Efficacy and Safety of Different Dosing Regimens of Rivaroxaban in Patients With Atrial Fibrillation for Stroke Prevention: A Systematic Review and Meta-Analysis

Atrial fibrillation (AF) poses a substantial risk of stroke, necessitating effective anticoagulation therapy. This systematic review and meta-analysis (SRMA) evaluates the efficacy and safety of different dosing regimens of rivaroxaban in patients with AF. A comprehensive search of relevant databases, focusing on studies published from 2017 onward, was conducted. Inclusion criteria comprised randomized controlled trials (RCTs) and observational studies comparing standard and reduced dosing of rivaroxaban in AF. Data extraction and risk of bias (ROB) assessment were performed, and a meta-analysis was conducted for relevant outcomes. A total of 21 studies fulfilled the inclusion criteria. Standard dosing demonstrates a slightly lower risk of composite effectiveness outcomes and safety outcomes (HR: 0.79, 95% CI: 0.66-0.94, P=0.01) compared to reduced dosing (HR: 0.83, 95% CI: 0.71-0.97, P=0.02). Notable differences in major bleeding, gastrointestinal bleeding (GIB), and intracranial bleeding favored standard dosing. Hemorrhagic stroke and all-cause stroke rates differed significantly, with standard dosing showing a more favorable profile for ischemic stroke prevention. This study highlights the pivotal role of personalized anticoagulation therapy in AF. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines. The study bridges evidence from clinical trials to real-world practice, offering insights into the evolving landscape of AF management.

Risk factors modification in atrial fibrillation: a brief review

INTRODUCTION

Atrial fibrillation (AF) is a supraventricular arrhythmia characterized by fibrillatory waves in the atria with an irregular ventricular rhythm. It is the most common arrhythmia treated in clinical practice. AF is associated with approximately five-fold increase in risk of cerebrovascular accident (stroke) and two-fold increase in cognitive dysfunction and all-cause mortality.

AREAS COVERED

Multiple risk factors have been identified for development of AF including age, hypertension, diabetes, and obesity. Primary and secondary prevention strategies aimed at reducing the incidence of AF can have a dramatic clinical and economic impact. Multiple studies have shown that lifestyle interventions can reduce predisposing factors, reverse the pathophysiology behind AF, and decrease disease burden. In this brief review we aim at exploring the current state of knowledge regarding risk factor modifications that decrease incidence and prevalence of AF.

EXPERT OPINION

This is an evolving field of research and further studies to elucidate the magnitude of effect of these interventions as well as the pathophysiological mechanisms driving these effects are underway.

Surgical ablation of long-standing persistent atrial fibrillation: 1-year outcomes from the CArdioSurgEry Atrial Fibrillation (CASE-AF) registry

OBJECTIVES

The CArdioSurgEry Atrial Fibrillation (CASE-AF) registry is a prospective, multicentre study for collecting and analysing real-world data of surgical atrial fibrillation (AF) treatment. This study aimed to evaluate outcomes of surgery for long-standing persistent AF at 1 year.

METHODS

In total, 17 centres consecutively include all eligible patients with continuous AF lasting for ≥1 year. Exclusion criteria are missing informed consent or age <18 years. For patient-reported outcomes measures, the European Heart Rhythm Association score was used. No presence of AF (based on ECG findings including Holter ECG and/or implanted devices), no re-ablation, no further cardioversion and no rehospitalization due to AF after a 3-month blanking period defined no AF recurrence at 1 year.

RESULTS

From January 2017 to January 2020, a total of 1115 patients were enrolled in CASE-AF. Of them, 202 patients (mean age 69.7 ± 7.8 years, 27.2% female) underwent surgical ablation of long-standing persistent AF (study cohort), mostly accompanied by left atrial appendage closure (n = 180 [89%], resection n = 75 [42%]) and predominantly performed as concomitant (n = 174 [86%]) and left atrial only procedure (n = 144 [71%]). Early mortality (30 days) was 2.0% and morbidity was low. At follow-up (median 14.4 months, interquartile range, 12.7-17.6 months, 100% complete), 106 patients (56%) had no AF recurrence and 93% of them were asymptomatic. AF recurrence was accompanied by AF-related rehospitalization (n = 12, P = 0.003), direct current shock cardioversion (n = 23, P < 0.001), AF ablation (n = 7, P = 0.003) and stroke (n = 3, P = 0.059). Multivariable analysis identified cryoablation, predominantly performed endocardially including additional left atrial (74%) and biatrial (42%) lesions, as a significant factor for freedom from AF recurrence (odds ratio 2.7, 95% confidence interval 1.07-6.79, P = 0.035).

CONCLUSIONS

According to CASE-AF, surgical ablation of long-standing persistent AF is most effective when concomitantly performed using endocardial cryoablation. Ongoing follow-up allows further elucidation of efficacious treatment strategies.

Deep Learning of Electrocardiograms in Sinus Rhythm From US Veterans to Predict Atrial Fibrillation

Importance

Early detection of atrial fibrillation (AF) may help prevent adverse cardiovascular events such as stroke. Deep learning applied to electrocardiograms (ECGs) has been successfully used for early identification of several cardiovascular diseases.

Objective

To determine whether deep learning models applied to outpatient ECGs in sinus rhythm can predict AF in a large and diverse patient population.

Design, Setting, and Participants

This prognostic study was performed on ECGs acquired from January 1, 1987, to December 31, 2022, at 6 US Veterans Affairs (VA) hospital networks and 1 large non-VA academic medical center. Participants included all outpatients with 12-lead ECGs in sinus rhythm.

Main Outcomes and Measures

A convolutional neural network using 12-lead ECGs from 2 US VA hospital networks was trained to predict the presence of AF within 31 days of sinus rhythm ECGs. The model was tested on ECGs held out from training at the 2 VA networks as well as 4 additional VA networks and 1 large non-VA academic medical center.

Results

A total of 907 858 ECGs from patients across 6 VA sites were included in the analysis. These patients had a mean (SD) age of 62.4 (13.5) years, 6.4% were female, and 93.6% were male, with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age, sex category) score of 1.9 (1.6). A total of 0.2% were American Indian or Alaska Native, 2.7% were Asian, 10.7% were Black, 4.6% were Latinx, 0.7% were Native Hawaiian or Other Pacific Islander, 62.4% were White, 0.4% were of other race or ethnicity (which is not broken down into subcategories in the VA data set), and 18.4% were of unknown race or ethnicity. At the non-VA academic medical center (72 483 ECGs), the mean (SD) age was 59.5 (15.4) years and 52.5% were female, with a mean (SD) CHA2DS2-VASc score of 1.6 (1.4). A total of 0.1% were American Indian or Alaska Native, 7.9% were Asian, 9.4% were Black, 2.9% were Latinx, 0.03% were Native Hawaiian or Other Pacific Islander, 74.8% were White, 0.1% were of other race or ethnicity, and 4.7% were of unknown race or ethnicity. A deep learning model predicted the presence of AF within 31 days of a sinus rhythm ECG on held-out test ECGs at VA sites with an area under the receiver operating characteristic curve (AUROC) of 0.86 (95% CI, 0.85-0.86), accuracy of 0.78 (95% CI, 0.77-0.78), and F1 score of 0.30 (95% CI, 0.30-0.31). At the non-VA site, AUROC was 0.93 (95% CI, 0.93-0.94); accuracy, 0.87 (95% CI, 0.86-0.88); and F1 score, 0.46 (95% CI, 0.44-0.48). The model was well calibrated, with a Brier score of 0.02 across all sites. Among individuals deemed high risk by deep learning, the number needed to screen to detect a positive case of AF was 2.47 individuals for a testing sensitivity of 25% and 11.48 for 75%. Model performance was similar in patients who were Black, female, or younger than 65 years or who had CHA2DS2-VASc scores of 2 or greater.

Conclusions and Relevance

Deep learning of outpatient sinus rhythm ECGs predicted AF within 31 days in populations with diverse demographics and comorbidities. Similar models could be used in future AF screening efforts to reduce adverse complications associated with this disease.

Kidney function estimators for drug dose adjustment of direct oral anticoagulants in older adults with atrial fibrillation

Background

The Cockcroft-Gault equation (CrClC-G) is recommended for dose adjustment of direct oral anticoagulant drugs (DOACs) to kidney function. We aimed to assess whether defining DOAC dose appropriateness according to various kidney function estimators changed the associations between dose appropriateness and adverse events in older adults with atrial fibrillation (AF).

Methods

Participants of the Berlin Initiative Study with AF and treated with DOACs were included. We investigated CrClC-G and estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration and European Kidney Function Consortium equations based on creatinine and/or cystatin C. Marginal structural Cox models yielded confounder-adjusted hazard ratios for the risk of mortality, thromboembolism and bleeding associated with dose status.

Results

A total of 224 patients were included in the analysis (median age 87 years). Using CrClC-G, 154 (69%) had an appropriate dose of DOACs, 52 (23%) were underdosed and 18 (8%) were overdosed. During a 39-month median follow-up period, 109 (14.9/100 person-years) participants died, 25 (3.6/100 person-years) experienced thromboembolism and 60 (9.8/100 person-years) experienced bleeding. Dose status was not associated with mortality and thromboembolism, independent of the equation. Underdose status was associated with a lower risk of bleeding with all the equations compared with the appropriate dose group. In participants with discrepancies in dose status using CrClC-G and eGFR equations, the occurrence of endpoints did not differ between participants having an appropriate dose using CrClC-G or eGFR.

Conclusion

In older adults with AF, the association of DOAC dose status with adverse events did not differ when using CrClC-G or eGFR. Our results suggest that eGFR equations are not inferior to CrClC-G within this context.

Improving Automatic Smartwatch Electrocardiogram Diagnosis of Atrial Fibrillation by Identifying Regularity within Irregularity

Smartwatches equipped with automatic atrial fibrillation (AF) detection through electrocardiogram (ECG) recording are increasingly prevalent. We have recently reported the limitations of the Apple Watch (AW) in correctly diagnosing AF. In this study, we aim to apply a data science approach to a large dataset of smartwatch ECGs in order to deliver an improved algorithm. We included 723 patients (579 patients for algorithm development and 144 patients for validation) who underwent ECG recording with an AW and a 12-lead ECG (21% had AF and 24% had no ECG abnormalities). Similar to the existing algorithm, we first screened for AF by detecting irregularities in ventricular intervals. However, as opposed to the existing algorithm, we included all ECGs (not applying quality or heart rate exclusion criteria) but we excluded ECGs in which we identified regular patterns within the irregular rhythms by screening for interval clusters. This "irregularly irregular" approach resulted in a significant improvement in accuracy compared to the existing AW algorithm (sensitivity of 90% versus 83%, specificity of 92% versus 79%, p < 0.01). Identifying regularity within irregular rhythms is an accurate yet inclusive method to detect AF using a smartwatch ECG.

Role of atrial high-rate episodes in stratifying thromboembolic risk: a multiple cut-off diagnostic meta-analysis

Aims

Despite the high prevalence rate of atrial high-rate episodes (AHREs) detected using cardiac implantable electronic devices (CIEDs), clinical guidelines and consensus documents have disagreed on a universal AHRE definition and a temporal cut-off related to subsequent thromboembolic events. This diagnostic test accuracy meta-analysis aims to derive the optimal temporal threshold of clinically significant AHREs from the available literature.

Methods

The PubMed/MEDLINE and EMBASE databases were screened for studies on CIED patients reporting the incidence of thromboembolic events related to at least one AHRE temporal cut-off. A total of 23 studies were included: 19 considering the longest single AHRE and four the AHRE burden, respectively. A random-effect diagnostic test accuracy meta-analysis with multiple cut-offs was performed. Two analyses were performed according to the AHRE temporal cut-off subtype (longest episode vs. cumulative burden).

Results

The analysis on the longest single AHRE indicated 0.07 min as the optimal duration to differentiate AHRE associated or not with thromboembolic events [sensitivity 65.4% (95% CI 48.8%-79.0%), specificity 52.7% (95% CI 46.0%-59.4%), and area under the summary receiver operating characteristic curve (AUC-SROC): 0.62]. The analysis on AHRE burden indicated 1.4 min as the optimal cut-off [sensitivity 58.2% (95% CI 25.6%-85.0%), specificity 57.5% (95% CI 42.0%-71.7%), and AUC-SROC 0.60]. A sensitivity analysis excluding patients with a history of atrial fibrillation and including high-quality studies only yielded similar results.

Conclusion

The presence of AHRE, rather than a specific duration, relates to an increased, albeit low, thromboembolic risk in CIED patients. Any AHRE should constitute an additional element in patient-specific thromboembolic risk assessment.

Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke

The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.

Evolving technology: the TRIFLO tri-leaflet mechanical valve without oral anticoagulation: a potential major innovation in valve surgery

The aortic valve is the most frequently diseased valve and aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries. The diseased native aortic valve can be replaced by either a biological or mechanical valve prosthesis. The main concerns relate to durability, the need for oral anticoagulants and the incidence of complications related to this medication. Experimental, computational and biomolecular blood flow studies have demonstrated that the systolic forward flow but also the reverse flow phase at the end of the systole and leakage during the diastolic phase is mainly responsible for platelet activation and thrombosis. Better design of mechanical prosthetic heart valves must ensure smooth closing during flow deceleration and must eliminate high-shear hinge flow during diastole to prevent life-threatening thrombosis. A novel tri-leaflet valve should combine the favorable hemodynamics and the durability of existing mechanical heart valves and eliminate the less favorable characteristics, including the extremely rapid closing. In this paper, we discuss some issues of current mechanical heart valve prostheses and present a new valve design with the potential for significant innovation in the field. The TRIFLO Heart Valve, is a rigid, three-leaflet central flow heart valve prosthesis consisting of an alloyed titanium housing, and three rigid polymer (PEEK) cusps. This valve has a physiological operating mode. During the forward flow phase, the intraventricular pressure opens the leaflets so that blood can freely flow through with little obstruction, and with the deceleration of the blood flow, the leaflets close early and smoothly, minimizing blood flow regurgitation, blood cell damage, and activation of the coagulation cascade. Pre-clinical studies have shown pretty favorable results and a first-in-man study should start very soon.

Antiplatelet and Anti-Coagulation Therapy for Left-Sided Catheter Ablations: What Is beyond Atrial Fibrillation?

Aim: International guidelines on the use of anti-thrombotic therapies in left-sided ablations other than atrial fibrillation (AF) are lacking. The data regarding antiplatelet or anticoagulation strategies after catheter ablation (CA) procedures mainly derive from AF, whereas for the other arrhythmic substrates, the anti-thrombotic approach remains unclear. This survey aims to explore the current practices regarding antithrombotic management before, during, and after left-sided endocardial ablation, not including atrial fibrillation (AF), in patients without other indications for anti-thrombotic therapy. Material and Methods: Electrophysiologists were asked to answer a questionnaire containing questions on antiplatelet (APT) and anticoagulation therapy for the following left-sided procedures: accessory pathway (AP), atrial (AT), and ventricular tachycardia (VT) with and without structural heart disease (SHD). Results: We obtained 41 answers from 41 centers in 15 countries. For AP, before ablation, only four respondents (9.7%) used antiplatelets and two (4.9%) used anticoagulants. At discharge, APT therapy was prescribed by 22 respondents (53.7%), and oral anticoagulant therapy (OAC) only by one (2.4%). In patients with atrial tachycardia (AT), before ablation, APT prophylaxis was prescribed by only four respondents (9.7%) and OAC by eleven (26.8%). At discharge, APT was recommended by 12 respondents (29.3%) and OAC by 24 (58.5%). For VT without SHD, before CA, only six respondents (14.6%) suggested APT and three (7.3%) suggested OAC prophylaxis. At discharge, APT was recommended by fifteen respondents (36.6%) and OAC by five (12.2%). Regarding VT in SHD, before the procedure, eight respondents (19.5%) prescribed APT and five (12.2%) prescribed OAC prophylaxis. At discharge, the administration of anti-thrombotic therapy depended on the LV ejection fraction for eleven respondents (26.8%), on the procedure time for ten (24.4%), and on the radiofrequency time for four (9.8%), with a cut-off value from 1 to 30 min. Conclusions: Our survey indicates that the management of anti-thrombotic therapy surrounding left-sided endocardial ablation of patients without other indications for anti-thrombotic therapy is highly variable. Further studies are necessary to evaluate the safest approach to these procedures.

Nurse-led multi-component behavioural activation programme to improve health outcomes in patients with atrial fibrillation: a mixed-methods study and feasibility analysis

AIMS

Patients with atrial fibrillation (AF) play passive roles in disease management. This study aimed to examine the feasibility and preliminary effects of an empowerment-based care model, titled 'the nurse-led multi-component behavioural activation (N-MBA) programme', on health-related quality of life, AF knowledge, psychological outcomes, medication adherence, and treatment decision-making in patients with AF.

METHODS AND RESULTS

This mixed-methods study comprised a pilot randomized controlled trial and a qualitative study. Patients with AF who had a moderate-to-high risk of stroke but were not prescribed oral anticoagulants were recruited. Forty participants were recruited and randomized in a 1:1 ratio to receive either the N-MBA programme or standard care. The 13-week programme comprised care components that prepared patients for shared decision-making, an empowerment-based educational module on AF self-care, and continuous support through telephone calls. The programme was feasible, and the overall attendance rate was 82.5%. The participants gave excellent ratings in the satisfaction survey. The N-MBA group showed greater improvements in health-related quality of life (HRQoL) and AF knowledge than the standard care group at the immediate post intervention and 6-month follow-up time points. No significant between-group changes in medication adherence, anxiety, and depression were detected. Participants in the N-MBA group actively raised concerns about AF and its treatment with their attending doctors. The qualitative data were consistent with the quantitative data, indicating that the programme built a comprehensive knowledge base of AF and self-care behaviours.

CONCLUSION

The N-MBA programme is feasible and acceptable to patients with AF. It improved patients' AF knowledge, treatment-related decision-making, and HRQoL.

REGISTRATION

ClinicalTrials.gov NCT03924739.

Changes in Antithrombotic Therapy Prescription in Patients with a Combination of Atrial Fibrillation and Myocardial Infarction in a Specialised Inpatient Department from 2016-2019 and Associations with Prognosis

Background and Objectives: The problem of treating patients with atrial fibrillation and myocardial infarction is relevant. The issue of optimal antithrombotic therapy in these patients has not been definitively resolved. This work analyzes the influence of clinical factors and treatment on the long-term prognosis of patients. Materials and Methods: The research included 360 patients with atrial fibrillation and myocardial infarction during 2016-2019. Results: The factors associated with fatal outcomes were age (hazard ratio (HR): 1.05; 95% confidence interval (CI): 1.03-1.07; p < 0.001); stroke (HR: 1.95; 95% CI: 1.27-3.00; p = 0.0002); glomerular filtration rate (HR: 0.988; 95% CI: 0.978-0.998; p = 0.03); left ventricular ejection fraction (HR: 0.975; 95% CI: 0.957-0.999; p = 0.007); and aspirin (HR: 0.48; 95% CI: 0.31-0.73; p < 0.001). The factors associated with the combined endpoint were chronic kidney disease (HR: 1.46; 95% CI: 1.01-2.10; p = 0.04); HAS-BLED (HR: 1.23; 95% CI: 1.06-1.43; p = 0.007); percutaneous coronary intervention (HR: 0.70; 95% CI: 0.51-0.96; p = 0.03); and aspirin (HR: 0.65; 95% CI: 0.44-0.97; p = 0.03). Conclusions: Double and triple antithrombotic therapy were not associated with outcomes. Aspirin improved the prognosis for survival and the combined endpoint.

Glucagon-like Peptide-1 Receptor Activation Reduces Pulmonary Vein Arrhythmogenesis and Regulates Calcium Homeostasis

Glucagon-like peptide-1 (GLP-1) receptor agonists are associated with reduced atrial fibrillation risk, but the mechanisms underlying this association remain unclear. The GLP-1 receptor agonist directly impacts cardiac Ca2+ homeostasis, which is crucial in pulmonary vein (PV, the initiator of atrial fibrillation) arrhythmogenesis. This study investigated the effects of the GLP-1 receptor agonist on PV electrophysiology and Ca2+ homeostasis and elucidated the potential underlying mechanisms. Conventional microelectrodes and whole-cell patch clamp techniques were employed in rabbit PV tissues and single PV cardiomyocytes before and after GLP-1 (7-36) amide, a GLP-1 receptor agonist. Evaluations were conducted both with and without pretreatment with H89 (10 μM, an inhibitor of protein kinase A, PKA), KN93 (1 μM, an inhibitor of Ca2+/calmodulin-dependent protein kinase II, CaMKII), and KB-R7943 (10 μM, an inhibitor of Na+/Ca2+ exchanger, NCX). Results showed that GLP-1 (7-36) amide (at concentrations of 1, 10, and 100 nM) reduced PV spontaneous activity in a concentration-dependent manner without affecting sinoatrial node electrical activity. In single-cell experiments, GLP-1 (7-36) amide (at 10 nM) reduced L-type Ca2+ current, NCX current, and late Na+ current in PV cardiomyocytes without altering Na+ current. Additionally, GLP-1 (7-36) amide (at 10 nM) increased sarcoplasmic reticulum Ca2+ content in PV cardiomyocytes. Furthermore, the antiarrhythmic effects of GLP-1 (7-36) amide on PV automaticity were diminished when pretreated with H89, KN93, or KB-R7943. This suggests that the GLP-1 receptor agonist may exert its antiarrhythmic potential by regulating PKA, CaMKII, and NCX activity, as well as modulating intracellular Ca2+ homeostasis, thereby reducing PV arrhythmogenesis.

Edoxaban use in the context of dental procedures: analysis from the EMIT-AF/VTE database

INTRODUCTION

Literature reviews support continuing anticoagulation during dental procedures. However, studies often present grouped anticoagulation data, and information on individual anticoagulant management would be helpful to dentists. The Edoxaban Management in Diagnostic and Therapeutic Procedures (EMIT-AF/VTE) programme (NCT02950168; NCT02951039) demonstrated low periprocedural bleeding and thrombotic event rates in patients with atrial fibrillation receiving edoxaban.

AIMS

To report periprocedural edoxaban interruption and clinical events in patients from EMIT-AF/VTE who underwent dental procedures.

METHODS

Dental procedures were categorised by type (cleaning/noncleaning). Edoxaban interruption, bleeding events, and thrombotic events were observed 5 days preprocedure through 29 days postprocedure.

RESULTS

Overall, 196 patients underwent 350 cleaning and/or noncleaning procedures; most patients (171/196 [87.2%]) underwent noncleaning procedures (282/350 [80.6%]), whereas 48/196 (24.5%) underwent 68/350 (19.4%) cleaning procedures. Edoxaban was uninterrupted for most cleanings (53/68 [77.9%]). Preprocedural interruption was common for single and multiple tooth extractions (single, 67/100 [67.0%]; multiple, 16/30 [53.3%]). The only major bleeding occurred after an unrelated cleaning. Minor bleeding occurred in 1/68 (1.5%) cleaning and 4/282 (1.4%) noncleaning procedures. There were no thrombotic events.

CONCLUSIONS

For most cleanings, edoxaban was not interrupted, whereas preprocedural interruption was more common for tooth extractions. Overall, bleeding rates were low, and no thrombotic events occurred.

Mid-term changes in cognitive functions in patients with atrial fibrillation: a longitudinal analysis of the Swiss-AF cohort

Background

Longitudinal association studies of atrial fibrillation (AF) and cognitive functions have shown an unclear role of AF-type and often differ in methodological aspects. We therefore aim to investigate longitudinal changes in cognitive functions in association with AF-type (non-paroxysmal vs. paroxysmal) and comorbidities in the Swiss-AF cohort.

Methods

Seven cognitive measures were administered up to five times between 2014 and 2022. Age-education standardized scores were calculated and association between longitudinal change in scores and baseline AF-type investigated using linear mixed-effects models. Associations between AF-type and time to cognitive drop, an observed score of at least one standard deviation below individual's age-education standardized cognitive scores at baseline, were studied using Cox proportional hazard models of each cognitive test, censoring patients at their last measurement. Models were adjusted for baseline covariates.

Results

2,415 AF patients (mean age 73.2 years; 1,080 paroxysmal, 1,335 non-paroxysmal AF) participated in this Swiss multicenter prospective cohort study. Mean cognitive scores increased longitudinally (median follow-up 3.97 years). Non-paroxysmal AF patients showed smaller longitudinal increases in Digit Symbol Substitution Test (DSST), Cognitive Construct Score (CoCo)and Trail Making Test part B (TMT-B) scores vs. paroxysmal AF patients. Diabetes, history of stroke/TIA and depression were associated with worse performance on all cognitive tests. No differences in time to cognitive drop were observed between AF-types in any cognitive test.

Conclusion

This study indicated preserved cognitive functioning in AF patients, best explained by practice effects. Smaller practice effects were found in non-paroxysmal AF patients in the DSST, TMT-B and the CoCo and could indicate a marker of subtle cognitive decline. As diabetes, history of stroke/TIA and depression-but not AF-type-were associated with cognitive drop, more attention should be given to risk factors and underlying mechanisms of AF.

Non-major bleeding risk of direct oral anticoagulants versus vitamin K antagonists for stroke prevention with atrial fibrillation: a systematic review and network meta-analysis

BACKGROUND

Direct oral anticoagulants (DOACs) are associated with bleeding. Patients often stop taking DOACs due to non-major bleeding, which may lead to stroke recurrence. We aimed to determine the risk of non-major bleeding using different DOACs to prevent strokes in atrial fibrillation (AF).

METHODS

A systematic search of four databases (PubMed, EMBASE, Web of Science, and Cochrane Library) was performed to identify randomized controlled trials (RCTs) reporting non-major bleeding events in patients taking DOACs or vitamin K antagonists (VKAs). In this frequency-based network meta-analysis, odds ratios and 95% confidence intervals were used for reporting. Based on the surface under the cumulative ranking curves (SUCRA), the relative ranking probability of each group was generated.

RESULTS

Nineteen randomized controlled trials (RCTs) (involving 85,826 patients) were included. For clinically relevant non-major bleeding, the risk for bleeding was lowest for apixaban (SUCRA, 93.9), followed by that for VKAs (SUCRA, 47.7), dabigatran (SUCRA, 40.3), rivaroxaban (SUCRA, 35.9), and edoxaban (SUCRA, 32.2). The minor bleeding safety of DOACs was ranked from highest to lowest as follows: apixaban (SUCRA, 78.1), edoxaban (SUCRA, 69.4), dabigatran (SUCRA, 48.8), and VKAs (SUCRA, 3.7).

CONCLUSIONS

Based on current evidence, for stroke prevention in patients with AF, the safest DOAC is apixaban in terms of non-major bleeding. This suggests that apixaban may have a lower risk of non-major bleeding than other anticoagulants and may help provide some clinical reference for choosing a more appropriate drug for the patient.

Healthcare resources and costs associated with nonvalvular atrial fibrillation in Spain: apixaban versus acenocoumarol

Aim: Healthcare resources usage and costs associated to nonvalvular atrial fibrillation (NVAF) were analyzed in Spain. Methods: This is an observational and retrospective study on patients with NVAF who started their treatment with apixaban or acenocoumarol between 1 January 2015 and 31 December 2017. Results: 2160 patients treated with apixaban were paired (1:1) with patients treated with acenocoumarol (propensity score matching). Apixaban reduced the incidence of strokes and systemic embolisms, minor and major bleedings and deaths, versus acenocoumarol. Apixaban led to reductions of 80, 55 and 43% in costs related to nursing visits, hospitalizations, and emergency visits, respectively, leading to annual cost savings of €274/patient, from the perspective of society. Conclusion: Our results suggested that apixaban is a cost-effective alternative for patients with NVAF.

Cardiac rehabilitation for heart failure and atrial fibrillation: a propensity- matched study

BACKGROUND

Atrial fibrillation (AF) is common in individuals with heart failure (HF). Individuals with HF and AF may have a reduced functional capacity and quality of life (QoL) which leads to hospital admission and burden on clinical services. Evidence supported the effect of exercise training in individuals with HF. However, there is no existing data on the effectiveness of comprehensive cardiac rehabilitation (CR) in individuals with coexisting HF and AF.

AIM

To explore the effect of CR in individuals with HF and AF compared with those with HF and no-coexisting AF.

METHODS

Using CR database, individuals with HF and AF were identified and propensity matched to those with no coexisting AF. The change in incremental shuttle walking test, Heart Disease Quality of Life questionnaire, Hospital Anxiety and Depression Scores were compared between groups pre-CR and post-CR.

RESULTS

149 individuals were propensity matched from each group. The mean±SD age of the matched sample was 73.4±8 years, body mass index 29±5.5 kg/m2, left ventricular ejection fraction 35.2±9.8% and 56% were male.A statistically significant improvements in exercise capacity, heart disease QoL, anxiety and depression scores were observed within each group. There were no significant differences between groups for any of these outcome measures.

CONCLUSIONS

Individuals with HF and AF gain a similar improvement in exercise capacity and health related QoL outcomes as individuals with no coexisting AF following CR. The presence of AF did not compromise the effectiveness of CR.

Validity of MENARI plus (self-pulse assessment and clinical scoring) mobile apps for detecting atrial fibrillation in high-risk population

Background

Even before it is clinically diagnosed, atrial fibrillation (AF) can cause a stroke. This study validates self-pulse assessment and clinical scoring (MENARI Plus) based on android apps.

Objective

The aim of this study was to examine the validity of AF screening using MENARI Plus compared with an ECG recording.

Methods

We collected a total of 1385 subjects from high-risk population according to CHA2DS2-VASc score ≥2, attending 8 primary care centers (PCCs) in Malang between July 2021 and December 2021. Every participant underwent self-pulse assessment, and then was evaluated for MENARI Plus Score on android Apps. These cases had been classified as low or high probability for AF (cut-off score 7). After that, electrocardiography examinations were performed and classified with AF and Sinus Rhythm group.

Results

In this study, the mean age of these patients was 61.5 ± 6.9 years old. We found that 156/1385 (11%) patients had AF. There were 68/156 (43.5%) new cases of AF. The sensitivity for self-pulse palpation was 73.1% (95% CI: 68%-76%) and specificity was 68.3% (95% CI: 65%-72%). MENARI Plus had an area under the receiver operating curve (AUC) of 0.86 (95% CI: 0.82-0.89) with sensitivity per measurement occasion was (84%, 95% CI: 82%-88%) and specificity was (87.9%, 95% CI: 82%-90%).

Conclusion

In this study, we found that MENARI Plus has high sensitivity and specificity for AF. It is therefore useful for ruling out AF. It may also be a useful screen that can be applied opportunistically for previously undetected AFs.

A framework for comparative study of databases and computational methods for arrhythmia detection from single-lead ECG

Arrhythmia detection from ECG is an important area of computational ECG analysis. However, although a large number of public ECG recordings are available, most research uses only few datasets, making it difficult to estimate the generalizability of the plethora of ECG classification methods. Furthermore, there is a large variability in the evaluation procedures, as well as lack of insight into whether they could successfully perform in a real-world setup. To address these problems, we propose an open-source, flexible and configurable ECG classification codebase-ECGDL, as one of the first efforts that includes 9 arrhythmia datasets, covering a large number of both morphological and rhythmic arrhythmias, as well as 4 deep neural networks, 4 segmentation techniques and 4 evaluation schemes. We perform a comparative analysis along these framework components to provide a comprehensive perspective into arrhythmia classification, focusing on single-lead ECG as the most recent trend in wireless ECG monitoring. ECGDL unifies the class information representation in datasets by creating a label dictionary. Furthermore, it includes a set of the best-performing deep learning approaches with varying signal segmentation techniques and network architectures. A novel evaluation scheme, inter-patient cross-validation, has also been proposed to perform fair evaluation and comparison of results.

Pre-procedural high serum visfatin and tumor necrosis factor-α might predict recurrent atrial fibrillation after catheter ablation

BACKGROUND

Many patients would require repeated ablation procedures owing to recurrent atrial fibrillation with its associated symptoms. Identifying those who are at risk of recurrent AF could assist us to develop preventive strategies and to properly select those who will benefit more from catheter ablation. Our aim is to study the role of preprocedural serum level of certain biomarkers in the prediction of AF recurrence after catheter ablation.

RESULTS

The present study included 117 patients: 26 patients with persistent and 91 patients with paroxysmal AF. Blood samples for estimation of serum levels of studied cytokines were obtained prior to the procedure. Pulmonary vein isolation was performed in all patients through point-by point radiofrequency ablation guided by 3D electroanatomical mapping system. Patients were followed for 12 months for AF recurrence. Forty-one (35%) patients developed AF recurrence. Those patients were significantly older, had significantly higher BMI, lower ejection fraction, and wider maximal left atrial diameter (LAD). Serum hs-CRP, IL-6, TNF-α, visfatin, and adiponectin levels were significantly higher compared to those who did not develop AF recurrence. Correlation analysis showed positive correlations between the incidence of RAF and patients' age, BMI, and maximum LAD and elevated cytokine levels and maximal LAD showed significant correlations with the type of AF and elevated serum TNF-α, visfatin, and adiponectin. Statistical analyses defined elevated serum levels of TNF-α, visfatin, and adiponectin as positive predictors for RAF, and automatic linear modeling analysis showed that elevated serum visfatin, TNF-α, and adiponectin can predict RAF by accuracy rates of 50%, 34%, and 16%, respectively.

CONCLUSIONS

RAF is most probably an outcome of the interplay between patients' clinical data, obesity, and inflammation. Pre-procedural estimation of serum levels of visfatin and TNF-α might determine patients with probability for RAF.

Sex-related differences in outcome after left atrial appendage occlusion: Insights from Europe and the EWOLUTION registry

BACKGROUND

Women with atrial fibrillation (AF) generally experience worse symptoms, poorer quality of life, and have a higher risk of stroke and death. There is limited availability of sex-related differences regarding left atrial appendage occlusion (LAAO).

AIMS

The aim of this study was to evaluate the sex-related differences in patients undergoing LAAO in EWOLUTION.

METHODS

A total of 1025 patients scheduled for elective LAAO therapy employing the WATCHMAN Gen 2.5 prospectively consented for participation; 1005 patients received a successful implant and were followed for 2 years. As we detected sex-related differences in baseline data we performed a propensity score matching. The primary endpoint is a combined endpoint of survival free from mortality, major bleeding, ischemic stroke, transitory ischemic attack (TIA) and systemic embolization (SE) up to 2-year clinical follow-up. Secondary Endpoints were periprocedural data and overall 2-year survival.

RESULTS

Women were older but had less often vascular disease and hemorrhagic stroke. There was no sex-related significant difference after LAAO at 2 years in the combined endpoint of survival free from mortality, major bleeding, ischemic stroke, TIA, and SE (female vs. male: 79% vs.76%, p = 0.24) or in overall survival (female vs. male: 85% vs. 82%, p = 0.16). Procedural data showed a higher sealing rate after the implantation in women (complete sealing female 94% vs. male 90%, p = 0.033), significantly more pericardial effusions (female 1.2% vs. male 0.2%, p = 0.031) and a similar periprocedural risk profile.

CONCLUSIONS

Females undergoing LAAO differ in various baseline variables, but after adjustment, we observed similar safety and efficacy of LAAO with no significant difference in long-term outcomes between women and men.

Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre

Atrial fibrillation (AF) is associated with an increased risk of stroke. Therefore, patients with AF require appropriate management and anticoagulant therapy. To balance therapy risks and benefits, oral anticoagulants (OAC) treatment should be 'tailored' in patients at a high risk of stroke and bleeding. However, some studies have demonstrated that certain groups of patients do not receive anticoagulants despite the high risk of stroke or thromboembolism. The study aimed to analyse therapeutic methods of stroke prevention in very high-risk patients (CHA2DS2-VASc score of ≥5 in men and ≥6 in women), identify factors predisposing against the use of OACs and assess the administration of anticoagulants before the introduction of non-vitamin K antagonist OAC (NOAC) in 2004-2011 and beyond (years 2012-2019). The analysis covered 2441 patients with AF at a very high thromboembolic risk who were hospitalised in a reference cardiological centre from 2004 to 2019. Data concerning patients' sex, age, comorbidities, type of AF, renal and echocardiographic parameters, reasons for hospitalisation and applied treatment were collected from medical records. HAS-BLED, CHADS2, and CHA2DS2-VASc scores were calculated for all patients. The treatment with oral anticoagulants was compared in the entire population over 2004-2011 and 2012-2019. In this study, a fifth of patients were not treated with OAC. Most patients hospitalised in the years 2012-2019 were treated with OAC. The predictors of not using OAC turned out to be: age of >74 years, heart failure, cancer, paroxysmal AF, and acute coronary syndrome (ACS) or elective coronary angiography/percutaneous coronary intervention (PCI) as a reason for hospitalisation. The introduction of NOAC was associated with a decline in the use of VKA (from 62% to 19.1%) and APT (from 29.1% to 1.3%). This study outlines reasons to initiate OAC treatment in very high-risk patients in clinical practice.

Contemporary trends and barriers to oral anticoagulation therapy in Non-valvular atrial fibrillation during DOAC predominant era

There is a need to reassess contemporary oral anticoagulation (OAC) trends and barriers against guideline directed therapy in the United States. Most previous studies were performed before major guideline changes recommended direct oral anticoagulant (DOAC) use over warfarin or have otherwise lacked patient level data. Data on overuse of OAC in low-risk group is also limited. To address these knowledge gaps, we performed a nationwide analysis to analyze current trends. This is a retrospective cohort study assessing non-valvular AF identified using a large United States de-identified administrative claims database, including commercial and Medicare Advantage enrollees. Prescription fills were assessed within a 90-day follow-up from the patient's index AF encounter between January 1, 2016, and December 31, 2020. Among the 339,197 AF patients, 4.4%, 8.0%, and 87.6% were in the low-, moderate-, and high-risk groups (according to CHA₂DS₂-VASc score). An over (29.6%) and under (52.2%) utilization of OAC was reported in low- and high-risk AF patients. A considerably high frequency for warfarin use was also noted among high-risk group patients taking OAC (33.1%). The results suggest that anticoagulation use for stroke prevention in the United States is still comparable to the pre-DOAC era studies. About half of newly diagnosed high-risk non-valvular AF patients remain unprotected against stroke risk. Several predictors of OAC and DOAC use were also identified. Our findings may identify a population at risk of complications due to under- or over-treatment and highlight the need for future quality improvement efforts.

L1 cell adhesion molecule may be a protective molecule for atrial fibrillation in patients with valvular heart disease

Background

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia. L1 cell adhesion molecule (L1CAM) served as a crucial regulator of signaling pathways. This research sought to examine the clinical value and functions of soluble L1CAM in the serum of AF patients.

Methods

In total, 118 patients (valvular heart disease patients [VHD, total: n = 93; AF: n = 47; sinus rhythm (SR): n = 46] and healthy controls [n = 25]) were recruited in this retrospective study. Plasma levels of L1CAM were detected by enzyme-linked immunosorbent assays. The Pearson's correlation approach, as applicable, was used for analyzing the correlations. The L1CAM was shown to independently serve as a risk indicator of AF in VHD after being analyzed by the multivariable logistic regression. To examine the specificity and sensitivity of AF, receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used. A nomogram was developed for the visualisation of the model. We further evaluate the prediction model for AF using calibration plot and decision curve analysis.

Results

The plasma level of L1CAM was substantially decreased in AF patients as opposed to healthy control and SR patients (healthy control = 46.79 ± 12.55 pg/ml, SR = 32.86 ± 6.11 pg/ml, AF = 22.48 ± 5.39 pg/ml; SR vs. AF, P < 0.001; control vs. AF, P < 0.001). L1CAM was significantly and negatively correlated with LA and NT-proBNP (LA: r = -0.344, P = 0.002; NT-proBNP: r = -0.380, P = 0.001). Analyses using logistic regression showed a substantial correlation between L1CAM and AF in patients with VHD (For L1CAM, Model 1: OR = 0.704, 95%CI = 0.607-0.814, P < 0.001; Model 2: OR = 0.650, 95% CI = 0.529-0.798, P < 0.001; Model 3: OR = 0.650, 95% CI = 0.529-0.798, P < 0.001). ROC analysis showed that inclusion of L1CAM in the model significantly improved the ability of other clinical indicators to predict AF. The predictive model including L1CAM, LA, NT-proBNP and LVDd had excellent discrimination and a nomogram was developed. The model had good the calibration and clinical utility.

Conclusion

L1CAM was shown to independently serve as a risk indicator for AF in VHD. In AF patients with VHD, the prognostic and predictive effectiveness of models incorporating L1CAM was satisfactory. Collectively, L1CAM may be a protective molecule for atrial fibrillation in patients with valvular heart disease.

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

Anteriolateral versus anterior-posterior electrodes in external cardioversion of atrial fibrillation: A systematic review and meta-analysis of clinical trials

The efficacy of anteriolateral versus anterior-posterior electrode positions in the success of atrial fibrillation's (AF) electrical cardioversion is unclear. Our aim is to perform a meta-analysis to compare the success rate of both electrode positions. PUBMED, WOS, OVID, and SCOPUS were searched. Inclusion criteria were clinical trials that compared anterior-lateral with anterior-posterior electrodes in external cardioversion of AF. After the full-text screening, 11 trials were included in the analysis. The total number of patients included in the study is 1845. The pooled analysis showed a statistically significant association between anterior-lateral electrode and increased cardioversion rate of AF (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.02-1.92, p = .04). Subgroup analysis revealed a statistically significant association between the anterior-lateral electrode and increased cardioversion rate of AF in subgroups of less than five shocks, patients with 60 years old or more and patients with left atrial (LA) diameter >45 mm (OR = 1.72, 95% CI = 1.17-2.54, p = .006), (OR = 1.73, 95% CI = 1.18-2.54, p = .005), and (OR = 1.86, 95% CI = 1.04-3.34, p = .04), respectively. Anteriolateral electrode is more effective than anterior-posterior electrode in external cardioversion of AF, particularly in patients who have received less than 5 shocks, are 60 years old or older and have a LA diameter greater than 45 mm.

Prevalence and treatment of atrial fibrillation in older adults

BACKGROUND

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia with an impact on morbidity and mortality found in the geriatric population.

OBJECTIVE

This retrospective study is the first to investigate the prevalence, treatment and comorbidities of AF in a large cohort of older adults.

MATERIAL AND METHODS

Older adults with AF hospitalized between 2010 and 2018. The mean age of the 10,700 AF patients in 2018 was 83.2 ± 6.4 years. The frequency of anticoagulation in older adults with AF between 2010 and 2018 was analyzed. The relationship between comorbidities and anticoagulation in 2018 was examined. Logistic regression analysis was used to identify possible predictive factors for anticoagulation.

RESULTS

The prevalence of AF in 35,887 hospitalized older adults was 29.8% in 2018. The mean CHA₂DS₂VASc score was 4.4 ± 1.3 (male 3.8 ± 1.3, female 4.7 ± 1.2). From 2010 to 2018, the frequency of anticoagulation for patients with AF rose from 32.1% to 64.2%. Statistically significant differences in the examined characteristics between anticoagulated and not anticoagulated patients were found. Furthermore, there were no predictive factors for anticoagulation in multivariate logistic analysis.

CONCLUSION

Hospitalized older adults have an increased prevalence of AF compared to the general population. Despite the higher risk of bleeding, older adults were more frequently anticoagulated in the observation period, preferably with direct oral anticoagulants (DOACs). Patients without anticoagulation had more diagnoses and were worse in functional tests. This study suggests that the decision to give anticoagulants to older adults should be personalized.

Inappropriate Combined Antiplatelet and Anticoagulant Therapy in Older Patients with Atrial Fibrillation: Trend over Time (2009-18)

BACKGROUND AND OBJECTIVES

Antiplatelet therapy, when prescribed in combination with anticoagulant therapy to older patients with atrial fibrillation and no recent cardiovascular event, is inappropriate and a reversible risk factor of major bleeding. We aimed to assess the trend over time of the prevalence of inappropriate combined antiplatelet and anticoagulant therapy and to determine its associated factors during the direct oral anticoagulant era.

METHODS

This was a study of consecutive older patients (age ≥ 75 years) with atrial fibrillation, receiving anticoagulant therapy upon admission, and undergoing a comprehensive geriatric assessment during their first admission in a Belgian teaching hospital between 2009 and 2018. Antiplatelet therapy was considered inappropriate in the absence of a recent cardiovascular event. We studied the prevalence of inappropriate combined antiplatelet and anticoagulant therapy by 2-year periods and assessed its associated factors since the year 2013.

RESULTS

Inappropriate combined antiplatelet and anticoagulant therapy was identified in 21% of the 654 patients (median age 84 years, 51% women), with a prevalence decreasing (p ≤ 0.01) from 25% (2009-10) to 14.8% (2017-18). Among the 469 patients recruited during the direct oral anticoagulant era, inappropriate combined antiplatelet and anticoagulant therapy (19%) was associated in a multivariable analysis with a history of stroke/transient ischemic attack (odds ratio 2.13, p = 0.007), anticoagulation with low-molecular-weight heparin (odds ratio 3.44, p = 0.015), and a history of vascular disease (odds ratio 5.68, p < 0.001).

CONCLUSIONS

While inappropriate combined antiplatelet and anticoagulant therapy has declined over the last decade, there is still room for improvement. Antiplatelet deprescribing should be considered in all patients with inappropriate combined antiplatelet and anticoagulant therapy, including those with vascular disease and no recent cardiovascular event.

Healthcare Resource Utilization and Costs of Rivaroxaban Versus Warfarin Among Non-valvular Atrial Fibrillation (NVAF) Patients with Diabetes in a US Population

INTRODUCTION

The healthcare resource utilization (HRU) and costs of oral anticoagulant-naïve patients with non-valvular atrial fibrillation (NVAF) and diabetes initiated on rivaroxaban or warfarin in the United States (US) has not been previously evaluated.

METHODS

This retrospective study used data from the Optum's de-identified Clinformatics^® Data Mart Database (1 January, 2012 to 30 September, 2021) to evaluate the HRU and costs of adult patients with NVAF and diabetes newly initiated on rivaroxaban or warfarin (on or after January 2013). Inverse probability of treatment weighting (IPTW) was used to adjust for confounding between cohorts. HRU and costs (USD 2021) were assessed per patient-year (PPY) post-treatment initiation. Weighted cohorts were compared using rate ratios (RR) from Poisson regression models, odds ratios (OR) from logistic regression models, and cost differences; 95% confidence intervals (CI) and p values were generated using non-parametric bootstrap procedures.

RESULTS

After IPTW, 17,881 and 19,274 patients initiated on rivaroxaban and warfarin were included, respectively (mean age: 73 years; 40% female). During 12 months of follow-up, the rivaroxaban cohort had lower all-cause HRU PPY across all components, including lower rates of inpatient stays (RR: 0.84, 95% CI 0.81, 0.88), outpatient visits (RR: 0.67, 95% CI 0.66, 0.68), and 30 day hospital readmission (OR: 0.75, 95% CI 0.66, 0.83; all p < 0.001) compared to the warfarin cohort. Moreover, rivaroxaban was associated with medical cost savings PPY (mean cost difference: - $9306, 95% CI - $11,769, - $6607), which compensated for higher pharmacy costs relative to warfarin (mean cost difference: $5518, 95% CI $5193, $5839), resulting in significantly lower all-cause total healthcare costs for rivaroxaban versus warfarin (mean cost difference: - $3788, 95% CI - $6258, - $1035; all p < 0.001).

CONCLUSION

Among NVAF patients with diabetes in a real-world US setting, rivaroxaban was associated with lower healthcare costs compared to warfarin.

Establishment and Verification of a Nomogram for Predicting the Probability of New-Onset Atrial Fibrillation After Dual-Chamber Pacemaker Implantation

BACKGROUND

This study aims to establish and validate a nomogram as a predictive model in patients with new-onset atrial fibrillation (AF) after dual-chamber cardiac implantable electronic device (pacemaker) implantation.

METHODS

A total of 1120 Chinese patients with new-onset AF after pacemaker implantation were included in this retrospective study. Patients had AF of at least 180/minute lasting 5 minutes or longer, detected by atrial lead and recorded at least 3 months after implantation. Patients with previous atrial tachyarrhythmias before device implantation were excluded. A total of 276 patients were ultimately enrolled, with 51 patients in the AF group and 225 patients in the non-AF group. Least absolute shrinkage and selection operator (LASSO) method was used to determine the best predictors. Through multivariate logistic regression analysis, a nomogram was drawn as a predictive model. Concordance index, calibration plot, and decision curve analyses were applied to evaluate model discrimination, calibration, and clinical applicability. Internal verification was performed using a bootstrap method.

RESULTS

The LASSO method regression analysis found that variables including peripheral arterial disease, atrial pacing-ventricular pacing of at least 50%, atrial sense-ventricular sense of at least 50%, increased left atrium diameter, and age were important predictors of developing AF. In multivariate logistic regression, peripheral arterial disease, atrial pacing-ventricular pacing of at least 50%, and age were found to be independent predictors of new-onset AF.

CONCLUSION

This nomogram may help physicians identify patients at high risk of new-onset AF after pacemaker implantation at an early stage in a Chinese population.

Body Mass Index Measured Repeatedly over 42 Years as a Risk Factor for Ischemic Stroke: The HUNT Study

BACKGROUND

Higher BMI in middle age is associated with ischemic stroke, but little is known about BMI over adulthood, and the risk for ischemic stroke as most studies relied on a single measurement of BMI.

METHODS

BMI was measured four times over a period of 42 years. We calculated average BMI values and group-based trajectory models and related these to the prospective risk of ischemic stroke after the last examination in Cox models with a follow-up time of 12 years.

RESULTS

A total of 14,139 participants, with a mean age of 65.2 years and 55.4% women, had information on BMI from all four examinations, and we observed 856 ischemic strokes. People with overweight and obesity over adulthood had a higher risk for ischemic stroke with a multivariable-adjusted hazard ratio of 1.29 (95% CI 1.11-1.48) and 1.27 (95% CI 0.96-1.67), respectively, when compared to normal weight participants. Excess weight tended to have stronger effects earlier than later in life. A trajectory of developing obesity throughout life was associated with higher risk than other trajectories.

CONCLUSIONS

High average BMI, especially at an early age, is a risk factor for ischemic stroke. Early weight control and long-term weight reduction for those with high BMI may decrease the later occurrence of ischemic stroke.

A Survey of Saudi General Practitioners on the Use of Thromboprophylaxis Guidelines and Risk Assessment Tools in Atrial Fibrillation

Clinical practice guidelines advise patients with atrial fibrillation who are at risk for stroke to undergo thromboprophylaxis with oral anticoagulants. However, it is noted that guidelines are not always followed. We sought to learn how Saudi Arabian general practitioners (GPs) self-reported using risk assessment tools and atrial fibrillation clinical practice guidelines created by cardiology associations, as well as how GPs felt about the resources that were available. Through the use of a self-administered questionnaire, we carried out a cross-sectional survey. A total of two-hundred GPs participated in the study. The guidelines were frequently used when a clinical decision regarding anticoagulation therapy appeared difficult (n = 57, 28.4%). The most predominant strengths of participants' chosen clinical guidelines were clear recommendations (n = 56, 27.9%), easy-to-follow algorithms (n = 39, 16.9%), detailed recommendations supported by evidence (n = 34, 16.9%), and online availability (n = 27, 13.4%). Many respondents said they used a formal stroke risk assessment tool in addition to their clinical judgment as a GP for most decisions (60%). Most respondents preferred using the CHA2DS2-VASc (n = 106, 52.7%), CHA2DS2-VA (n = 45, 22.4%), CHADS2 (n = 35, 17.4%), and GARFIELD (n = 14, 7.0%). HAS-BLED (n = 100, 49.8%) and HEMORR2HAGES (n = 50, 24.9%) were the most frequently utilized formal tools for assessing the risk of bleeding among GPs. Over half of the participants referred to guidelines when deciding thromboprophylaxis in patients with atrial fibrillation. Additionally, many respondents used formal procedures for assessing the risks of bleeding and stroke in addition to their clinical judgement in their roles as GPs. The guideline was assessed as being extremely helpful overall by GPs who used it to make thromboprophylaxis decisions.

Early rhythm control vs. rate control in atrial fibrillation: A systematic review and meta-analysis

Objective

It has long been debated whether rhythm control vs. rate control strategies have differing effects on mortality and morbidity for atrial fibrillation (AF). Recently, several randomized controlled studies (RCTs) and observational trials described that an early rhythm management method was linked to a lower likelihood of negative clinical outcomes in individuals with AF. We wanted to see if an early rhythm management method may help patients with AF.

Methods

We performed a systematic search to retrieve studies assessing the outcomes of early rhythm control vs. rate control in AF by using PubMed, Web of Science, Cochrane Library, and Embase published between 01/01/2000 and 15/04/2022.

Results

Finally, two RCTs, one retrospective analysis of RCTs, and four observational studies were identified. Compared with rate control, early rhythm control has been linked to lower all-cause mortality. [risk ratio (RR), 0.76; 95% CI 0.69-0.83; P < 0.00001; I 2 = 77%]. The early rhythm control group was also associated with a lower risk of cardiovascular mortality (RR, 0.68; 95% CI 0.63-0.74; P < 0.00001; I 2 = 33), stroke (RR, 0.77; 95% CI 0.67-0.87; P < 0.001; I 2 = 64), and heart failure hospitalization (RR, 0.74; 95% CI 0.59-0.93; P = 0.0009; I 2 = 93%). We found no significant difference in nights spent in hospital per year, acute coronary syndrome, major bleeding, and cardiac arrest/ventricular arrhythmia between the groups.

Conclusion

In this meta-analysis, early rhythm therapy was linked to a lower risk of all-cause mortality, cardiovascular mortality, stroke, and heart failure hospitalization compared with the rate control group.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022333592.

Bleeding events among patients concomitantly treated with direct oral anticoagulants and macrolide or fluoroquinolone antibiotics

Fluoroquinolones and macrolides may, due to a potential drug-drug interaction, increase the concentration of any concomitantly administered direct oral anticoagulant (DOAC) and thereby increase the risk of severe bleeding. However, clinical evidence for such an effect is scarce. The present study aimed to evaluate the association between the use of fluoroquinolones or macrolides and bleeding events in patients with concomitant DOAC use. This was a nationwide cohort study including 19 288 users of DOACs in 2008-2018 using information from Swedish national health registers. We compared the incidence of bleeding events associated with use of fluoroquinolones or macrolides using doxycycline as a negative control. Cox regression was used to calculate crude and adjusted hazard ratios (aHRs) in time windows of various length of follow-up after the start of antibiotic use. The incidence rates for fluoroquinolones and macrolides ranged from 12 to 24 and from 12 to 53 bleeding events per 100 000 patients in the investigated time windows. The aHRs (95% confidence interval) for use of fluoroquinolones and macrolides were 1.29 (0.69-2.44) and 2.60 (0.74-9.08) at the concomitant window, 1.31 (0.84-2.03) and 1.79 (0.75-4.29) at 30 days, and 1.34 (0.99-1.82) and 1.28 (0.62-2.65) at 150 days, respectively. With regard to fluoroquinolones, the present study suggests that the risk of bleeding when combined with DOACs, if any, is small. Codispensation of macrolides in patients on DOACs was not associated with an increased risk of bleeding. However, due to the small number of macrolide users, the results must be interpreted with caution.

Factors affecting wearable ECG device adoption by general practitioners for atrial fibrillation screening: cross-sectional study

Introduction

Atrial fibrillation (AF) is a challenging cardiovascular disease worldwide. Wearable electrocardiograph devices (WEDs) have great potential to improve the detection rate of AF in primary care. However, the factors that influence general practitioners' (GPs) perception and acceptance of WEDs are not well understood. To identify factors that influence the intention of GPs to utilize WEDs in a clinical setting to screen patients for AF.

Method

The research hypotheses and questionnaire items were designed and developed based on the unified theory of acceptance and technology (UTAUT) framework. We used stratified sampling and obtained the data through an online survey. Structural equation modeling was used to analyze the collected data.Results: A total of 1,004 valid questionnaires from GPs across Sichuan province in China were collected. Three factors increased GPs' intention to utilize WEDs to screen patients for AF, including performance expectancy (β = 0.121, p = 0.004), social influence (β = 0.356, p < 0.001), and price perception (β = 0.587, p < 0.001). Perception risk (β = -0.059, p < 0.001) decreased usage intention, while effort expectancy (β = -0.079, p = 0.155) and facilitating conditions (β = -0.014, p = 0.868) did not affect usage intention. Gender (β = -0.022, p = 0.179), age (β = 0.006, p = 0.699), education level (β = -0.22, p = 0.184) and training (β = 0.007, p = 0.69) were not significantly correlated with usage intention, and these four factors had no moderating effect on the path coefficients.

Discussion

GPs' intention to utilize WEDs is affected by performance expectancy, price perception, perception risk and social influence. Researcher should improve the usability and perception of WEDs for screening and carry out studies to provide high-quality evidence for the security and efficacy of wearable devices.

Preliminary findings on left atrial appendage occlusion simulations applying different endocardial devices

Atrial fibrillation (AF) is one of the most investigated arrhythmias since it is associated with a five-fold increase in the risk of strokes. Left atrium dilation and unbalanced and irregular contraction caused by AF favour blood stasis and, consequently, stroke risk. The left atrial appendage (LAA) is the site of the highest clots formation, increasing the incidence of stroke in AF population. For many years oral anticoagulation therapy has been the most used AF treatment option available to decrease stroke risk. Unfortunately, several contraindications including bleeding risk increase, interference with other drugs and with multiorgan functioning, might outweigh its remarkable benefits on thromboembolic events. For these reasons, in recent years, other approaches have been designed, including LAA percutaneous closure. Unfortunately, nowadays, LAA occlusion (LAAO) is restricted to small subgroups of patients and require a certain level of expertise and training to successfully complete the procedure without complications. The most critical clinical problems associated with LAAO are represented by peri-device leaks and device related thrombus (DRT). The anatomical variability of the LAA plays a key role in the choice of the correct LAA occlusion device and in its correct positioning with respect to the LAA ostium during the implant. In this scenario, computational fluid dynamics (CFD) simulations could have a crucial role in improving LAAO intervention. The aim of this study was to simulate the fluid dynamics effects of LAAO in AF patients to predict hemodynamic changes due to the occlusion. LAAO was simulated by applying two different types of closure devices based on the plug and the pacifier principles on 3D LA anatomical models derived from real clinical data in five AF patients. CFD simulations were performed on the left atrium model before and after the LAAO intervention with each device. Blood velocity, particle washout and endothelial damage were computed to quantify flow pattern changes after the occlusion in relation to the thrombogenic risk. Our preliminary results confirmed an improved blood washout after the simulated implants and the capability of foreseeing thrombogenic risk based on endothelial damage and maximum blood velocities in different scenarios. This tool may help to identify effective device configurations in limiting stroke risk for patient-specific LA morphologies.

Antithrombotic Treatment in Coronary Artery Disease

Coronary artery disease exhibits growing mortality and morbidity worldwide despite the advances in pharmacotherapy and coronary intervention. Coronary artery disease is classified in the acute coronary syndromes and chronic coronary syndromes according to the most recent guidelines of the European Society of Cardiology. Antithrombotic treatment is the cornerstone of therapy in coronary artery disease due to the involvement of atherothrombosis in the pathophysiology of the disease. Administration of antiplatelet agents, anticoagulants and fibrinolytics reduce ischemic risk, which is amplified early post-acute coronary syndromes or post percutaneous coronary intervention; though, antithrombotic treatment increases the risk for bleeding. The balance between ischemic and bleeding risk is difficult to achieve and is affected by patient characteristics, procedural parameters, concomitant medications and pharmacologic characteristics of the antithrombotic agents. Several pharmacological strategies have been evaluated in patients with coronary artery disease, such as the effectiveness and safety of antithrombotic agents, optimal dual antiplatelet treatment schemes and duration, aspirin de-escalation strategies of dual antiplatelet regimens, dual inhibition pathway strategies as well as triple antithrombotic therapy. Future studies are needed in order to investigate the gaps in our knowledge, including special populations.

Early myocardial injury and coagulation activation in thoracoscopic left atrial appendage clipping

BACKGROUND

Thoracoscopic left atrial appendage clipping as a new strategy for stroke prevention. This study was established to observe the changes in myocardial injury and coagulation during the perioperative to provide the basis for anticoagulation strategy.

METHODS

Fifty-two patients with nonvalvular atrial fibrillation who completed thoracoscopic left atrial appendage clipping alone and 52 matched controls with thoracoscopic lobectomy were included in the study. The changes in coagulation and myocardial enzyme during the perioperative period were compared by t-test or nonparametric test. Linear correlation analysis was performed on the trend changes of each indicator in the left atrial appendage clipping group.

RESULTS

Compared with the control group, the postoperative cardiac troponin I level in the thoracoscopic left atrial appendage clip group was significantly higher than that before the operation; there was no significant difference in the increase of myoglobin between the two groups. In the coagulation function, there was no significant difference in the increase of fibrinogen between the two groups. Postoperative D-dimer and fibrin degradation products were significantly increased, especially the left atrial appendage clip group was significantly higher than the control group, and even showed a trend of secondary increase. Cardiac troponin I was positively correlated with C-reactive protein, fibrinogen and von Willebrand Factor activity, and the Spearman nonparametric correlation coefficients were 1, 0.829, and 0.829, respectively (all p < .05).

CONCLUSION

Thoracoscopic left atrial appendage closure surgery presents early myocardial injury and activation of coagulation function. The secondary increase of coagulation index needs our attention.

Trends of use and factors that determine the choice of oral anticoagulants in women and men with atrial fibrillation

The aim was to identify sex-specific factors linked with oral anticoagulant initiation in a cohort of patients with atrial fibrillation using administrative data from Quebec (Canada) between 2014 and 2017. Cohort entry defined as new users, that is, no claims in last 12 months, a cohort of 32 050 patients was stratified in two groups, that is, women and men. Multivariable regression models were used to identify factors of initiations for low- and standard-dose direct oral anticoagulants (DOACs) versus warfarin, and low- versus standard-dose DOACs. In both sexes, warfarin initiation decreased and DOAC initiation increased, with year of initiation as major factors of DOACs use. In 2017, the increase was of 2- to 4-fold and 3- to 8-fold for low- and standard-dose DOACs (vs. warfarin), respectively. The proportion of patients starting on a low-dose DOAC was higher in women than men. Older age for both sexes and CHADS2 score ≥2 (only women) were major factors of low-dose dabigatran and rivaroxaban versus warfarin use. The only significant factor of standard-dose DOAC versus warfarin use was age of 65-79 for women or men treated with apixaban by 1.8- and 1.4-fold, respectively. Factors that made women and men less likely to receive a standard-dose DOAC versus warfarin were higher CHADS2 (for dabigatran and rivaroxaban), HAS-BLED and frailty scores, prior coronary disease, major bleeding, and chronic kidney disease (CKD) status. The choice of a low- versus standard-dose DOAC was mainly driven by age and CKD, and higher CHADS2 score (for dabigatran and apixaban) for both sexes.

Polypharmacy and Major Adverse Events in Atrial Fibrillation

ABSTRACT

Patients with atrial fibrillation (AF) often receive multiple medications daily. The purpose of this study was to examine the prognostic implications of polypharmacy in patients with AF. This is a retrospective post hoc analysis of 1113 AF patients, enrolled in a randomized trial during an acute hospitalization (MISOAC-AF, NCT02941978). The presence of polypharmacy (use of >4 drugs daily) was assessed at hospital discharge. Regression analyses were performed to identify clinical predictors of polypharmacy and compare the outcomes of patients with or without confirmed polypharmacy. The coprimary outcomes were all-cause and cardiovascular (CV) mortality. Among patients with polypharmacy, the difference in the risk of mortality was also assessed per each added drug as a numeric variable. Polypharmacy was found in 36.9% of participants. Dyslipidemia, coronary artery disease, lower left ventricular ejection fraction, and higher glomerular filtration rates were independent predictors of polypharmacy. Polypharmacy was an independent predictor for all-cause death (adjusted hazard ratio [aHR]: 1.29, 95% confidence interval [CI]: 1.01-1.64) and CV death (aHR: 1.39, 95% CI: 1.05-1.84). Among patients with polypharmacy, each additional concomitant medication was independently associated with a 4% increased risk of all-cause mortality (aHR = 1.04, 95% CI: 1.00-1.08) and a 5% increased risk of CV mortality (aHR = 1.05, 95% CI: 1.00-1.10). Polypharmacy was common among patients with AF hospitalized in a tertiary hospital and was incrementally associated with higher rates of mortality.

'Out of sync': a qualitative investigation of patients' experiences of atrial fibrillation and perceptions of weight management

OBJECTIVES

To explore ways to enhance the design of risk factor management and weight-loss services for people with overweight/obesity and atrial fibrillation (AF).

BACKGROUND

AF is the most common cardiac arrhythmia, with serious consequences for health and quality of life. Some evidence indicates weight reduction in people with AF and overweight/obesity may improve symptoms. This population may require additional support with weight management due to factors associated with ageing and health.

DESIGN

Qualitative investigation based on semi-structured interviews.

METHODS

12 adult participants (4 female, 8 male) with diagnosed AF and a current or previous body mass index >27 kg/m² were recruited at a large tertiary cardiac referral centre in southern England between September 2020 and January 2021. Participants completed quality of life and AF symptom questionnaires using Think-Aloud technique and semi-structured interviews relating to their weight management experiences, needs and preferences. Interviews were audio recorded and analysed thematically using the Capability, Opportunity and Motivation-Behaviour model as a theoretical framework.

RESULTS

Three main themes were identified. Being out of rhythm explores the psychological and physical impact of AF on weight management; doing the right thing discusses participants' weight management experiences and broaching the subject explores participants' perspectives on weight management conversations with clinicians.

CONCLUSIONS

There was dissatisfaction with the weight management advice received from healthcare professionals including cardiologists. Participants wanted open, non-judgemental discussion of cardiac health implications of overweight/obesity supported by referral to weight management services. Improved communication including research findings regarding the benefits of weight loss as a factor in AF management might increase motivation to adhere to weight-loss advice in this population.

Voluntary Unemployment Is Associated With Increased Prevalence of Stroke and its Risk Factors in Middle-Aged Adults

OBJECTIVE

The aim of the study is to investigate the association between the prevalence of stroke, its risk factors, and occupational status, with a differentiation between voluntary and involuntary unemployment.

METHODS

This is a cross-sectional study, which included 3013 individuals aged 40 to 65 years. We compared the prevalence of stroke, comorbidities, self-reported stroke-like symptoms, healthy behaviors, and knowledge about stroke among the voluntarily and involuntarily unemployed versus the employed.

RESULTS

Voluntary unemployment was associated with increased chances of stroke (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.05-3.57), hypertension (OR, 1.18; 95% CI, 1.06-1.32), diabetes (OR, 1.16; 95% CI, 1.01-1.35), and obesity (OR, 1.16; 95% CI, 1.05-1.29). Involuntary job loss was associated with increased odds of hypertension (OR, 1.69; 95% CI, 1.16-2.50) and more frequent self-reported stroke-like symptoms.

CONCLUSIONS

We found higher chances of stroke among the voluntarily unemployed middle-aged adults, presumably because of increased prevalence of hypertension, diabetes, and obesity.

Identifying unmet antithrombotic therapeutic need, and implications for stroke and systemic embolism in atrial fibrillation patients: a population-scale longitudinal study

Aims

Guidelines recommend anticoagulation (AC) in atrial fibrillation (AF) to reduce stroke and systemic embolism (SSE) risk; however, implementation has been slow across many populations. This study aimed to quantify the potential impact of changing prevalence of AF, associated risk, and AC prescribing on SSE hospitalizations and death.

Methods and results

We evaluated temporal trends of AF, CHA2DS2-VASc, antithrombotic prescriptions, SSE hospitalizations, death, and their associations between 2012 and 2018 in a longitudinal cohort of AF patients in Wales UK. Multi-state Markov models were used to estimate expected SSE rates given the AC coverage, adjusting for CHA2DS2-VASc scores. SSE rates were modelled for various past and future AC scenarios. A total of 107 137 AF patients were evaluated (mean age = 74 years, 45% female). AF prevalence increased from 1.75 to 2.22% (P-value <0.001). SSE hospitalizations decreased by 18% (2.34-1.92%, P-value <0.001). Increased AC coverage from 50 to 70% was associated with a 37% lower SSE rate, after adjustment for individual time-dependent CHA2DS2VASc scores. The observed AC increase accounted for approximately 80 fewer SSE hospitalizations per 100 000/year. If 90% AC coverage had been achieved since 2012, an estimated 279 SSE per 100 000/year may have been prevented. Our model also predicts that improving AC coverage to 90% over the next 9 years could reduce annual SSE rates by 9%.

Conclusion

We quantified the relationship between observed AC coverage, estimating the potential impact of variation in the timing of large-scale implementation. These data emphasize the importance of timely implementation and the considerable opportunity to improve clinical outcomes in the Wales-AF population.

Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial

INTRODUCTION

Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA2DS2-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population.

METHODS AND ANALYSIS

This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200058109.

Control of Therapeutic Levels of Anticoagulation and Associated Factors: A Prospective Cohort Study

Maintaining therapeutic levels of anticoagulation is essential to avoid health complications in people who take vitamin K antagonists. This study aimed to analyze the influence of people's characteristics and the presence of changes in their lives in the control of therapeutic levels of anticoagulation. A longitudinal multicenter study with a 1-year follow-up of a cohort of 199 people receiving anticoagulant therapy was performed. The effect of biological, clinical, social, lifestyle, and changes in life on the international normalized ratio (INR) was analyzed. During the follow-up, 46.7% of participants presented good INR control. At baseline, a diagnosis of atrial fibrillation (P = .00), the lack of comorbidities (P = .03), absence of depression (P = .04), and not following a pharmacological treatment with hypoglycemia drugs (P = .01) were associated with good INR control. During the follow-up, the variable of making changes to the usual diet was associated with poor INR control (P = .05). In the binary multiple regression model, factors associated with poor control were taking hypoglycemia drugs (P = .02) and the presence of depression (P = .04), and only the diagnosis of atrial fibrillation was associated with good control (P = .03). People with a diagnosis of atrial fibrillation had good INR control. Having comorbidities, suffering depression, taking hypoglycemia drugs, and making changes to the diet have a negative effect on INR control.

Photoplethysmography-Based Smart Devices for Detection of Atrial Fibrillation

Atrial fibrillation is the most commonly experienced type of cardiac arrhythmia and is the most associated with substantial clinical occurrences and expenses. This arrhythmia often occurs in its "silent" asymptomatic form, revealed only after complications such as a stroke or congestive heart failure have transpired. New smart devices confer effective advantages in the detection of this heart arrhythmia, of which photoplethysmography-based smart devices have shown great potential, according to previous research. However, the solution becomes a problem as widespread use and high availability of various applications and smart devices may lead to substantial amounts of false and misleading recordings and information, causing unnecessary anxiety regarding arrhythmic occurrences diagnosed by the devices but not professionally confirmed. Thus, with most of the devices being photoplethysmography based for detection of atrial fibrillation, it is important to research devices studied up to this point to find the best smart device to detect the aforementioned arrhythmias.