Atrial fibrillation as an independent risk factor for stroke: the Framingham Study

Utilizing engineered extracellular vesicles as delivery vectors in the management of ischemic stroke: a special outlook on mitochondrial delivery

Ischemic stroke is a secondary cause of mortality worldwide, imposing considerable medical and economic burdens on society. Extracellular vesicles, serving as natural nano-carriers for drug delivery, exhibit excellent biocompatibility in vivo and have significant advantages in the management of ischemic stroke. However, the uncertain distribution and rapid clearance of extracellular vesicles impede their delivery efficiency. By utilizing membrane decoration or by encapsulating therapeutic cargo within extracellular vesicles, their delivery efficacy may be greatly improved. Furthermore, previous studies have indicated that microvesicles, a subset of large-sized extracellular vesicles, can transport mitochondria to neighboring cells, thereby aiding in the restoration of mitochondrial function post-ischemic stroke. Small extracellular vesicles have also demonstrated the capability to transfer mitochondrial components, such as proteins or deoxyribonucleic acid, or their sub-components, for extracellular vesicle-based ischemic stroke therapy. In this review, we undertake a comparative analysis of the isolation techniques employed for extracellular vesicles and present an overview of the current dominant extracellular vesicle modification methodologies. Given the complex facets of treating ischemic stroke, we also delineate various extracellular vesicle modification approaches which are suited to different facets of the treatment process. Moreover, given the burgeoning interest in mitochondrial delivery, we delved into the feasibility and existing research findings on the transportation of mitochondrial fractions or intact mitochondria through small extracellular vesicles and microvesicles to offer a fresh perspective on ischemic stroke therapy.

Impact of a clinical atrial fibrillation risk estimation tool on cardiac rhythm monitor utilization following acute ischemic stroke: A prepost clinical trial

BACKGROUND

Detection of undiagnosed atrial fibrillation (AF) after ischemic stroke through extended cardiac monitoring is important for preventing recurrent stroke. We evaluated whether a tool that displays clinically predicted AF risk to clinicians caring for stroke patients was associated with the use of extended cardiac monitoring.

METHODS

We prospectively included hospitalized ischemic stroke patients without known AF in a preintervention (October 2018 - June 2019) and intervention period (March 11, 2021 - March 10, 2022). The intervention consisted of an electronic health record (EHR)-based best-practice advisory (BPA) alert which calculated and displayed 5-year risk of AF. We used a multivariable Fine and Gray model to test for an interaction between predicted AF risk and period (preintervention vs intervention) with regards to incidence of extended cardiac monitoring. We compared the incidence of extended cardiac monitoring within 6-months of discharge between periods, stratified by BPA completion.

RESULTS

We included 805 patients: 493 in the preintervention cohort and 312 in the intervention cohort. In the intervention cohort, the BPA was completed for 180 (58%) patients. The association between predicted clinical risk of AF and incidence of 6-month extended cardiac monitoring was not different by time period (interaction HR = 1.00 [95% Confidence Interval (CI) 0.98; 1.02]). The intervention period was associated with an increased cumulative incidence of cardiac monitoring (adjusted HR = 1.32 [95% CI 1.03-1.69]).

CONCLUSIONS

An embedded EHR tool displaying predicted AF risk in a poststroke setting had limited clinician engagement and predicted risk was not associated with the use of extended cardiac monitoring.

CLINICAL TRIAL REGISTRATION

NCT04637087.

The left atrial appendage exclusion for prophylactic stroke reduction (LEAAPS) trial: Rationale and design

INTRODUCTION

Left atrial appendage exclusion (LAAE) has been shown in randomized trials to reduce ischemic stroke risk in patients undergoing cardiac surgery with known atrial fibrillation (AF). Many patients undergoing cardiac surgery without pre-existing AF are at risk of stroke and may benefit from LAAE.

METHODS

Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction (LeAAPS) is an international, prospective, randomized, multicenter, blinded trial evaluating the effectiveness of LAAE in preventing ischemic stroke or systemic embolism in patients undergoing cardiac surgery at increased risk of AF and ischemic stroke. The trial will enroll 6500 patients at increased risk of stroke in whom a cardiac surgery is planned at 250 sites worldwide. Eligible patients are ≥18 years old, have no pre-existing AF but are at increased risk for AF and stroke (based on age, CHA2DS2-VASc score, left atrium size or brain natriuretic peptide). Patients are randomized 1:1 to receive either LAAE with AtriClip or no LAAE during cardiac surgery. Healthcare providers outside of the operating room and the patient will be blinded to allocation. The primary effectiveness endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or surgical or endovascular LAA closure. The powered secondary effectiveness endpoint is ischemic stroke or systemic arterial embolism. The primary safety endpoint is the occurrence of one of the following events (through 30 days): pericardial effusion requiring percutaneous or surgical treatment, peri-operative major bleeding, deep sternal wound infection, or myocardial infarction. Other endpoints include mortality, rehospitalizations, clinically diagnosed AF, transient ischemic attack, and cognitive and quality of life assessments. Follow-up is every 6 months for a minimum of 5 years; primary analysis occurs when 469 patients have had an ischemic stroke or systemic embolism.

CONCLUSION

The results of the LeAAPS trial will demonstrate whether LAAE with AtriClip at the time of other routine cardiac surgery reduces stroke or systemic arterial embolism during long-term follow-up in patients at high risk of stroke without pre-existing AF.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT05478304, https://clinicaltrials.gov/study/NCT05478304?term=%20NCT05478304&rank=1.

Reasons for omitting anticoagulant treatment in patients with atrial fibrillation: an audit of patient records in general practice

BACKGROUND

Anticoagulant treatment is recommended for most patients with atrial fibrillation. Yet, register studies show a persisting treatment gap, which may lead to preventable strokes. This study aimed to explore the reasons for omitting anticoagulant treatment in patients with atrial fibrillation.

METHODS

We performed a comprehensive audit of electronic patient records in Danish general practice, including 12 clinics served by 39 general practitioners. All patients with atrial fibrillation, prevalent on 1 January 2023 and receiving no anticoagulant treatment, were identified using data from nationwide health registers. Patient records were reviewed retrospectively, covering the period 1 January 2001-1 January 2023. Information on care trajectories, follow-up patterns, decisions on anticoagulant treatment and reasons for omission were extracted and summarised using descriptive statistics.

RESULTS

In a representative sample of patients with atrial fibrillation receiving no anticoagulant treatment (n = 166), the absence of treatment was based on clinical decisions explicitly noted in the patient records in 93.4% of cases. In 34.3% of non-users, anticoagulants were deselected due to a low risk of stroke and no treatment indication, and 59.1% represented clinical decisions made in areas with no firm guideline recommendations. Reasons for anticoagulant treatment omission included minimal atrial fibrillation burden, left atrial appendage closure, palliative care, risk-benefit considerations and patient preference. However, in 6.6% of patients, the absence of treatment reflected unjustified or outdated decisions. For patients with atrial fibrillation receiving no anticoagulant treatment, care trajectories were characterised by contacts across healthcare sectors. For 64.4% of patients, the most recent contact for atrial fibrillation occurred in the hospital setting, while 30.7% had theirs in general practice. Most follow-up consultations were planned in general practice, but 59.0% had no follow-up plan. A decision on anticoagulant treatment was explicitly documented in the electronic patient record (at least once since diagnosis) for 94.6% of patients, with 22.3% revised in the past year.

CONCLUSION

This study found that most anticoagulant treatment omissions in patients with atrial fibrillation were supported by documented clinical reasoning, suggesting that the extent of inappropriate undertreatment may be lower than expected. Nevertheless, optimising care pathways could facilitate timely anticoagulation for some patients with atrial fibrillation.

Identification of causal plasma metabolite biomarkers for ischemic stroke using Mendelian randomization and mediation analysis

The Global Burden of Disease Study 2021 reports that stroke remains a leading cause of death, with ischemic stroke (IS) presenting significant challenges in screening, prevention, and treatment. We explored the causal effects of 1,400 plasma metabolites on IS outcomes using a two-sample Mendelian randomization (MR) framework. We assessed causal relationships between IS and 11 common clinical risk factors and further examined these relationships for metabolites. Mediation analysis identified mechanisms for metabolites affecting both IS and its risk factors. Finally, a phenome-wide association study (PheWAS) MR analysis evaluated the side effects and additional indications of IS-associated metabolites across 3,948 phenotypes from the UKBB GWAS. Nineteen metabolites showed a causal relationship with IS. MR analysis confirmed body mass index (BMI), high-density lipoprotein (HDL), systolic blood pressure (SBP), diastolic blood pressure (DBP), and type 2 diabetes (T2D) as risk factors for IS. Among 136 metabolites associated with at least one IS risk factor, 132 were linked to risk factors but not directly to IS. BMI, DBP, and coffee intake mediated the causal relationship between IS and the levels of 1-stearoyl-GPG (18:0), 1-oleoyl-2-linoleoyl-GPE (18:1/18:2), Octadecadienedioate (C18:2-DC), and X-24,951. Phe-MR analysis indicated that these metabolites were protective and affected other indications similarly to IS. Our findings reveal causal pathways and identify four potential biomarkers for IS, providing new insights for its screening, prevention, and treatment.

Pattern of anticoagulation prescription for elderly atrial fibrillation patients with or without severe dementia: A retrospective analysis of patient data

Atrial fibrillation (AF) is a very common type of cardiac arrhythmia. Use of an anticoagulant is highly recommended. We aimed to identify the pattern of prescribing of an oral anticoagulant (OA) in patients with AF and severe dementia or patients with AF aged > 80 years. A retrospective review of medical charts was conducted in 2 tertiary care centers in Riyadh, Saudi Arabia: King Saud University Medical City and King Abdulaziz Medical City. Data for people with AF retrieved between January 2016 and December 2020 from hospital information systems. Collected data included demographics, medical history, medication history (including use of an OA or antiplatelet agent), stroke and major bleeding history. Adjusted binary logistic regression was used to predict the odds ratio (OR) of the primary outcome and secondary outcomes. The data of 620 patients were assessed. Most (60%) were women. The average age of study cohort was 79 ± 6.1 years. Most patients (88.2%) were prescribed an OA. The most commonly prescribed OA was a direct inhibitor of factor Xa (DIFXa; 48%), followed by a coumarin derivative (36%), and direct inhibitor of thrombin (16%). Patients using a coumarin derivative carried higher OR of developing severe dementia (adjusted OR = 2.687, 95%CI = 1.795-4.021, P-value < .001). Most patients suffering from AF were prescribed an OA. A DIFXa inhibitor was the most prescribed OA. Use of a coumarin derivative carried a high prevalence of dementia among our study cohort.

Stroke Prevention With Oral Anticoagulants in High-Risk Atrial Fibrillation in an Aging Population

Aging societies will pose unique health challenges in the near future. Elderly and very elderly patients often have complex medical needs, including comorbidities and polypharmacy. Contributing to this, atrial fibrillation (AF) is common among elderly patients. Direct oral anticoagulants are widely used to prevent stroke in patients with AF. However, patients in randomized controlled trials tend to be younger than many patients with AF and may not have the complicating factors that can influence treatment decisions. In this review, we summarize what is currently known about direct oral anticoagulants in elderly (age 65-79 years) and very elderly (age ≥80 years) patients with AF, and highlight the remaining gaps in the literature. Although further randomized controlled trials are needed, the ELDERCARE-AF (Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients) trial may have contributed to filling these gaps.

General practice-related variation in oral anticoagulant treatment of atrial fibrillation: a nationwide cohort study

BACKGROUND

Guideline-adherent oral anticoagulant (OAC) treatment in atrial fibrillation (AF) remains a challenge. In Denmark, most patients with AF are treated in general practice. Nevertheless, determinants of OAC prescription in primary care are poorly understood.

AIM

To investigate variation in OAC treatment adherence between general practice clinics and to identify clinic characteristics associated with a lower propensity to prescribe OAC treatment.

DESIGN & SETTING

Nationwide register-based cohort study including prevalent and incident patients with AF and CHA2DS2-VASc score ≥2 (n = 165 731) listed with Danish general practice clinics (n = 1666) in 2021.

METHOD

The main outcome was OAC treatment adherence assessed as proportion of days covered (PDC). We used clinic OAC propensity to evaluate variation. OAC propensity was quantified as ratios between observed and expected adherence. Expected adherence was estimated based on the composition of the clinic patient populations. Sampled reference populations were constructed to account for random variation. Linear regression models examined associations between OAC propensity and clinic characteristics.

RESULTS

The PDC with OAC treatment in the AF population was 78%. OAC propensity in clinics in the 90th percentile was 20% higher compared with clinics in the 10th percentile; however, this difference was reduced to 3% when accounting for random variation. Modest associations were observed between clinic characteristics and OAC propensity. The most significant difference was in the correlation between geographic location and OAC propensity, showing an 8% gap between top and bottom-performing regions.

CONCLUSION

The study suggests persistent underutilisation of OAC treatment in patients with AF and little variation in OAC prescription patterns across general practice clinics.

Comparative analysis of therapeutic strategies in atrial fibrillation patients with left atrial appendage thrombus despite optimal NOAC therapy

BACKGROUND AND AIMS

Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Non-vitamin-K oral anticoagulants (NOACs) effectively reduce LAA thrombus prevalence and stroke risk. However, the optimal treatment of a NOAC-resistant thrombus remains unclear. We aimed to evaluate therapeutic strategies for resolving LAA thrombus in patients on optimal NOAC therapy.

METHODS

We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 with LAA thrombus on transesophageal echocardiography (TEE) despite being on optimal NOAC therapy. We assessed how the applied management strategy affected thrombus resolution.

RESULTS

Among the analyzed 120 patients, a change to a different NOAC occurred in 41% of cases, a transition to a VKA in 30%, and the supplementation with antiplatelet therapy in 11%. In contrast, 18% of the patients received unchanged therapy. Follow-up imaging at 65 [44 - 95] days showed successful thrombus resolution in 92 (77%) of cases, predicted by a lower CHA2DS2-VASc score (p = 0.01). Any modification of antithrombotic therapy was an independent predictor of thrombus resolution (OR 5.28 [1.55-18], p = 0.01). Of the four strategies, there was a trend toward better thrombus resolution with switching to a VKA (OR 3.23 [1.03-10.1], p = 0.04).

CONCLUSION

Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the anticoagulation strategy. In addition, transitioning from NOAC to VKA might be considered.

Unique Characteristics of Stroke in Women and Rehabilitation Considerations

Stroke is the third leading cause of death of women in the United States, and women have a higher lifetime risk of stroke than men. Studies show that women live longer but with poorer functional outcomes and higher rates of disability compared with men. Sex-specific disparities exist between clinical symptoms, medical evaluation, and management after stroke. Stroke rehabilitation strategies specific to women should take into consideration both physiologic and psychosocial demands more common in women to improve functional outcomes. Additional resources for education, clinical research, and implementation of best practices are needed to eliminate gender-related disparities in poststroke care.

Comparative Efficacy and Safety of Low-Dose Direct Oral Anticoagulants Versus Dual Antiplatelet Therapy Following Left Atrial Appendage Occlusion in Patients With Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

Left atrial appendage occlusion (LAAO) is an alternative to chronic oral anticoagulation (OAT) for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients with contraindications to OAT. Postprocedure antithrombotic therapy (ATT) is essential to reduce the risk of device-related thrombosis (DRT), but the optimal regimen remains uncertain.

AIMS

This study aims to compare the safety and efficacy of low-dose direct oral anticoagulants (DOACs) versus dual antiplatelet therapy (DAPT) following LAAO.

METHODS

A comprehensive search of PubMed, Scopus, Cochrane, and Web of Science was conducted in August 2024. Studies comparing low-dose DOACs and DAPT post-LAAO were included. The primary outcomes were a composite efficacy endpoint (DRT, strokes, and systemic embolism [SE]) and major bleeding events as the safety endpoint. Secondary outcomes included all bleeding events, all-cause mortality, and a composite of efficacy and safety endpoints.

RESULTS

Four studies with 727 patients were included. Low-dose DOACs were associated with lower rates of the primary composite efficacy endpoint compared to DAPT (OR = 0.36; 95% CI [0.16, 0.85], p = 0.01). No significant difference in major bleeding events was observed (OR = 0.36; 95% CI [0.11, 1.18]; p = 0.091; I² = 0%). Compared to DAPT, low-dose DOACs were also associated with lower rates of DRT events (OR = 0.36; 95% CI [0.16, 0.79], p = 0.011).

CONCLUSION

Low-dose DOACs effectively reduce thromboembolic events post-LAAO without increasing bleeding risk. These findings support their use as a viable ATT option, but larger trials are needed to confirm optimal regimens.

The clinical impact of prophylactic concomitant left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis

Background

Recently, concomitant left atrial appendage occlusion (LAAO) has emerged as prophylactic treatment option for preventing thromboembolic events in patients undergoing cardiac surgery with no known history of atrial fibrillation. The efficacy of prophylactic LAAO remains unknown.

Methods

PubMed, Embase, Web of Science, Emcare, and the Cochrane Library were searched for studies on prophylactic LAAO in patients undergoing cardiac surgery. The primary endpoints were postoperative thromboembolic complications and postoperative atrial fibrillation (POAF).

Results

Three randomized trials and seven retrospective observational studies were included: in total, 7369 patients received either prophylactic LAAO (n = 3823) or no prophylactic LAAO (n = 3546) during their index cardiac surgery. Prophylactic LAAO reduced the risk of early thromboembolic events by 58 % (risk ratio: 0.42; 95 % confidence interval: 0.25 to 0.73; p = 0.002; I2 = 0 %) with an estimated absolute risk reduction of 0.8 %. On the other hand, a higher risk, albeit statistically not significant, of POAF was seen with LAAO (risk ratio: 1.15; 95 % confidence interval: 1.00 to 1.32; p = 0.051; I2 = 64 %). Prophylactic LAAO also reduced the risk of all-time thromboembolic complications by 52 % (hazards ratio: 0.48; 95 % CI: 0.29 to 0.80; p = 0.005; I2 = 41 %).

Conclusion

Prophylactic LAAO was associated with a reduction in early and all-time thromboembolic events but demonstrated a potential relation to a higher risk of POAF.

Left atrial appendage occlusion in atrial fibrillation: shaping the future of stroke prevention

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of thromboembolic events, particularly ischemic stroke. The left atrial appendage (LAA) is the predominant site of thrombus formation in patients with AF, making it a crucial target for stroke prevention strategies. Left atrial appendage occlusion (LAAO) has emerged as an important therapeutic alternative to oral anticoagulation, particularly in patients with contraindications to long-term anticoagulant therapy. This review examines the role of LAAO in AF management, discussing current indications, patient selection, procedural techniques, and clinical outcomes. We also explore the latest evidence from major clinical trials and real-world studies, highlighting the efficacy and safety of LAAO compared to standard anticoagulation. Additionally, we consider the unresolved questions and the potential future directions for this intervention, including emerging technologies and the integration of LAAO into broader AF management protocols. Our review underscores the growing importance of LAAO in reducing thromboembolic risk in AF patients, particularly those unable to tolerate traditional anticoagulation, and offers insights into the ongoing evolution of this treatment modality in clinical practice.

A silent surge: Increasing stroke deaths among older adults with atrial fibrillation in the United States (1999-2020)

BACKGROUND

Atrial fibrillation (AF) significantly increases stroke risk, particularly among older adults, leading to severe outcomes and elevated mortality. This study investigates trends and disparities in AF-related stroke mortality among U.S. adults aged 65 and older from 1999 to 2020.

METHODS

Mortality data from the CDC WONDER database were analyzed, identifying stroke as the underlying cause of death (ICD-10 codes I60-I69) with AF as a contributing cause (ICD-10 code I48). Age-adjusted mortality rates (AAMRs) per 100,000 persons were calculated. Annual percentage change (APC) and average annual percentage change (AAPC) were used to assess trends over time using Joinpoint regression.

RESULTS

A total of 197,453 deaths were recorded between 1999 and 2020. The AAMR increased from 20.85 in 1999 to 24.09 in 2020, reflecting an AAPC of 0.55 % (95 % CI: 0.19-0.95). Women had a slightly higher overall AAMR (21.69) compared to men (20.38). AAMR for Non-Hispanic (NH) Whites (22.15) was 1.5 times higher than that for Hispanics (14.17). Nonmetropolitan areas reported a higher AAMR (22.68) compared to metropolitan areas (21.03). The West had the highest regional overall AAMR (26.57). States in the top 90th percentile reported nearly double the rates of the lowest 10th percentile states.

CONCLUSION

AF-related stroke mortality in older adults has risen over the past two decades, with disparities across gender, race, and geography. Targeted interventions are essential to address these disparities and reduce the burden of AF-related stroke mortality.

A Platform Designed to Empower Quality Improvement for Patients with Atrial Fibrillation

There are significant gaps in care for patients with atrial fibrillation (AF) and is a need to focus on improving guideline-concordant care. Recognizing challenges encountered in pursuing sustainable quality improvement (QI) in AF care, the Heart Rhythm Society spearheaded a multifaceted collaboration grounded in the principles of Improvement Science to develop a robust platform aimed specifically at demystifying QI for clinicians and health care systems interested in closing care gaps for patients with AF. Solution development included an innovative discovery process, a design phase, piloting, and refinement, and finished with transformation into a comprehensive digital platform. End-users were engaged throughout the 4-phase process to help ensure the final platform would meet the needs of clinicians and health care systems. The result was the launch of www.CardiQ.org featuring the Atrial Fibrillation QI Framework and an extensive, curated Resource Library that has been accessed by more than 10 000 users spanning over 100 countries.

Association of Atrial Fibrillation Burden With Cardiovascular Outcomes in New-Onset Atrial Fibrillation Complicating Myocardial Infarction

BACKGROUND

New-onset atrial fibrillation (NOAF) is a common complication after acute myocardial infarction (AMI) and is associated with poor survival. Atrial fibrillation (AF) burden is used to characterize the severity of AF. However, the association of AF burden with cardiovascular outcomes in NOAF complicating AMI is poorly understood. We aimed to investigate the prognostic impact of AF burden in NOAF complicating AMI.

METHODS AND RESULTS

This multicenter retrospective cohort study included patients with AMI without a medical history of AF who developed the first documented AF during hospitalization between January 2014 and January 2022. AF burden was defined as the percentage of time spent in AF during hospitalization. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, reinfarction, or ischemic stroke. A total of 812 patients with AMI and NOAF (mean age, 72.7±10.9 years; 552 men) were included. An AF burden of 15.29% was identified as the cutoff value for prognostic stratification; 663 patients with complete follow-up data were then classified into the low-burden (AF burden <15.29%; n=447) and high-burden (AF burden ≥15.29%; n=216) groups. During a median of 4.2 years of follow-up, high AF burden was associated with an increased risk of the composite outcomes (hazard ratio [HR], 1.66 [95% CI, 1.30-2.12]; P<0.001) after multivariable adjustment. When measured as a continuous scale, increasing AF burden remained an independent predictor of the composite outcomes (HR, 1.06 per 10% AF burden [95% CI, 1.02-1.09]; P=0.004).

CONCLUSIONS

A greater burden of AF is associated with a higher risk of cardiovascular outcomes among patients with NOAF complicating AMI.

A different perspective on studying stroke predictors: joint models for longitudinal and time-to-event data in a type 2 diabetes mellitus cohort

BACKGROUND

Most predictive models rely on risk factors and clinical outcomes assessed simultaneously. This approach does not adequately reflect the progression of health conditions. By employing joint models of longitudinal and survival data, we can dynamically adjust prognosis predictions for individual patients. Our objective was to optimize the prediction of stroke or transient ischemic attack (TIA) via joint models that incorporate all available changes in the predictive variables.

METHODS

A total of 3442 patients with type 2 diabetes mellitus (T2DM) and no history of stroke, TIA or myocardial infarction were followed for 12 years. Models were constructed independently for men and women. We used proportional hazards regression models to assess the effects of baseline characteristics (excluding longitudinal data) on the risk of stroke/TIA and linear mixed effects models to assess the effects of baseline characteristics on longitudinal data development over time. Both submodels were then combined into a joint model. To optimize the analysis, a univariate analysis was first performed for each longitudinal predictor to select the functional form that gave the best fit via the deviance information criterion. The variables were then entered into a multivariate model using pragmatic criteria, and if they improved the discriminatory ability of the model, the area under the curve (AUC) was used.

RESULTS

During the follow-up period, 303 patients (8.8%) experienced their first stroke/TIA. Age was identified as an independent predictor among males. Among females, age was positively associated with atrial fibrillation (AF). The final model for males included AF, systolic blood pressure (SBP), and diastolic blood pressure (DBP), with albuminuria and the glomerular filtration rate (GFR) as adjustment variables. For females, the model included AF, blood pressure (BP), and renal function (albuminuria and GFR), with HbA1c and LDL cholesterol as adjustment variables. Both models demonstrated an AUC greater than 0.70.

CONCLUSIONS

Age, AF, and SBP have been confirmed as significant predictive factors in both sexes, whereas renal function was significant only in women. Interestingly, an increase in DBP may serve as a protective factor in our cohort. These factors were particularly relevant in the last 3-7 years of follow-up.

Rationale and design of the anticoagulant therapy after left atrial appendage closure (ATLAAC) trial

INTRODUCTION

Left atrial appendage closure (LAAC) has become a recommended addition to oral anticoagulation for patients with atrial fibrillation, who undergo cardiac surgery. The procedure significantly reduces the risk of stroke and systemic arterial embolism, potentially making oral anticoagulation (OAC) unnecessary or even harmful, when considering the associated increased risk of bleeding. This publication describes the rationale and design of a randomized trial, testing the hypothesis that stopping OAC is noninferior to continuing OAC after surgical LAAC in terms of the primary endpoint.

METHODS

The ATLAAC trial is a multicenter, randomized, controlled trial, aiming to enroll 1,220 patients with atrial fibrillation, who have undergone surgical LAAC and remain on OAC. A cardiac CT scan is performed to confirm success of the LAAC. Patients with successful closure are randomized to stop or continue OAC. The primary endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or major bleeding over an expected mean follow-up of 4 years. Secondary endpoints include all-cause mortality, cardiovascular mortality, any bleeding leading to hospitalization, blood transfusion, venous thromboembolism, myocardial infarction, and quality of life measures.

TRIAL STATUS

Enrollment for the ATLAAC trial began in March 2024. As of January 18th, 2025, 554 patients have been enrolled in the study and 319 patients have been randomized. Recruitment is expected to continue for approximately 12 months. Follow-up will be stopped once 128 primary endpoints have occurred.

CONCLUSIONS

The ATLAAC trial will evaluate the safety of stopping OAC after surgical LAAC.

TRIAL REGISTRATION NUMBER

EU-CT: 2022-502986-92-00, clinicaltrials.gov ID: NCT06401616.

Low blood flow velocity in the left atrial appendage in sinus rhythm as a predictor of atrial fibrillation: results of a prospective cohort study with 3 years of follow-up

BACKGROUND

Atrial fibrillation (AF) is a common cause of cardioembolic stroke and can lead to severe and recurrent cerebrovascular events. Thus, identifying patients suffering from cardioembolic events caused by undetected AF is crucial. Previously, we found an association between increasing stroke severity and a decreasing left atrial appendage (LAA) blood flow velocity below 60 cm/s.

METHODS

This was a prospective single-center cohort study including hospitalized patients who underwent a transesophageal echocardiography (TEE) in sinus rhythm. The participants were divided into two groups (≥ 60 cm/s;<60 cm/s) based on their maximum LAA blood flow velocity. The results of the cardiovascular risk assessment and 24- to 72-hour ECG Holter were recorded. Follow-up appointments were scheduled at 3, 6, 12, 24 and 36 months. The primary endpoint was new-onset AF. The statistics included a Cox-proportional-hazard-model and a binary logistic regression. Numerical data or categorical data were analyzed with the Mann-Whitney U test or chi-square test.

RESULTS

A total of 166 patients were recruited. The median LAA blood flow velocity was 64 cm/s. New-onset AF was diagnosed in 22.9% of the patients. An LAA blood flow velocity ≤ 60 cm/s was associated with a threefold increased risk of new-onset AF (35.8% vs. 11.5%; HR3.56; CI95%1.70-7.46; p < 0.001), independently according to a multivariate analysis (p = 0.035). Furthermore, a decreasing LAA blood flow velocity was associated with an increased risk of new-onset AF (OR1.043; CI95%1.021-1.069; p < 0.001).

CONCLUSION

A low LAA blood flow velocity (≤ 60 cm/s) in sinus rhythm is prospectively associated with an increased risk of new-onset AF. Additional simple LAA-TEE examinations could help to identify patients who benefit from more accurate cardiac rhythm monitoring.

Atrial Fibrillation Ablation: Impact on Burden and Cardiovascular Outcomes

Atrial fibrillation [AF] is the most common sustained arrhythmia observed in clinical practice with considerable cardiovascular morbidity and mortality. AF burden provides a quantitative measurement of AF and is now more readily achievable utilizing wearable and implantable cardiac monitoring devices. This review summarizes the current literature on AF burden and cardiovascular outcomes and outlines the effect and role of catheter ablation in ameliorating AF burden.

Outcomes of hospitalized black patients with atrial fibrillation based on sex

INTRODUCTION

Despite oral anticoagulation (AC), male patients with atrial fibrillation (AF) have worse inpatient outcomes versus females. This disparity is not well studied in Black Americans. Our objective was to evaluate in-patient outcomes of Black males hospitalized with AF versus Black females for whom AC was utilized.

METHODS

We conducted a retrospective analysis of the National Inpatient Sample and identified hospitalizations of Black Americans with AF prescribed AC between 4th quarter 2015 to 2020 using ICD-10 codes. Males were compared to females with the primary endpoint of major cardiovascular events (MACE) (acute myocardial infarction, cardiogenic shock, ischemic stroke, cardiac arrest, or in-patient mortality). Secondary endpoints included any major bleeding event, length-of-stay (LOS), and adjusted hospital charges. A logistic regression model was used to control potential confounders including age, Charlson Comorbidity Index, and in-hospital mortality.

RESULTS

A total of 180,650 Black patient hospitalizations were identified with AF prescribed AC, among which, 83,135 (46 %) were male. Males had more baseline comorbidities. After adjusting for selected confounders, Black males had higher odds of MACE (adjusted odds ratio [aOR] 1.16), major bleeding event (aOR 1.34), longer LOS (5.7 vs. 5.5 days), and higher adjusted hospital charges ($68,227 vs. $63,027); all p < 0.05.

CONCLUSION

In this "real life" inpatient cohort, compared with Black females, Black males with AF prescribed AC exhibit higher rates of MACE and major bleeding.

Incidence, Prevalence, and Trends in Mortality and Stroke among Medicare Beneficiaries With Atrial Fibrillation: 2013 to 2019

BACKGROUND

Atrial fibrillation (AF) is known to be associated with increased risks of stroke and death, but contemporary studies of this association are lacking. We evaluated trends in stroke and death among Medicare beneficiaries with AF between 2013 and 2019.

METHODS

Medicare fee-for-service beneficiaries >65 years old (2011-2019) were included. AF incidence and prevalence were calculated overall and by age group, sex, race, and rurality. Within incident cohorts, the 1-year stroke rate was assessed. Age- and sex-adjusted mortality at 30 days, 1 year, and 3 years was calculated in each incident cohort.

RESULTS

The mean number of Medicare beneficiaries with incident AF per year was 572 630 from 2013 to 2019 (30.44 per 1000 patient-years). The study cohort on average was 79±7.7 years old, 52% female, 88% white, and 83% urban dwelling. Incidence and prevalence of AF increased with age and was highest among White beneficiaries; the incidence was greater in male compared with female beneficiaries. Differences by rurality were not seen. Overall AF prevalence per 1000 beneficiaries increased minimally but steadily from 2013 to 2019 reflecting an increase among male (104-109 per 1000) but not female beneficiaries (82.5 per 1000). The 1-year rate of stroke after incident AF peaked in the 2015 cohort (50.5 per 1000); the rate was at its lowest among the 2018 cohort (41.89 per 1000). Incident AF was associated with mortality that was 3.2× greater than expected at 1 year, but overall mortality and the magnitude of the AF-related mortality risk decreased steadily over time from 22% to 20%.

CONCLUSIONS

From 2013 to 2019, AF incidence and prevalence among Medicare beneficiaries were relatively stable but have varied by important demographic subgroups with age and sex remaining powerful risk factors. In contrast, mortality and stroke after incident AF have decreased significantly throughout this era.

Safety of edoxaban for delayed bleeding in gastrointestinal endoscopic procedures with a high risk of bleeding

Objectives

There are limited reports on the safety of gastrointestinal endoscopic procedures in individuals taking edoxaban, one of the direct oral anticoagulants. We clarified the incidence of delayed bleeding in patients who were on edoxaban in the perioperative period of gastrointestinal endoscopic procedures with a high risk of bleeding.

Methods

This was an investigator-initiated, single-center, open-label, prospective, single-arm study. Patients on warfarin or edoxaban undergoing endoscopy with a high risk of bleeding were enrolled from June 2018 to September 2021. Warfarin was replaced with edoxaban in patients on warfarin. Patients taking other direct oral anticoagulants, and antiplatelet drugs, were excluded. The primary endpoint was severe delayed bleeding (Common Terminology Criteria for Adverse Events [CTCAE] grades III-V) and the secondary endpoints included thromboembolism, all adverse events, any delayed bleeding (CTCAE grades I or II), and hospital stay durations.

Results

Twenty-one patients on edoxaban underwent high-risk endoscopy. Three cases (14%) experienced CTCAE grade III delayed bleeding, requiring endoscopic hemostasis. No CTCAE grade I-II delayed bleeding or thromboembolic events occurred. Cholangitis and aspiration pneumonia (conservatively treated) occurred during the hospital stay. The median length of hospital stay was 8 days (range 3-24 days). Patients with delayed bleeding had higher systolic blood pressure at admission and longer hospital stays.

Conclusions

The delayed bleeding incidence in high-risk endoscopic procedures for patients on edoxaban was acceptable. Higher blood pressure may be associated with increased risk, but further research is needed.

Pulsed field ablation for atrial fibrillation

INTRODUCTION

Atrial fibrillation is the most common sustained arrhythmia, associated with substantial morbidity and a reduced quality of life. The current standard of care, transcatheter pulmonary vein isolation using thermal ablation techniques, provides symptom relief but carries a risk of collateral tissue damage. In recent years, pulsed field ablation, a nonthermal technique based on irreversible electroporation, has emerged as a promising alternative to conventional thermal ablation methods.

AREAS COVERED

This review provides an overview of pulsed field ablation, a novel nonthermal ablation technique. We briefly explain its biophysical principles and general technical aspects, describe currently available technologies, and summarize findings from clinical studies. Additionally, we discuss its safety profile, unresolved issues, and limitations, while also exploring future perspectives.

EXPERT OPINION

Pulsed field ablation offers distinct advantages over traditional thermal ablation methods, such as shorter procedure times and a favorable safety profile due to precise tissue targeting. Future improvements in ablation device design, energy delivery settings, integration with mapping systems, workflow efficiency, ablation protocols, and patient selection criteria are expected to further enhance clinical outcomes.

Ischemic stroke prevention in patients with atrial fibrillation and a recent ischemic stroke, TIA, or intracranial hemorrhage: A World Stroke Organization (WSO) scientific statement

BACKGROUND

Secondary stroke prevention in patients with atrial fibrillation (AF) is one of the fastest growing areas in the field of cerebrovascular diseases. This scientific statement from the World Stroke Organization Brain & Heart Task Force provides a critical analysis of the strength of current evidence on this topic, highlights areas of current controversy, identifies knowledge gaps, and proposes priorities for future research.

METHODS

We select topics with the highest clinical relevance and perform a systematic search to answer specific practical questions. Based on the strength of available evidence and knowledge gaps, we identify topics that need to be prioritized in future research. For this purpose, we adopt a novel classification of evidence strength based on the availability of publications in which the primary population is patients with recent (<6 months) cerebrovascular events, the primary study endpoint is a recurrent ischemic stroke, and the quality of the studies (e.g. observational versus randomized controlled trial).

SUMMARY

Priority areas include AF screening, molecular biomarkers, AF subtype classification, anticoagulation in device-detected AF, timing of anticoagulation initiation, effective management of breakthrough strokes on existing anticoagulant therapy, the role of left atrial appendage closure, novel approaches, and antithrombotic therapy post-intracranial hemorrhage. Strength of currently available evidence varies across the selected topics, with early anticoagulation being the one showing more consistent data.

CONCLUSION

Several knowledge gaps persist in most areas related to secondary stroke prevention in AF. Prioritizing research in this field is crucial to advance current knowledge and improve clinical care.

Association of Baseline Thyroid Stimulating Hormone With In-Hospital Outcomes in Patients With Atrial Fibrillation and Coronary Artery Diseases

OBJECTIVE

Thyroid stimulating hormone (TSH) is related to increased atrial fibrillation (AF) inducibility and plays an important role in a variety of cardiovascular diseases. However, the association of baseline TSH with in-hospital outcomes in patients with AF and coronary artery disease (CAD) is unknown. This study aimed to investigate the distribution of baseline TSH and its association with in-hospital outcomes (major adverse cardiovascular events, all-cause death, or heart failure [HF]) in AF patients combined with CAD.

METHODS

A total of 19 725 patients with AF were included. The status of blood TSH was investigated. Patients with AF and CAD were divided into low, median, and high-TSH subgroups based on tertiles of baseline TSH levels. Clinical characteristics and in-hospital outcomes were compared. Logistic regression analysis was performed to determine the association of TSH with in-hospital outcomes. Subgroup analysis was also performed.

RESULTS

In patients with AF and CAD, compared with the low-TSH group, the median-TSH (OR 0.277, 95% CI 0.078-0.991, P = .048) and high-TSH (OR 0.163, 95% CI 0.036-0.750, P = .020) groups were associated with decreased all-cause death. Besides, high TSH showed a protective role for HF events, and the same results were seen in females, age ≥75, and non-non-hypertension subgroups.

CONCLUSION

Higher baseline TSH presented a protective effect on in-hospital all-cause death and HF in patients with AF combined with CAD.

Blood pressure and in-hospital outcomes in patients hospitalized with atrial fibrillation: findings from the CCC-AF project

The relationship between blood pressure (BP) levels and adverse outcomes in patients with atrial fibrillation (AF) is incompletely understood. Our study aims to elucidate the relationship between BP levels upon admission and in-hospital outcomes in patients hospitalized with AF. Based on the Improving Care for Cardiovascular Disease in China-AF (CCC-AF) project, patients hospitalized with AF collected from 236 hospitals in China from 2015 to 2019 were included in current analysis. A total of 60 390 patients hospitalized with AF were included. Using systolic BP (SBP)/diastolic BP (DBP) of 130-139/80-89 mmHg upon admission as the reference, SBP/DBP ≥160/100 mmHg was associated with an increased risk of stroke/transient ischemic attack (TIA) (adjusted OR, 1.65; 95% CI, 1.27-2.15; P < 0.001) and heart failure (HF) (adjusted OR, 1.29; 95% CI, 1.18-1.41; P < 0.001). SBP/DBP < 120/ < 80 mmHg was associated with an increased risk of HF (adjusted OR, 1.24; 95% CI, 1.14-1.34; P < 0.001), and all-cause death (adjusted OR, 1.90; 95% CI, 1.90-3.86; P < 0.001). A similar pattern was observed in the analysis of the relationship between SBP and DBP levels and in-hospital outcomes, respectively. Among patients hospitalized with AF, higher BP levels upon admission are associated with an increased risk of stroke/TIA and HF, and lower BP levels are associated with an increased risk of HF and all-cause death. Hence, physicians should pay attention to higher and lower BP levels. Randomized trials to identify the optimal treatment target for AF patients are warranted.

Atrial Fibrillation in Geriatric Patients: A Cross-Sectional Analysis of Risk Factors and Disease Patterns

Background Atrial fibrillation (AF) is the most common type of heart rhythm disorder worldwide, and it disproportionately affects elderly populations, contributing to elevated risks of stroke, heart failure, and cardiovascular mortality. Despite its clinical significance, there remains an underrepresentation of age-specific prevalence trends and modifiable risk factors among elderly cohorts in tertiary care settings. This observational study aimed to quantify AF prevalence, identify age-stratified patterns, and evaluate associations with comorbidities in elderly patients. Methods A cross-sectional study was carried out in a tertiary care hospital, involving 500 patients aged 60 years and older, who were enrolled consecutively upon admission. AF diagnosis was confirmed via a 60-lead electrocardiogram (ECG) or documented medical history. Demographic variables (age and gender) and comorbidities - hypertension, diabetes mellitus (DM), coronary artery disease (CAD), chronic kidney disease (CKD), obesity (body mass index, or BMI ≥30 kg/m²), and prior stroke - were systematically recorded. Risk factor prevalence was compared between AF and non-AF groups using descriptive statistics, without adjustment for potential confounders. Results The cohort had a mean age of 72.5 years (range: 60-89), with a male predominance (n = 300, or 60%). AF was identified in 60 participants, yielding a prevalence of 12%. Age stratification revealed a peak in AF prevalence among those aged 70-79 years: 15 (25%) cases were observed in the 60-69 age group, 30 (50%) in the 70-79 group, and 15 (25%) in the 80-89 group. A Chi-square test for trend confirmed that this variation across age strata was statistically significant (p = 0.03), supporting a true mid-elderly peak in AF occurrence. Hypertension was the most prevalent comorbidity in the overall cohort (n = 360, or 72%), and it was present in 45 (75%) of AF patients. DM was seen in 35 of the 60 AF patients (58.3%), compared to 200 out of 500 overall (40%). Obesity was also disproportionately higher among AF patients (n = 30, or 50%) than in the total cohort (n = 140, or 28%). Similarly, CAD was more frequent in AF patients (n = 25, or 41.7%) compared to the overall population (n = 125, or 25%). CKD was present in 20 (33.3%) AF patients versus 90 (18%) in the full cohort, and a prior history of stroke was noted in 15 (25%) AF patients, compared to 75 (15%) in the overall group. Although the gender distribution in AF cases (n = 36 males, or 60%) mirrored the overall cohort, a Chi-square test showed no statistically significant difference in AF prevalence between males and females (p = 0.99), indicating that gender was not a significant determinant in this study. Conclusion This study reports a 12% prevalence of AF among elderly inpatients, with a statistically significant peak in the 70-79 age group. Key modifiable risk factors - hypertension, diabetes, obesity, and CAD - were more common in patients with AF, highlighting the interplay of metabolic and cardiovascular contributors in its pathogenesis. While routine ECG screening in high-risk subgroups appears feasible in tertiary care settings, the cross-sectional design and potential selection bias limit broader applicability. These findings underscore the need for longitudinal, community-based studies to confirm age-specific trends and develop scalable AF screening strategies for elderly populations.

Patterns and Outcomes of Endovascular Thrombectomy Among Patients Over Age 80 Years: The Florida Stroke Registry

BACKGROUND

Older patients (≥80 years of age) were under-represented in randomized trials of endovascular thrombectomy (EVT). In the large Florida Stroke Registry (FSR), we aimed to evaluate the characteristics of the older patients receiving EVT in routine practice and to study the impact of age on EVT outcomes.

METHODS AND RESULTS

Data prospectively collected from Get With The Guidelines-Stroke hospitals in the FSR from January 2010 to December 2022 were analyzed for EVT outcomes. Among patients receiving EVT, characteristics associated with age ≥80 years and the impact of age on EVT outcomes of discharge directly to home or acute inpatient rehabilitation, and independent ambulation at discharge were studied using multivariable analysis with generalized estimating equations. Among 20 004 EVT FSR patients (mean age 71±15, 50% women), 29% were ≥80 years of age. In multivariable analysis, older patients with EVT had a similar rate of symptomatic intracerebral hemorrhage and in hospital mortality but were less likely to achieve independent ambulation at discharge (odds ratio [OR]: 0.44 [95% CI, 0.39-0.49]), be discharged directly home (OR: 0.46 [95% CI, 0.42-0.51]) or to a rehabilitation facility (OR: 0.68 [95% CI, 0.61-0.75]).

CONCLUSIONS

In routine practice, close to 30% of EVT treated stroke patients are over the age of 80 years. Our data shows that EVT is safe in this population; however, age remains an independent predictor of poor discharge outcomes post EVT.

Stroke incidence in heart failure and atrial fibrillation: a population-based retrospective cohort study

BACKGROUND

Heart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following an HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores.

AIM

To examine stroke incidence in people with HF and AF compared with AF alone, considering the competing risk of death.

DESIGN AND SETTING

A population-based retrospective cohort study in English primary care, linked to secondary care Hospital Episode Statistics data.

METHOD

In total, 2 381 941 people aged ≥45 years were identified in the Clinical Practice Research Datalink from 2000 to 2018. HF and AF were included as time-varying covariates; 69 575 had HF and AF, 141 562 had AF alone, and 91 852 had HF alone. Hazard ratios (HRs) for first stroke are reported using the Cox model and the Fine-Gray model.

RESULTS

Over median follow-up of 6.62 years, 93 665 people (3.9%) had a first stroke and 314 042 (13.2%) died. Over half (51.3%) of those with HF, with or without AF, died. In the fully adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95% confidence interval [CI] = 2.38 to 2.48), followed by HF and AF (HR 2.20, 95% CI = 2.14 to 2.26). The cumulative incidence function of stroke was also highest among those with AF only once accounting for the competing risk of all-cause mortality. In a Fine-Gray model, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95% CI = 2.33 to 2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95% CI = 1.44 to 1.53).

CONCLUSION

HF is an aetiological risk factor for stroke, yet its prognostic significance is reduced by the high incidence of death. Use of the CHA2DS2-VASc score may overestimate stroke incidence in some people with HF, particularly those with a poor prognosis.

External validation of a machine learning-based classification algorithm for ambulatory heart rhythm diagnostics in pericardioversion atrial fibrillation patients using smartphone photoplethysmography: the SMARTBEATS-ALGO study

AIMS

The aim of this study was to perform an external validation of an automatic machine learning (ML) algorithm for heart rhythm diagnostics using smartphone photoplethysmography (PPG) recorded by patients with atrial fibrillation (AF) and atrial flutter (AFL) pericardioversion in an unsupervised ambulatory setting.

METHODS AND RESULTS

Patients undergoing cardioversion for AF or AFL performed 1-min heart rhythm recordings pericardioversion at least twice daily for 4-6 weeks, using an iPhone 7 smartphone running a PPG application (CORAI Heart Monitor) simultaneously with a single-lead electrocardiogram (ECG) recording (KardiaMobile). The algorithm uses support vector machines to classify heart rhythm from smartphone-PPG. The algorithm was trained on PPG recordings made by patients in a separate cardioversion cohort. Photoplethysmography recordings in the external validation cohort were analysed by the algorithm. Diagnostic performance was calculated by comparing the heart rhythm classification output to the diagnosis from the simultaneous ECG recordings (gold standard). In total, 460 patients performed 34 097 simultaneous PPG and ECG recordings, divided into 180 patients with 16 092 recordings in the training cohort and 280 patients with 18 005 recordings in the external validation cohort. Algorithmic classification of the PPG recordings in the external validation cohort diagnosed AF with sensitivity, specificity, and accuracy of 99.7%, 99.7% and 99.7%, respectively, and AF/AFL with sensitivity, specificity, and accuracy of 99.3%, 99.1% and 99.2%, respectively.

CONCLUSION

A machine learning-based algorithm demonstrated excellent performance in diagnosing atrial fibrillation and atrial flutter from smartphone-PPG recordings in an unsupervised ambulatory setting, minimizing the need for manual review and ECG verification, in elderly cardioversion populations.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT04300270.

Clinical management after surgical left atrial appendage exclusion

BACKGROUND

Surgical left atrial appendage (LAA) closure is an increasingly utilized approach to mitigate the risk of cardioembolic stroke in patients with atrial fibrillation (AF). Consensus is lacking regarding optimal stroke prevention management after surgical LAA management.

OBJECTIVE

To elucidate real world clinical management of anticoagulation in patients undergoing surgical LAA management.

METHODS

Over a 7-year period at a single center, 458 participants carried a diagnosis of AF and underwent surgical exclusion of their LAA during concomitant cardiac surgery. Follow-up was catalogued via retrospective chart review; median follow-up was 2 years. Successful LAA ligation was defined as maximal stump depth < 1.0 cm by transesophageal echocardiography (TEE) without distal leak.

RESULTS

Among 458 patients, 299 were discharged on OAC (142 DOAC and 157 warfarin). Of these, 31% (94/299) had a follow-up TEE. Among those without a TEE, 32% (65/205) were taken off OAC; among those who underwent TEE, 59% (55/94) were taken off OAC. Using a logistic regression model, there was no relationship between age, sex, CHA2DS2-VASc score, or creatinine and the probability of coming off of OAC. Among the 94 patients discharged on OAC who had a follow-up TEE:10 were unable to assess adequacy of closure, 69 were successful, and 15 showed unsuccessful closure. In the group with imaging confirmed successful exclusion of their LAA, 67% (46/69) were taken off their oral anticoagulation, with cessation occurring after the TEE in 93% (43/46) of those patients.

CONCLUSION

Clinical management after surgical LAA management, particularly with regard to LAA imaging and OAC continuation, is highly heterogeneous.

Systolic Blood Pressure Modifies the Effect of Endovascular Thrombectomy in Acute Ischemic Stroke: A Mediation Analysis

BACKGROUND

Systolic blood pressure (BP) is a key factor in the outcomes of patients with acute ischemic stroke (AIS) receiving endovascular thrombectomy (EVT). However, the factors that mediate the association between BP and clinical outcome are unclear.

METHODS

Consecutive patients with AIS in the anterior circulation underwent continuous BP monitoring for 24 hours. The 3-month modified Rankin scale (mRS) score was defined as the clinical functional outcome. The systolic BPI indices (BPIs) were successive variation, standard deviation, variability independent of mean BP (VIM), and 24-hour mean BP. Regression analysis was used to assess the correlation between different BPIs and functional outcomes, whereas mediation analysis was employed to assess the potential mediating effects of baseline risk factors through BP on functional outcomes.

RESULTS

A total of 140 of 292 patients (47.9%) achieved functional independence, and 87 (29.8%) experienced hemorrhagic transformation (HT). A history of stroke or hypertension and NIHSS score at onset were associated with SD and VIM (P < 0.05). BP variation (BPV) was still strongly associated with functional outcomes after adjustment for different risk factors. Mediation analysis revealed that stroke affected functional outcomes by affecting BPV, while the hypertension history affected functional prognosis by impacting the 24-hour mean BP and BPV. In addition, higher National Institute of Health stroke scale (NIHSS) scores were associated with increased BPV, whereas increased BPV was correlated with a greater proportion of unfavorable outcomes.

CONCLUSIONS

To our knowledge, this study is the first to explore the mediating effects of different BPIs on the relationships between risk factors and functional outcomes and may provide new insights and potential mechanisms for improving AIS prognosis.

Predictors of left atrial thrombi for subsequent thromboembolisms: Risk factors derived from echocardiography

BACKGROUND

Evidence regarding the management of left atrial thrombi (LATs) is limited.

OBJECTIVES

We aimed to investigate factors associated with subsequent thromboembolism in patients with LATs and explored potential management approaches.

METHODS

This multicenter retrospective study consecutively enrolled patients who underwent morphological assessment of LAT using echocardiography. We evaluated associations between clinical and echocardiographic variables and the occurrence of symptomatic thromboembolism.

RESULTS

Two hundred six patients from 15 centers were enrolled. During follow-up period after echocardiographic diagnosis (651 days; interquartile range 174-1316 days), 19 patients (9.2%) developed thromboembolism. Cox regression analysis identified 3 independent predictors of thromboembolism: LAT maximum length > 20 mm (hazard ratio [HR] 2.63; 95% confidence interval [CI] 1.03-6.68; P=.043), reduced left ventricular ejection fraction (≤40%) (HR 2.95; 95% CI 1.14-7.63; P=.026), and thrombus mobility (HR 3.40; 95% CI 1.27-9.11; P=.015). Patients with ≥2 of these factors (52 [25.2%]) were categorized as the high-risk group, while those with <2 factors (154 [74.8%]) formed the low-risk group. Patients in the high-risk group had a higher incidence of thromboembolism (12 [23.1%] vs 7 [4.5%]; P<.001), despite a higher proportion undergoing urgent surgical thrombectomy (UST; 9 [17.3%] vs 9 [5.8%]; P=.025) compared with the low-risk group. In high-risk patients, UST was associated with a significantly lower rate of adverse outcomes, including all-cause mortality, heart failure hospitalizations, major bleeding, and thromboembolisms, at 90 days (0% vs 35.6%; log-rank, P=.048).

CONCLUSION

In patients with LATs, large thrombus size, reduced left ventricular ejection fraction, and thrombus mobility were associated with subsequent thromboembolism. UST was associated with fewer adverse clinical outcomes in patients with ≥2 risk factors.

A pictorial neuroradiological review of brain vascular abnormalities in patients with kidney disease

A well-known link exists between cerebrovascular disease and chronic kidney disease. Cerebrovascular pathology in patients with kidney disease may be asymptomatic and occasionally discovered through neuroradiological examinations or it may present with neurological symptoms. Covert cerebrovascular lesions represent the earliest injuries associated with chronic kidney disease and primarily result from small vessel damage. These conditions often manifest incidentally, appearing as structural changes (such as lacunes, white matter lesions, enlarged perivascular spaces, cerebral microbleeds, and atrophy) as well as microstructural and hemodynamic alterations, detectable through routine and advanced functional MRIs. These alterations may be associated with a higher risk of stroke, cognitive decline, and dementia. Patients with end-stage renal disease or chronic kidney disease undergoing dialysis may be at increased risk of large-artery atherosclerosis, cardio-embolism, or small-vessel occlusion, and they may experience symptomatic acute ischemic strokes as rare complications. Currently, there are no established guidelines or standardized diagnostic protocols for preventing cerebrovascular disease in patients with kidney disease. Clinical and radiological studies are warranted to evaluate the usefulness of incorporating neuroimaging into the diagnostic work-up of these patients in order to improve prognosis and reduce diagnostic delays.

Severity, Outcomes, and their Secular Changes in 33,870 Ischemic Stroke Patients with Atrial Fibrillation in a Hospital-Based Registry: Japan Stroke Data Bank

AIM

Severity, functional outcomes, and their secular changes in acute atrial fibrillation (AF)-associated stroke patients were determined.

METHODS

Acute ischemic stroke patients with AF in a hospital-based, multicenter, prospective registry from January-2000 through December-2020, were compared with those without AF. The co-primary outcomes were the initial severity assessed by the NIH Stroke Scale (NIHSS) score and favorable outcome assessed by the modified Rankin Scale scores 0-2 at hospital discharge.

RESULTS

Of the 142,351 patients studied, 33,870 had AF. AF patients had higher NIHSS scores (median 9 vs. 3, adjusted coefficient 5.468, 95% CI 5.354-5.582) than non-AF patients. Favorable outcome was less common in AF patients than in non-AF patients in the unadjusted analysis (48.4% vs. 70.4%), but it was more common with adjustment for the NIHSS score and other factors (adjusted OR 1.110, 95% CI 1.061-1.161). In AF patients, the NIHSS score decreased throughout the 21-year period (adjusted coefficient -0.088, 95% CI -0.115 - -0.061 per year), and the reduction was steeper than in non-AF patients (P＜0.001). In AF patients, favorable outcome became more common over the period (adjusted OR 1.018, 95% CI 1.010-1.026), and the increase was steeper than in non-AF patients (P＜0.001); the increase was no longer significant after further adjustment by reperfusion therapy.

CONCLUSIONS

Initial stroke severity became milder and functional outcomes improved in AF patients over the 21-year period. These secular changes were steeper than in non-AF patients, suggesting that AF-associated stroke seemed to reap more benefit of recent development of stroke care than stroke without AF.

Effects of plant extracts and derivatives on cardiac K+, Nav, and Cav channels: a review

Natural products (NPs) are endless sources of compounds for fighting against several pathologies. Many dysfunctions, including cardiovascular disorders, such as cardiac arrhythmias have their modes of action regulation of the concentration of electrolytes inside and outside the cell targeting ion channels. Here, we highlight plant extracts and secondary metabolites' effects on the treatment of related cardiac pathologies on hERG, Nav, and Cav of cardiomyocytes. The natural product's pharmacology of expressed receptors like alpha-adrenergic receptors causes an influx of Ca2+ ions through receptor-operated Ca2+ ion channels. We also examine the NPs associated with cardiac contractions such as myocardial contractility by reducing the L-type calcium current and decreasing the intracellular calcium transient, inhibiting the K+ induced contractions, decreasing amplitude of myocyte shortening and showed negative ionotropic and chronotropic effects due to decreasing cytosolic Ca2+. We examine whether the NPs block potassium channels, particular the hERG channel and regulatory effects on Nav1.7.

Oxygen-ozone therapy for myocardial ischemic stroke and cardiovascular disorders

Cardiovascular diseases (CVDs) represent a major concern for human health worldwide. Emergencies in this field include wide repertories of studies dealing primarily with CVD prevention. In addition to dietary habits and lifestyles, medical knowledge is fully needed to improve public educational programs toward cardiovascular risk factors and to enrich the endowment of pharmaceutical options and therapies to address CVDs, particularly for ischemic damage due to an impairment in the endothelial-myocardial relationship. Because ozone is a stimulator of the endothelial nitric oxide synthase/nitric oxide pathway, ozone therapy has been widely demonstrated to have the ability to counteract endothelial-cardiac disorders, providing a novel straightforward opportunity to reduce the impact of CVDs, including atrial fibrillation. In this review, we attempt to establish a state-of-the-art method for the use of ozone in CVD, suggesting that future remarks be addressed to provide fundamental insights into this issue. The purpose of this study was to highlight the role of ozone in the adjunctive medical treatment of cardiovascular pathologies such as acute myocardial infarction due to ischemic disorders.

Atrial fibrillation and short-term outcomes after cancer-related ischemic stroke

INTRODUCTION

Atrial fibrillation (AF) and cancer are each associated with worse outcomes in patients with acute ischemic stroke (AIS). Few studies have evaluated the impact of AF on outcomes of cancer-related stroke.

PATIENTS AND METHODS

We conducted a retrospective cross-sectional study using the 2016-2019 National Inpatient Sample, identifying all hospitalizations with diagnosis codes for cancer and AIS. The primary exposure was a diagnosis of AF. The primary outcome was in-hospital mortality. The secondary outcomes were length-of-stay and discharge to non-home locations. We used multiple logistic and linear regression models, adjusted for age, gender, race-ethnicity, and the Charlson Comorbidity Index, to examine the association between AF and study outcomes.

RESULTS

Among 150,200 hospitalizations with diagnoses of cancer and AIS (mean age 72 years, 53% male), 40,084 (26.7%) included comorbid AF. Compared to hospitalizations without AF, hospitalizations with AF had higher rates of in-hospital mortality (14.8% [95% CI, 14.0%-15.6%] vs 12.1% [95% CI, 11.6%-12.5%]) and non-home discharge disposition (83.5% [95% CI, 82.7%-84.3%] vs 75.1% [95% CI, 74.5%-75.7%]) as well as longer mean length-of-stay (8.4 days [95% CI, 8.2-8.6 days] vs 8.2 days [95% CI, 8.0-8.3 days]). In multivariable analyses, AF remained independently associated with higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.34; 95% CI, 1.24-1.46), non-home discharge disposition (aOR, 1.32; 95% CI, 1.23-1.42), and longer length-of-stay (adjusted mean difference, 13.7%; 95% CI, 10.9%-16.7%).

DISCUSSION AND CONCLUSION

In cancer-related AIS, comorbid AF is associated with worse short-term outcomes, including higher odds for in-hospital mortality, poor discharge disposition, and longer hospital stays.

Arterial Stiffness and Markers of Atrial Myopathy

BACKGROUND

Arterial stiffness, measured using carotid-femoral pulse wave velocity (c-f PWV) and heart rate-corrected augmentation index (Aix75), is associated with cardiovascular disease, and in some studies incident atrial fibrillation (AF). In this cross-sectional study, we aimed to investigate whether arterial stiffness is associated with markers of atrial myopathy, which refers to structural and electrical changes in the atria that indicate increased AF risk.

METHODS

We included 1050 participants (age 57 ± 4.3 years, 47% males) from the population-based Swedish CArdioPulmonary bioImage Study with c-f PWV and Aix75 data. A random subsample (n = 331) underwent echocardiography. The association between arterial stiffness and atrial myopathy markers was studied using multivariable-adjusted negative binomial regression models for premature atrial complexes (PACs) on 24 h ECG, linear regression for P-wave duration and left atrial volume index (LAVi), and logistic regression models for abnormal P-wave terminal force in V1 (PWTFV1) and P-wave axis.

RESULTS

Arterial stiffness was associated with fewer PACs: incidence rate ratio (IRR) 0.45 (95% CI: 0.31 to 0.65, p < 0.001) per 1 m/s increase in c-f PWV and IRR 0.66 (95% CI: 0.49 to 0.89, p = 0.01) per % increase in Aix75. There was no association between arterial stiffness and P-wave indices, OR 1.09 (95% CI: 0.85 to 1.40), p = 0.50 for abnormal PWTFV1, and β -0.003 (-0.10 to 0.09), p = 0.95 for P-wave duration, both per 1 m/s increase in c-f PWV.

CONCLUSIONS

Arterial stiffness, measured as either c-f PWV or Aix75, was associated with fewer PACs, whereas no association was found with P-wave indices. The association between arterial stiffness and atrial myopathy is complex and merits further study.

Epidemiology of Atrial Fibrillation in Heart Failure

Atrial fibrillation and heart failure are common cardiovascular conditions that are intricately linked to each other, with a significant impact on morbidity, mortality, and quality of life. These two conditions can create a vicious pathophysiologic milieu associated with neurohormonal changes, elevated cardiac filling pressure, myocardial remodeling, systemic and regional inflammation, fibrosis, and diminished myocardial contractility. It is well known that cardiomyopathy can cause atrial fibrillation and vice-versa, but often it is difficult to sort which came first. Unfortunately, the disease burden will only continue to rise with an aging population, and understanding the epidemiology of the disease and the interplay of these two conditions is vital to improved patient care.

Prevalence and Risk Factors of Stroke in Patients with Nonvalvular Atrial Fibrillation: A Case-Control Study

OBJECTIVE

To analyze the prevalence and influencing factors of stroke in patients with nonvalvular atrial fibrillation (SIPWNVAF), and to provide a reference basis for the prevention and control of stroke.

METHODS

Data were obtained from the China National Stroke Screening Survey. From January 2016 to December 2023, a total of 15,471 permanent residents aged ≥40 years in Yinchuan were screened. Patients with nonvalvular atrial fibrillation who had their first stroke were selected as the stroke group (86 patients), and patients with nonvalvular atrial fibrillation who had never had a stroke as the control group (477 patients).

RESULTS

In 563 residents, the crude prevalence of SIPWNVAF was 15.28%, and the standardized prevalence was 9.33%. The multivariable logistic regression analysis revealed that age (odds ratio [OR]: 1.42; 95% confidence interval [CI]: 1.17-1.71), smoking (OR: 2.10; 95% CI: 1.46-3.01), drinking (OR: 2.00; 95% CI: 1.28-3.13), lack of exercise (OR: 2.18; 95% CI: 1.18-4.03), family history of stroke (OR: 4.39; 95% CI: 1.82-10.57), hypertension (OR: 1.94; 95% CI: 1.03-3.63), diabetes (OR: 3.10; 95% CI: 1.37-7.05), dyslipidemia (OR: 2.15; 95% CI: 1.16-3.99), homocysteine ≥15 μmol/L (OR: 2.13; 95% CI: 1.14-3.97), and carotid atherosclerosis (OR: 2.86; 95% CI: 1.53-5.37) were independent risk factors, but educational level (OR: 0.31; 95% CI: 0.17-0.58) was a protective factor for SIPWNVAF.

CONCLUSIONS

The stroke group is significantly more burdened by other independent common risk factors for stroke.

Morphing the left atrium geometry: The role of the pulmonary veins on flow patterns and thrombus formation

BACKGROUND

Despite the significant advances made in the field of computational fluid dynamics (CFD) to simulate the left atrium (LA) in atrial fibrillation (AF) conditions, the connection between atrial structure, flow dynamics, and blood stagnation in the left atrial appendage (LAA) remains unclear. Deepening our understanding of this relationship would have important clinical implications, as the thrombi formed within the LAA are one of the main causes of stroke.

AIM

To highlight and better understand the fundamental role of the PV orientation in forming atrial flow patterns and systematically quantifying its effect on blood stasis within the LAA.

METHODS

Two patients with opposite atrial flow patterns were selected for the study. The atria were segmented and subsequently morphed to modify the pulmonary vein (PV) orientations in a highly controlled manner. CFD analysis were performed using a kinematic model able to reproduce AF conditions. Results were projected into the universal left atrial appendage coordinate (ULAAC) system to enhance data visualization and comparison.

RESULTS

The position of the main atrial vortex can be modified by controlled changes in the PV orientations, which to the best of our knowledge was not demonstrated before. This finding may have important clinical implications, as the behavior and position of the main atrial vortex is crucial to define the LA flow patterns and thus the LAA washing, making possible to assess the stroke risk for a particular patient.

National Trends in Mortality Due to Ischemic Stroke Among Older Adults With Atrial Fibrillation in the USA, 1999-2020

BACKGROUND

Atrial fibrillation (AF) is a significant contributor to ischemic stroke risk and mortality, particularly in aging populations. This study examines mortality trends from ischemic stroke secondary to AF in the U.S. from 1999 to 2020, focusing on demographic and regional disparities.

METHODS

Using data from the CDC WONDER database, this cross-sectional analysis included individuals aged ≥ 65 years with death certificates indicating ischemic stroke (ICD I63) and AF (ICD I48) as contributing causes. Age-adjusted mortality rates (AAMR) were calculated, and temporal trends were analyzed using join-point regression to estimate annual percentage changes (APC). Data were stratified by age, sex, race/ethnicity, urbanization, and geographic regions.

RESULTS

From 1999 to 2020, ischemic stroke with AF caused 62,443 deaths (AAMR: 6.75/100,000; 95% CI: 6.70-6.80). Mortality rates increased significantly after 2010, peaking between 2014 and 2017 (APC: 31.3 for females, 28.1 for males). Older adults (≥ 85 years) exhibited the highest AAMR (43.2/100,000; 95% CI: 41.6-44.8). Nonmetropolitan areas consistently showed higher mortality compared to metropolitan regions. Demographic disparities were evident, with higher AAMRs in females, Whites, and the Western U.S., though Hispanics had the sharpest APC increase during 2014-2017.

CONCLUSION

Mortality rates from ischemic stroke with AF are rising in older adults, with significant demographic and regional disparities. The findings underscore the need for targeted public health strategies to mitigate AF-related stroke risks and improve healthcare equity.

Causal associations between hypertension and abnormal brain cortical structures: Insights from a bidirectional Mendelian randomization study

Background

Observational studies suggest that hypertension affects brain cortical structure. However, the potential causal association has yet to be entirely determined. Thus, we aim to assess the causality between hypertension and abnormal cortical structure.

Methods

We conducted a bidirectional Mendelian randomization (MR) study to estimate their relationship. Genome-wide association study summary statistics of hypertension (n = 484,598) and brain cortical (surface area and thickness) (n = 51,665) were derived from publicly available databases. Sensitivity analyses were applied to ensure the robustness of the results.

Results

The study showed that hypertension was associated with a decline in total brain cortical thickness [β, -0.0308 mm; 95 % confidence interval (CI), -0.0610 to -0.0007; p = 0.045] and the insula thickness [β, -0.0415 mm; 95 % CI, -0.0772 to -0.0057; p = 0.023]. A null association was observed between hypertension and other brain regions. In the reverse MR analysis, the total cortical surface area (per 1 SD increase) significantly decreased the incidence of hypertension [odds ratio (OR), 0.976; 95 % CI, 0.963 to 0.990; p = 5.15E-04]. The caudal anterior cingulate cortex thickness (per 1 SD increase) was significantly associated with an increased risk of hypertension [OR, 1.057; 95 % CI, 1.034 to 1.082; p = 1.08E-06]. Moreover, we found several nominally associated gyri, including cuneus, isthmus cingulate, middle temporal, para hippocampal, posterior cingulate, superior temporal, and medial orbitofrontal, influence the incidence of hypertension.

Conclusion

Our study showed causal relationships between hypertension and changes in specific brain cortical, providing new evidence for the heart-brain axis theory.

Patient Characteristics and Real-World Treatment of Very Elderly Patients with Nonvalvular Atrial Fibrillation in Japan: An Administrative Claims Database Study

INTRODUCTION

Very elderly patients with nonvalvular atrial fibrillation (NVAF) are at high risk for both ischemic and hemorrhagic events. This study aimed to understand the characteristics and real-world treatment of very elderly patients with NVAF in Japan.

METHODS

We conducted a retrospective analysis of electronic health records and claims data from acute care hospitals for very elderly patients with NVAF with medical records available on or after their 80th birthday. The outcomes of interest were (1) characteristics of very elderly patients and (2) patterns of anticoagulation and impact of clinical condition on anticoagulation.

RESULTS

Of 1,278,404 patients with newly diagnosed atrial fibrillation (AF), 443,820 were eligible for the analysis. Mean ± standard deviation age was 84.5 ± 5.5 years, CHADS2 score was 2.4 ± 1.0, and CHA2DS2-VASc score was 4.3 ± 1.3. Among patients diagnosed with NVAF before age 80 years, 39.1% were not receiving anticoagulation therapy, while among those diagnosed with NVAF at age ≥ 90 years, 46.1% were not prescribed any anticoagulant. Patients diagnosed with NVAF before 80 years of age tended to stop anticoagulation therapy, especially those receiving warfarin, upon reaching 80 years of age. Among those who were newly diagnosed with NVAF after 80 years, most received reduced doses of direct oral anticoagulants (DOACs).

CONCLUSIONS

A significant proportion of very elderly patients with NVAF in Japan were diagnosed with NVAF after the age of 80 years and were not receiving anticoagulation therapy, particularly with increasing age. Furthermore, warfarin use declined with age, and patients on DOACs frequently received reduced doses.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The efficiency of endocardial suture occlusion of the left atrial appendage at a single institution: MICs vs. sternotomy

BACKGROUND

Most thrombi originate from the left atrial appendage (LAA), preventing thromboembolic stroke is an important aspect of stroke prevention. Previous studies have found that LAA closure is beneficial for preventing thrombosis. Currently, surgical procedures can achieve LAA closure by closing the endocardium or epicardium. LAA endocardial suture technique is performed concomitantly during sternotomy cardiac surgery but can also be performed during right minimally invasive cardiac surgery (MICS).

AIMS

This study aims to evaluate the efficacy of left atrial appendage closure (LAAC) with MICS.

METHODS

A total number of 74 patients who underwent LAAC during valve operation between 2017 and 2021 were retrospectively analyzed in this study. LAA was closed by continuous suture through the endocardium of the left atrium during cardiac surgery. 42 patients performed LAA endocardial suture during MICS, while 32 patients performed with the same LAAC technique during sternotomy. Patients underwent cardiac computed tomography (CT) follow-up after surgery to verify the completeness of the LAAC. The heart structure and function were recorded by echocardiography Transthoracic echocardiography (TTE), and the heart rhythm was recorded by electrocardiogram.

RESULTS

The LAA closure procedure was successful in 26 cases (81%) in the sternotomy group and 20 cases (48%) in the right minimally invasive group. Residual shunting (failed LAA closure) was more common in the right minimally invasive group (p = 0.003), and no correlation was found between residual shunting and left atrial (LA), left ventricular end-diastolic diameter (LVDD), and left ventricular ejection fraction (LVEF). The incidence of leaks was not associated with mitral valve replacement or valvuloplasty.

CONCLUSIONS

Compared to sternotomy, residual shunting after MICS was more common. CT imaging analysis of 22 patients with failed closure in the MICS group showed that residual shunting was mainly concentrated on margins of the suture (anterior superior and posterior inferior) (86%), with a middle area accounting for 3 (14%). Based on this finding, reinforcing the suture margins may significantly reduce the incidence of incomplete closure.

THE CLINICAL TRIAL NUMBER

KY-2023-001.

Impact of insurance coverage for non-vitamin K antagonist oral anticoagulants on quality of care and care disparities in patients hospitalised with atrial fibrillation in tertiary hospitals in China: interrupted time series analysis

OBJECTIVE

To examine recent patterns regarding oral anticoagulant (OAC) use among patients hospitalised with atrial fibrillation (AF) and quantify the impact of insurance coverage for non-vitamin K oral anticoagulants (NOACs) on quality of care and care inequality regarding OAC use among hospitalised patients with AF.

DESIGN

Interrupted time series analysis.

SETTING

Hospitals in China.

PARTICIPANTS

A total of 36 393 patients hospitalised with non-valvular AF were involved between 2015 and 2019 across China.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcome was the impact of insurance coverage for NOACs on quality of care regarding OAC prescription using interrupted time series analysis with segmented regression models.

RESULTS

OAC prescription rate during hospitalisation was 52.1% (31.3% for warfarin and 20.8% for NOACs) in patients with high-risk AF and 66.3% (29.8% for warfarin and 36.5% for NOACs) in low-risk patients. Insurance coverage for NOACs was associated with an immediate 10.9% (95% CI 7.6% to 14.3%) increase in NOAC prescription and a 0.33% (95% CI 0.08% to 0.58%) increase in the slope of the secular trend of NOAC prescription among all the patients. Disparities in NOAC prescription among hospitals decreased from 18.9 before the insurance coverage for NOACs to 3.4 after that. Similar results were found in patients with high risk of stroke.

CONCLUSION

A large gap exists between clinical practice and guideline recommendations regarding OAC prescription among patients hospitalised with AF in China. Insurance coverage may be an effective healthcare strategy to improve quality of care and reduce care disparities regarding OAC prescription among patients with AF.

TRIAL REGISTRATION NUMBER

NCT02309398.