successful implantation, caval vein regurgitant volume was reduced leading to symptomatic and clinical improvement at three-month follow-up. The Tricento device represents a promising, novel therapeutic option for patients with severe tricuspid regurgitation who are not candidates for open heart surgery.

Clinical Features and Outcomes of Patients With Malignancy and Takotsubo Syndrome: Observations From the International Takotsubo Registry

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short- and long-term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short- and long-term mortality. A subanalysis was performed comparing long-term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long-term mortality was higher in patients with malignancy (P<0.001), while short-term outcome was comparable (P=0.17). In a subanalysis, long-term mortality was comparable between TTS patients with malignancies and ACS patients with malignancies (P=0.13). Malignancy emerged as an independent predictor of long-term mortality. Conclusions A substantial number of TTS patients show an association with malignancy. History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients. Clinical Trial Registration URL: http://www.clinicaltrial.gov. Unique identifier: NCT01947621.

Heart diseases and echocardiography in rural Tanzania: Occurrence, characteristics, and etiologies of underappreciated cardiac pathologies

BACKGROUND

Little is known about heart diseases and their treatment in rural sub-Saharan Africa. This study aimed to describe the occurrence, characteristics, and etiologies of heart diseases, and the medication taken before and prescribed after echocardiography in a rural referral Hospital in Tanzania.

METHODS

This prospective descriptive cohort study included all adults and children referred for echocardiography. Clinical and echocardiographic data were collated for analysis.

RESULTS

From December 2015 to October 2017, a total of 1'243 echocardiograms were performed. A total of 815 adults and 59 children ≤15 years had abnormal echocardiographic findings; in adults 537/815 (66%) had hypertension, with 230/537(43%) on antihypertensive drugs, and 506/815 (62%) were not on regular cardiac medication; 346/815 (42%) had severe eccentric or concentric left ventricular hypertrophy, and 182/815 (22%) had severe systolic heart failure. Only 44% demonstrated normal left ventricular systolic function. The most frequent heart diseases were hypertensive heart disease (41%), valvular heart disease (18%), coronary heart disease (18%), peripartum cardiomyopathy (7%), and other non-hypertensive dilated cardiomyopathies (6%) in adults, and congenital heart disease (34%) in children. Following echocardiography, 802/815 (98%) adults and 40/59 (68%) children had an indication for cardiac medication, 70/815 (9%) and 2/59 (3%) for oral anticoagulation, and 35/815 (4%) and 23/59 (39%) for cardiac surgery, respectively.

CONCLUSION

Hypertension is the leading etiology of heart diseases in rural Tanzania. Most patients present with advanced stages of heart disease, and the majority are not treated before echocardiography. There is an urgent need for increased awareness, expertise and infrastructure to detect and treat hypertension and heart failure in rural Africa.

Pacemaker implantation after transcatheter aortic valve: why is this still happening?

During the past years, the industry and most transcatheter aortic valve operators have focused on reduction of paravalvular leaks rather than on the reduction of permanent pacemakers (PPM). However, since indication for transcatheter aortic valve implantation (TAVI) is moving toward a healthier and younger patient population, new PPMs may become more of an issue. Certain factors such as pre-existing conduction disorders or anatomical features cannot be changed. However, the amount of mechanical trauma to the conduction system and periprocedural medical management offers the potential for optimization. By optimizing our procedure, we may finally be able to achieve low, surgical-like, PPM rates.

Transfemoral Implantation of the Acurate neo for the Treatment of Aortic Regurgitation

OBJECTIVES

We report an international experience of transfemoral transcatheter aortic valve replacement (TAVR) using the self-expanding Acurate neo valve (Boston Scientific) in aortic regurgitation.

METHODS

This series comprises 20 patients with pure aortic regurgitation undergoing transfemoral TAVR with the Acurate neo prosthesis at nine centers in Europe and Israel.

RESULTS

Mean age was 79 ± 8 years and mean STS score was 8.3 ± 9.3%. Leaflet calcification was none/minimal in 19 patients (95%). Prosthesis size selection was based on perimeter-derived annular diameter, with a tendency to over-size in cases of borderline annuli. One patient required implantation of a second valve. Device success rate was 18/20 (90%). At discharge, aortic regurgitation was none in 14 patients (70%), mild in 5 patients (25%), and moderate in 1 patient (5%). Left ventricular end-diastolic diameter decreased from 58 ± 7 mm at baseline to 53 ± 7 mm before discharge (P<.001). At 30-day follow-up, there was no mortality, no stroke, and 3 patients (15%) had received a permanent pacemaker. New York Heart Association class had improved significantly compared to baseline (85% in class I/II compared to 15% at baseline; P<.001).

CONCLUSIONS

In a selected patient population, transfemoral TAVR using the Acurate neo transcatheter heart valve was successful in treating aortic regurgitation, significantly reduced left ventricular dimensions, and improved clinical symptoms.