2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Clinical and Genetic Risk Factors Predict Atrial Fibrillation on the Basis of Hypertrophic Cardiomyopathy

BACKGROUND

Clinical and genetic predispositions are significant in predicting atrial fibrillation (AF); however, their role in patients with hypertrophic cardiomyopathy (HCM) remains unclear. This study aims to elucidate the impact of clinical and genetic risk factors on the development of AF in patients with and without HCM.

METHODS AND RESULTS

This retrospective analysis involved data from the UK Biobank cohort. Participants were divided into 3 groups based on their validated polygenic risk score for AF: the bottom 10% as low risk, the top 10% as high risk, and the rest as intermediate risk. We assessed the incidence of AF and cardiovascular complications and analyzed its predictors, including genetic risk. We examined 1180 patients with HCM (mean age, 61.1±7.1; 63.0% men) and 476 238 participants without HCM (mean age, 57.0±8.1; 45.3% men). During the 11.6-year follow-up period, the age- and sex-adjusted AF incidence rates for the low, intermediate, and high genetic risk groups were 2.4, 3.6, and 5.4 per 100 person-years in participants with HCM and 0.2, 0.5, and 1.0 per 100 person-years in participants without HCM, respectively. Genetic risk, evaluated as a continuous variable using polygenic risk score, was a less significant predictor of AF in the HCM group (hazard ratio [HR], 1.35 [95% CI, 1.21-1.49]) than in non-HCM group (HR, 1.57 [95% CI, 1.56-1.59]; P=0.005 for interaction). A high genetic risk was significantly associated with the risk of cardiovascular complications in both groups.

CONCLUSIONS

Genetic predisposition is associated with the development of AF and cardiovascular complications in people with and without HCM; this association was weaker in the HCM group.

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.

Catheter Ablation of Atrial Fibrillation in Patients With Psoriasis: A Multicenter Study

BACKGROUND

Psoriasis is linked to an increased risk of atrial fibrillation (AF). However, data on the electrophysiological substrate and outcomes of AF ablation in patients with psoriasis are lacking.

METHODS

We conducted a retrospective, multicenter study involving 48 patients with psoriasis (median age, 66 years [56-72]; 79% male) and paroxysmal (n=25.52%) or persistent AF (n=23.48%) who underwent ablation at 4 high-volume institutions between 2018 and 2023. Propensity score-matching identified 96 controls without psoriasis undergoing AF ablation at the same institutions. The primary end point was survival free from atrial tachyarrhythmia recurrence after an 8-week blanking period.

RESULTS

Baseline clinical characteristics were well balanced between groups. However, patients with psoriasis had higher CRP (C-reactive protein) than controls (0.85 mg/dL [0.45-1.2] versus 0.3 mg/dL [0.3-0.4], P<0.001) and a greater burden of left atrial low-voltage regions at electroanatomical mapping (20% [11%-20%] versus 5% [5%-10%]; P=0.013). Over a median follow-up of 20 (13-32) months, atrial tachyarrhythmia recurrence occurred in a higher proportion of patients with psoriasis (40% versus 24%, log-rank P=0.023). Patients with psoriasis also had a slightly higher risk of acute coronary syndrome (log-rank P=0.045), with similar risks of death (log-rank P=0.517) and procedural complications (2% versus 2%, P=1.000), whereas no stroke occurred. Multivariable analysis identified early recurrence within blanking period (adjusted hazard ratio [aHR], 5.9, P<0.001), preablation CRP levels (aHR, 1.2, P=0.016), and psoriasis history (aHR, 2.2, P=0.046) as predictors of atrial tachyarrhythmia recurrence. In the group with psoriasis, the optimal CRP cutoff associated with atrial tachyarrhythmia recurrence was found to be 1 mg/dL.

CONCLUSIONS

Psoriasis is associated with low-grade systemic inflammation, more severe electroanatomical markers of atrial cardiomyopathy, and worse postablation outcomes. The association between CRP levels and rhythm outcomes suggests that inflammation may drive recurrences among patients with psoriasis undergoing AF ablation.

Bleeding and New Malignancy Diagnoses After Anticoagulation for Atrial Fibrillation: A Population-Based Cohort Study

BACKGROUND

Bleeding after starting anticoagulation for atrial fibrillation (AF) may be the first sign of malignancy, especially in elderly individuals. There are no recommendations to guide investigations for malignancy after new-onset bleeding after anticoagulation for AF. Our objective was to determine the association of bleeding after starting oral anticoagulation for AF with new diagnoses of malignancy in a population-wide sample.

METHODS

We conducted a population-based cohort study using linked administrative data sets of people ≥66 years of age who newly initiated warfarin or direct oral anticoagulants after diagnosis with AF between 2008 and 2022. Follow-up was 2 years after starting anticoagulation. We excluded patients with valvular disease, chronic dialysis, venous thromboembolism, previous cancer, or previously documented bleeding. Bleeding was identified from hospital/emergency department discharge records and physician billings, then handled as a time-varying covariate in cause-specific regression models while adjusting for baseline characteristics. The primary outcome was incident malignancy. We also determined the site of origin of the malignancy and the stage at diagnosis if indicated in the Ontario Cancer Registry. Analyses were repeated while limiting the exposure to specific bleeding sites.

RESULTS

Among 119 480 people (mean age, 77.4 years; 52% men) who started anticoagulants, 26 037 (21.8%) had documented bleeding, and 5800 (4.9%) were diagnosed with malignancy within the next 2 years. Bleeding was associated with a higher hazard of cancer diagnosis with a hazard ratio (HR) of 4.0 (95% CI, 3.8-4.3). The HRs for any malignancy were 5.0 (95% CI, 4.6-5.5) for gastrointestinal, 5.0 (95% CI, 4.4-5.7) for genitourinary, 4.0 (95% CI, 3.5-4.6) for respiratory, 1.8 (95% CI, 1.4-2.2) for intracranial, and 1.5 (95% CI, 1.2-2.0) for nasopharyngeal bleeds. The HRs were substantially higher for cancers concordant with the bleeding site (gastrointestinal, 15.4; genitourinary, 11.8; respiratory, 10.1). Cancers were diagnosed at an earlier stage after bleeding (27.6% stage 4 after bleeding versus 31.3% without bleeding; P=0.029).

CONCLUSIONS

In anticoagulated patients with AF, bleeding was strongly associated with new cancer diagnoses. Antecedent bleeding was associated with cancer diagnosis at an earlier stage. This highlights the importance of timely investigations in patients with bleeding after anticoagulation for AF, rather than attributing bleeding as an expected adverse effect.

Identifying a Heterogeneous Effect of Atrial Fibrillation Screening in Older Adults: A Secondary Analysis of the VITAL-AF Trial

Background

One-time atrial fibrillation (AF) screening trials have produced mixed results; we sought a subset for whom screening is effective.

Methods

We conducted a secondary analysis of VITAL-AF, a randomized trial of one-time, brief, single-lead ECG screening during primary care visits. We tested two approaches to identify a subgroup where screening is effective. First, we developed an effect-based model using a T-learner. Specifically, we separately predicted the likelihood of AF diagnosis under screening and usual care conditions; the difference in probabilities was the predicted screening effectiveness. Second, we used a validated AF risk model to test for heterogeneous screening effectiveness.

Results

In the effect-based analysis, in the highest quartile of predicted screening effectiveness, AF diagnosis rates were higher in the screening group (4.00 vs. 2.88 per 100 person-years, rate difference 1.12, 95% CI 0.11 to 2.13). In the risk-based analysis, in the highest quartile of baseline AF risk, AF diagnosis rates were also higher in the screening group (5.55 vs. 4.23 per 100 person-years, rate difference 1.32, 95% CI 0.14 to 2.50). Predicted screening effectiveness and predicted baseline AF risk were weakly correlated (Spearman correlation coefficient 0.23). Patients with low primary care use, using rate control medications, females, and Black patients were overrepresented in the high-effectiveness group even when they were not at high risk of developing AF.

Conclusions

In a secondary analysis of VITAL-AF, we identified subgroups where one-time screening was associated with increased AF diagnoses using both effect-based and risk-based approaches. In this study, predicted AF risk was only a partial proxy for predicted screening effectiveness. Even when individuals are not in the high-risk subset, features like low primary care use and rate control medication use can identify individuals for whom AF screening has a large impact. Future AF screening efforts should focus on screening both "high-risk" and "high-effectiveness" individuals.

What is Known

Because trials testing office-based screening for atrial fibrillation have produced mixed results, some have suggested we focus screening efforts on high-risk individuals.Newer methods allow us to test for screening heterogeneity using risk-based analyses and separately effect-based analyses, which disentangle screening effects from baseline disease risk.

What the Study Adds

Both the risk-based analysis and the effect-based analysis identified "high-risk" and "high-effectiveness" subgroups, respectively, where one-time AF screening was effective."High-risk" and "high-effectiveness" groups only partially overlap; even when individuals are not in the high-risk subset, features like low primary care use and rate control medication use an identify individuals for whom AF screening has a large impact.Future AF screening efforts should focus on screening both "high-risk" and "high-effectiveness" people.

Domestic water hardness, genetic risk, and distinct phenotypes of cardiovascular disease

AIMS

The study aimed to investigate the association between domestic water hardness and the incidence of AF and the interaction effects between water hardness and genetic susceptibility to incident AF risk. As a secondary objective, its associations with incident heart failure (HF), coronary heart disease (CHD), and stroke were measured.

METHODS

The UK Biobank is a prospective cohort study comprising over 500,000 participants recruited in the United Kingdom between 2006 and 2010, aged 37 to 73 years. A total of 447,950 participants did not have prevalent AF, and 423,946 participants who were free of HF, CHD, and stroke at baseline were included. Water hardness was assessed by CaCO3 concentration. The genetic risk score for AF was based on the standard polygenic risk score. Cox proportional hazards regression models and restricted cubic spline (RCS) analysis were conducted.

RESULTS

During a median follow-up of 13.74 years, 30,726 (6.86%) individuals were diagnosed with AF for the first time. Compared with those with water hardness ≤ 60 mg/L, individuals with domestic water hardness 121-180 mg/L had a 17% lower risk of developing AF (HR 0.83, 95% CI 0.79-0.87), but water hardness of 61-120 mg/L and > 180 mg/L was associated with a higher risk of incident AF (both 1.04, 1.01-1.07). A non-linear relationship between water hardness and incident AF (P for non-linear = 0.001) was found. Individuals with water hardness 121-180 mg/L were also significantly associated with a lower risk of incident HF (HR 0.82, 95% CI 0.75-0.89), CHD (HR 0.80, 95% CI 0.76-0.84) and stroke (HR 0.88, 95% CI 0.81-0.95). There were no significant interaction effects between water hardness level and genetic susceptibility to AF, HF, CHD, and stroke risk (all P for interaction > 0.05).

CONCLUSION

Potential U-shaped associations between domestic water hardness and incident AF across varying levels of genetic risk were found. Hard water (121-180 mg/L) may offer the most benefits compared to soft water when considering overall cardiovascular health, including AF, HF, CHD, and stroke.

Exploration of the relationships between immune cells, metabolic mediators, and atrial fibrillation: A bidirectional Mendelian randomization study

Studies have shown a close correlation among immune cells, plasma metabolites, and atrial fibrillation (AF). However, it is not clear if this association is related, which we used Mendelian randomization (MR) to investigate. We analyzed the association between immune cells, plasma metabolites, and AF by using summarized data from genome-wide association studies. Among them, we explored the associations between immune cells and AF by using bidirectional MR analysis. Combined with mediation analysis and multivariable MR, we further identified potential mediating plasmic metabolites. Results shows that causal relationships between 8 immune cell phenotypes and AF were identified with all 8 exhibiting reverse causality. Furthermore, 22 plasma metabolites have a causal relationship with AF. In addition, 2 immune cell phenotypes including CD25 on IgD + CD38dim and CX3CR1 on CD14 + CD16-monocyte, which were found to have causal relationships with 4 plasma metabolites, including 4-acetamidobutanoate levels, Octadecanedioylcarnitine (C18-DC) levels, Linolenate [alpha or gamma; (18:3n3 or 6)] levels, and N-acetyl-aspartyl-glutamate levels, which might be mediators. Ultimately, only 4-acetamidobutanoate levels, CD25 on IgD + CD38dim, and AF did appear to function as mediators (P-value = .030 < .05). In conclusion, immune cells and plasma metabolites are causally associated with AF. We have identified that 4-acetamidobutanoate levels appear to mediate the pathway linking CD25 on IgD + CD38dim to AF. This finding provides a new perspective for the early prevention and diagnosis of preatrial AF.

Novel tailored very-high-power short-duration radiofrequency ablation around the esophagus guided by left atrial voltage

BACKGROUND

Very-high-power short-duration (vHPSD) radiofrequency (RF) ablation is expected to make shallow lesions and reduce collateral damage. This study investigated the power setting and quality of acute lesions performed by a modified vHPSD RF ablation guided by left atrial (LA) voltage around the esophagus.

METHODS

A voltage map was obtained by an OCTARAY catheter (3-mm spacing) during pacing from the high right atrium. The power setting of the vHPSD was modified according to the LA voltage around the esophagus: 65 W for <1.8 mV, 75 W for <2.7 mV, and 90 W for ≥2.7 mV. The incidence of gaps after the 1st pass and spontaneous, isoproterenol-induced, and adenosine-induced reconnections were evaluated. The limit of esophagus temperature rise was set at 40 °C. Gastric hypomotility was assessed.

RESULTS

A modified vHPSD RF ablation guided by the LA voltage was performed for 450 lesions in 32 patients (median age 73 years, 15 females). The RF setting was 65 W for 221 lesions (49 %), 75 W for 104 lesions (23 %), and 90 W for 125 lesions (28 %). Gaps after the 1st pass were observed in 3 patients (9.4 %). Any reconnections were observed in 6 patients (19 %). Esophageal temperature rises of >40 °C were observed at 39 lesions. RF ablation at the areas modified to 65 W more frequently resulted in esophageal temperature rise of >40 °C than the areas modified to 75 W or 90 W (12 % vs. 5.2 %, p = 0.017). No-gap-no-reconnection lesions were more frequently achieved for lesions ablated with 65 W (216/221 lesions, 98 %) than for lesions ablated with 90 W (113/125 lesions, 90 %, p = 0.004). No gastric hypomotility and atrio-esophageal fistulae were observed.

CONCLUSIONS

The modified vHPSD RF ablation guided by the LA voltage was a reasonable option for reducing the power setting without compromising the acute pulmonary vein isolation quality.

Acromegaly and Cardiovascular Disease: Associated Cardiovascular Risk Factors, Cardiovascular Prognosis, and Therapeutic Impact

Acromegaly is a chronic disease characterized by the excessive production of growth hormone (GH), resulting in elevated levels of insulin-like growth factor-1 (IGF-1). It is associated with a significantly increased risk of cardiovascular complications, including arrhythmias and acromegalic cardiomyopathy, which are major contributors to morbidity and mortality in patients with acromegaly. Providing a comprehensive analysis of the cardiovascular risk factors and cardiovascular diseases associated with acromegaly, as well as examining their impact on prognosis and therapeutic strategies that can improve cardiovascular health in these patients, is key to understanding the magnitude of the problem and optimizing clinical management. The presence of traditional cardiovascular risk factors such as diabetes (with a prevalence ranging from 22.3% to 76.8%), hypertension (from 18% to 77%), and dyslipidemia (up to 61%) is worsened by disease activity and duration, increasing the likelihood of adverse cardiovascular events. Early diagnosis and effective treatment are critical to alleviating these complications, as the normalization of GH and IGF-1 levels can improve cardiovascular prognosis. In addition, comprehensive management, including the control of cardiovascular risk factors and regular assessment of cardiac function, is essential. Data suggest that with appropriate treatment, the incidence of myocardial infarction and stroke can be similar to that in the general population. In conclusion, paying careful attention to cardiovascular complications in patients with acromegaly will not only enhance their quality of life, but may also increase their life expectancy through the effective management of comorbidities associated with this disease.

Who are we bridging? Description of warfarin patients receiving injectable bridging therapy

PURPOSE

The evidence guiding the decision to provide injectable anticoagulant bridging therapy during periods of subtherapeutic warfarin anticoagulation is sparse. This study aims to identify the types of patients currently bridged within an academic medical center's Thrombosis Service, to highlight patient populations for future study of bridging outcomes.

METHODS

This descriptive cohort study included patients taking warfarin managed by University of Utah Health Thrombosis Service who received outpatient enoxaparin bridging between January 1 and December 31, 2022. Anticoagulation indication, reason for bridging, and type of procedure were validated via manual chart review.

RESULTS

During the one-year study period, 181 unique patients (9.4 % of the service's total warfarin population) experienced 244 bridging episodes, mostlyin the periprocedural setting (67.6 %) for gastrointestinal-type procedures (39.4 %). The most common anticoagulation indications in all bridged patients were antiphospholipid syndrome (APS) (23.2 %), venous thromboembolism (VTE) (21.5 %), or a mechanical mitral valve plus another indication (13.3 %). Most bridging episodes for VTE occurred >3 months from the acute event, with the rationale for bridging including breakthrough VTE (31 %) or APS (23 %). Just over one-half of bridged patients fit the guideline-recommended criteria for high thrombotic risk, and just over one-third were low-moderate thrombotic risk.

CONCLUSIONS

In this one-year outpatient study, warfarin patients received enoxaparin bridging most commonly due to a gastrointestinal procedural interruption in the setting of APS, VTE with a prior breakthrough thrombotic event, or mechanical mitral valve. Just over one-third of bridged patients were guideline-classified as low-moderate thrombotic risk, indicating these populations may warrant further investigation or bridging de-escalation.

The Effectiveness of Digital Animation-Based Multistage Education for Patients With Atrial Fibrillation Catheter Ablation: Randomized Clinical Trial

BACKGROUND

Digital education for outpatient patients with atrial fibrillation (AF) has gradually increased. However, research on digital education for patients undergoing atrial fibrillation catheter ablation (AFCA) is limited.

OBJECTIVE

This study aimed to develop a novel digital animation-based multistage education system and evaluate its quality-of-life benefits for patients with AFCA.

METHODS

This randomized controlled clinical trial included 208 patients with AF who underwent catheter ablation in the Department of Cardiology at Renmin Hospital of Wuhan University between January 2022 and August 2023. The patients were randomly assigned to the digital animation intervention (n=104) and standard treatment (n=104) groups. The primary outcome was the difference in the quality of life of patients with atrial fibrillation (AF-QoL-18) scores at 3 months. Secondary outcomes included differences in scores on the 5-item Medication Adherence Report Scale (MARS-5), Self-rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) at 3 months.

RESULTS

In the digital animation intervention group, the AF-QoL-18 score increased from 38.02 (SD 6.52) to 47.77 (SD 5.74), the MARS-5 score increased from 17.04 (SD 3.03) to 20.13 (SD 2.12), the SAS score decreased from 52.82 (SD 8.08) to 45.39 (SD 6.13), and the SDS score decreased from 54.12 (SD 6.13) to 45.47 (SD 5.94), 3 months post discharge from the hospital. In the conventional treatment group, the AF-QoL-18 score increased from 36.97 (SD 7.00) to 45.31 (SD 5.71), the MARS-5 score increased from 17.14 (SD 3.01) to 18.47 (SD 2.79), the SAS score decreased from 51.83 (SD 7.74) to 47.31 (SD 5.87), and the SDS score decreased from 52.78 (SD 5.21) to 45.37 (SD 6.18). The mean difference in AF-QoL-18 score change between the 2 groups was 1.41 (95% CI 2.42-0.40, P=.006) at 3 months. The mean difference in MARS-5 score change was 1.76 (95% CI 2.42-1.10, P<.001). The mean difference in SAS score was -2.91 (95% CI -3.88 to -1.95, P<.001). Additionally, the mean difference in SDS score was -1.23 (95% CI -0.02 to -2.44, P=.047).

CONCLUSIONS

Our study introduces a novel digital animation educational approach that provides multidimensional, easily understandable, and multistage education for patients with AF undergoing catheter ablation. This educational model effectively improves postoperative anxiety, depression, medication adherence, and quality of life in patients at 3 months post discharge.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2400081673; https://www.chictr.org.cn/showproj.html?proj=201059.

Impact of catheter ablation on atrial fibrillation outcomes in various cardiomyopathies: findings from LGE-MRI quantified atrial fibrosis analysis

BACKGROUND

Cardiomyopathy (CM) is associated with atrial remodeling and atrial fibrillation (AF), often complicating rhythm management. Ventricular dysfunction contributes to AF through pressure and volume overload, while AF worsens ventricular function via tachycardia and irregular activation. Evidence suggests catheter ablation improves outcomes in CM patients, though success is influenced by the extent of atrial and ventricular remodeling.

METHODS

Patients undergoing their first catheter ablation for AF were divided into hypertrophic (HCM), ischemic (ICM), non-ischemic (NICM), and no-CM groups. Pre-ablation late-gadolinium enhancement cardiac magnetic imaging (LGE-MRI) was used to assess left atrial (LA) fibrosis burden and anatomical distribution. Patients were followed prospectively for arrhythmia recurrence.

RESULTS

A total of 552 patients, 39 HCM (69% obstructive), 39 ICM, 115 with NICM, and 359 without CM were included between January 2015 and December 2022. LA fibrosis was significantly higher in patients with CM (19.1 ± 7.5% vs. 16.5 ± 6.9%; P = 0.01). HCM and ICM had the greatest LA fibrosis among the different CM subtypes (21.3 ± 8.7% and 21.9 ± 9.1%, respectively). There was no significant difference in the regional distribution of fibrosis among the various groups. AF recurrence was observed in 321 (58.2%) after 456 (175-1204) days. Multivariate analysis revealed that compared to no CM, HCM was associated with a three-fold increase in AF recurrence (HR = 3.07, 95% CI 2.06-4.58, P < 0.001), followed by ICM (HR 1.61, 95%, CI 0.95-2.72; P = 0.07) and NICM (HR of 1.53, 95% CI 1.14-2.06; P = 0.05). LA fibrosis and volume index were independently associated with recurrence (HR = 1.03, 95% CI 1.01-1.06, P = 0.01 and HR = 1.02, 95% CI 1.01-1.03, P = 0.01). Genetic testing revealed key distinctions between HCM and NICM, with MYBPC3 and MYH7 as prominent genes in HCM and a heterogeneous genetic basis in NICM.

CONCLUSION

Hypertrophic cardiomyopathy is associated with the highest risk of AF recurrence followed by ischemic and non-ischemic cardiomyopathy after catheter ablation. LA fibrosis regional patterns did not differ between cardiomyopathy types, while overall fibrosis and volume predicted recurrence.

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.

Predictors of atrial fibrillation freedom postablation with the pentaspline pulsed field ablation catheter: Subanalysis of the ADVENT Study

BACKGROUND

Pulsed field ablation (PFA) has proven to be at least noninferior to thermal ablation for paroxysmal atrial fibrillation (AF). Predictors of AF freedom for PFA have not yet been described.

OBJECTIVE

The purpose of this study was to identify clinical and procedural predictors of treatment success in paroxysmal AF patients treated with the pentaspline PFA catheter.

METHODS

ADVENT (Randomized Controlled Trial for Pulsed Field Ablation versus Standard of Care Ablation for Paroxysmal Atrial Fibrillation) was a prospective randomized trial comparing PFA to thermal ablation with centers designated to randomize patients to either radiofrequency or cryoballoon ablation. Hazard ratios were estimated to evaluate clinical and procedural characteristics associated with ablation success. Subgroup analyses were performed by ablation modality and operator/center experience.

RESULTS

Of the 607 randomized patients (age 62.4 years, 34.6% female), treatment failure was documented in 26.7% of PFA and 28.7% of thermal ablation patients. The most common failure was arrhythmia recurrence (73.8% vs 76.5%) with no difference in subtype (non-AF arrhythmia: 12.1% PFA vs 14.6% thermal). Patients who previously failed Class I/III antiarrhythmic drugs (AADs) were more likely to benefit from PFA (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.44-0.96). Shorter left atrial dwell time was associated with higher success (HR 0.48, 95% CI 0.30-0.76), and a trend toward better outcomes was noted for patients enrolled during the second half of the trial (75.5% vs 69.9%, P = .17). PFA patients had similar success across radiofrequency and cryoballoon centers.

CONCLUSION

PFA with the pentaspline catheter is not associated with a higher incidence of postablation atypical flutters/tachycardias. Patients with previous Class I/III AAD failure are more likely to benefit from PFA and greater operator experience, irrespective of previous thermal modality, may be associated with better outcomes.

Incidence of arrhythmias in chronic obstructive pulmonary disease, obstructive sleep apnea, and overlap syndrome: A retrospective cohort study

BACKGROUND

New-onset arrhythmias are common in patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA). However, scarce data exist regarding arrhythmia risk in overlap syndrome (OS), encompassing COPD and OSA.

OBJECTIVE

We compared the incidence of new-onset atrial and ventricular arrhythmias in patients with COPD, OSA, and OS.

METHODS

We conducted a retrospective cohort study using the TriNetX Network, comprising >140 million patients to identify patients with COPD, OSA, and OS. Patients with pre-existing arrhythmias were excluded. Propensity score matching (PSM) was used to adjust for demographics, comorbidities, and medications. Adjusted odds ratios (aORs) were estimated to compare incidence of arrhythmias across cohorts.

RESULTS

Between 2010 and 2020, a total of 2,438,454 patients with COPD only, 1,960,845 patients with OSA only, and 440,018 patients with OS (age ≥18 years) were identified. After PSM, we included 359,496 patients per cohort for the OS vs OSA-only comparison and 399,235 patients per cohort for the OS vs COPD-only comparison. Over a mean follow-up of 5.3 years, incidence of new-onset atrial fibrillation/flutter was 10.0% in OS vs 7.0% in COPD (aOR 1.472, 95% confidence interval [CI] 1.449-1.496) and 6.4% in OSA (aOR 1.568, 95% CI 1.541-1.595). Patients with OS had higher incidence of new-onset ventricular tachycardia and cardiac arrest than those with COPD (aOR 1.442 and 1.189, respectively) and OSA (aOR 1.645 and 1.777, respectively). Patients with COPD preceding OSA diagnosis had higher odds of new-onset arrhythmias.

CONCLUSION

Patients with OS have a higher incidence of new-onset atrial fibrillation/flutter, ventricular tachycardia, and cardiac arrest compared with those with OSA and COPD alone.

Aggressive ablation vs. regular ablation for persistent atrial fibrillation: a multicentre real-world cohort study

AIMS

Current guidelines for the optimal ablation strategy for persistent atrial fibrillation (PerAF) remain unclear. While our previous RCT confirmed the favourable prognosis of aggressive ablation, real-world evidence is still lacking.

METHODS AND RESULTS

Among 4833 PerAF patients undergoing catheter ablation at 10 centres, two groups were defined: regular ablation (PVI-only or PVI plus anatomical ablation) and aggressive ablation (anatomical plus electrogram-guided ablation), with 1560 patients each after propensity score (PS) matching. The primary endpoint was 12-month AF/atrial tachycardia (AT) recurrence-free survival off anti-arrhythmic drugs after a single procedure. Additional PS matching was performed within the regular group between PVI-only and anatomical ablation (n = 455 each). Furthermore, anatomical ablation from the regular group was independently matched with aggressive ablation (n = 1362 each). At 12 months, the aggressive group showed superior AF/AT-free survival (66.2% vs. 59.3%, P < 0.001; HR 0.745), similar AT recurrence (12.0% vs. 11.3%, P = 0.539), and significantly higher procedural AF termination (67.0% vs. 21.0%, P < 0.001) than regular group. Moreover, patients with AF termination had improved AF/AT-free survival (72.3% vs. 55.2%, P < 0.001). Safety endpoints did not differ significantly between the two groups. Both the ablation outcomes and AF termination rate showed increasing trends with the extent of ablation aggressiveness but declined with extremely aggressive ablation. After additional PS matching, within the regular group, no statistical differences were observed though AF/AT-free survival in the anatomical group was slightly higher than the PVI-only group (60.7% vs. 55.6%, P = 0.122); while aggressive ablation showed improved AF/AT-free survival compared to anatomical ablation alone from regular group (67.5% vs. 59.9%, P < 0.001).

CONCLUSION

Aggressive ablation achieved more favourable outcomes than regular ablation, and moderately aggressive ablation may be associated with better clinical outcomes. AF termination is a reliable ablation endpoint.

Association of comorbidity patterns with outcomes and relation with the ABC pathway effectiveness in European patients with atrial fibrillation

BACKGROUND

Patients with atrial fibrillation (AF) show increasingly complex comorbidity profiles, with detrimental effects on prognosis.

OBJECTIVE

The purpose of this study was to explore patterns of comorbidities in patients with AF.

METHODS

From a European-wide prospective observational registry of AF patients, we performed a latent class analysis to identify patterns of comorbidities. We analyzed association with use of oral anticoagulant (OAC) and with clinical outcomes at 2 years. Primary outcome was a composite of all-cause mortality and major adverse cardiovascular events. Association of the Atrial fibrillation Better Care (ABC) pathway on the risk of primary outcome across groups was also assessed.

RESULTS

A total of 9613 AF patients were included (mean age 68.9 ± 11.4 years, 40.2% female). We identified 5 comorbidity patterns, with increasing clinical complexity phenotypes: low morbidity (46.1%), cardiovascular (25.0%), metabolic (11.3%), "heart failure" (9.7%), and multisystemic pattern (8.0%). OACs were less used in the "heart failure" and multisystemic patterns (odd ratio [OR] 0.69, 95% confidence interval [CI] 0.53-0.90; and OR 0.36, 95% CI 0.26-0.50, respectively), and more used in the metabolic pattern (OR 1.41, 95% CI 1.06-1.86). Compared with the low-morbidity phenotype, all other patterns except for the metabolic pattern were associated with hazard of the primary outcome, with highest magnitude observed for the "heart failure" (hazard ratio [HR] 2.18, 95% CI 1.74-2.72) and multisystemic patterns (HR 2.14, 95% CI 1.62-2.82). Adherence to the ABC pathway was similarly associated with reduced hazard of the primary outcome across all groups (P for interaction = .885).

CONCLUSION

Comorbidities patterns are heterogeneously associated with treatment and prognosis in AF patients. Adherence to the ABC integrated pathway showed similar association with outcomes across all comorbidity patterns.

Interleukin-6: Molecular Mechanisms and Therapeutic Perspectives in Atrial Fibrillation

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia with a multifactorial pathophysiology involving electrical, structural, and autonomic remodeling of the atria. AF is closely associated with elevated interleukin-6 (IL-6) levels, which contribute to atrial remodeling and the progression of AF. This review summarizes the mechanisms by which IL-6 promotes AF through inflammatory pathways, atrial fibrosis, electrical remodeling, and calcium mishandling. Experimental models have demonstrated that IL-6 neutralization reduces the incidence of AF, highlighting its potential as a therapeutic target. Future studies should focus on IL-6 blockade strategies to manage AF, aiming to improve patient outcomes.

Artificial intelligence-derived electrocardiographic aging and risk of atrial fibrillation: a multi-national study

BACKGROUND AND AIMS

Artificial intelligence (AI) algorithms in 12-lead electrocardiogram (ECG) provides promising age prediction methods. This study investigated whether the discrepancy between ECG-derived AI-predicted age (AI-ECG age) and chronological age, termed electrocardiographic aging (ECG aging), is associated with atrial fibrillation (AF) risk.

METHODS

An AI-ECG age prediction model was developed using a large-scale dataset (1 533 042 ECGs from 689 639 participants) and validated with six independent and multi-national datasets (737 133 ECGs from 330 794 participants). The AI-ECG age gap was calculated across two South Korean cohorts [mean (standard deviation) follow-up: 4.1 (4.3) years for 111 483 participants and 6.1 (3.8) years for 37 517 participants], one UK cohort [3.0 (1.6) years; 40 973 participants], and one US cohort [12.9 (8.6) years; 90 639 participants]. Participants were classified into two groups: normal group (age gap < 7 years) and ECG-aged group (age gap ≥ 7 years). The predictive capability of ECG aging for new- and early-onset AF risk was assessed.

RESULTS

The mean AI-ECG ages were 51.9 (16.2), 47.4 (12.5), 68.4 (7.8), and 56.7 (14.6) years with age gaps of .0 (6.8), -.1 (6.0), 4.7 (8.7), and -1.4 (8.9) years in the two South Korean, UK, and US cohorts, respectively. In the ECG-aged group, increased risks of new-onset AF were observed with hazard ratios (95% confidence intervals) of 2.50 (2.24-2.78), 1.89 (1.46-2.43), 1.90 (1.55-2.33), and 1.76 (1.67-1.86) in the two South Korean, UK, and US cohorts, respectively. For early-onset AF, odds ratios were 2.89 (2.47-3.37), 1.94 (1.39-2.70), 1.58 (1.06-2.35), and 1.79 (1.62-1.97) in these cohorts compared with the normal group.

CONCLUSIONS

The AI-derived ECG aging was associated with the risk of new- and early-onset AF, suggesting its potential utility to identify individuals for AF prevention across diverse populations.

Non-traditional risk factors for atrial fibrillation: epidemiology, mechanisms, and strategies

Atrial fibrillation (AF) has become the pre-dominant arrhythmia worldwide and is associated with high morbidity and mortality. Its pathogenesis is intricately linked to the deleterious impact of cardiovascular risk factors, emphasizing the pivotal imperative for early detection and mitigation strategies targeting these factors for the prevention of primary AF. While traditional risk factors are well recognized, an increasing number of novel risk factors have been identified in recent decades. This review explores the emerging non-traditional risk factors for the primary prevention of AF, including unhealthy lifestyle factors in current society (sleep, night shift work, and diet), biomarkers (gut microbiota, hyperuricaemia, and homocysteine), adverse conditions or diseases (depression, epilepsy, clonal haematopoiesis of indeterminate potential, infections, and asthma), and environmental factors (acoustic pollution and other environmental factors). Unlike traditional risk factors, individuals have limited control over many of these non-traditional risk factors, posing challenges to conventional prevention strategies. The purpose of this review is to outline the current evidence on the associations of non-traditional risk factors with new-onset AF and the potential mechanisms related to these risk factors. Furthermore, this review aims to explore potential interventions targeting these risk factors at both the individual and societal levels to mitigate the growing burden of AF, suggesting guideline updates for primary AF prevention.

Effectiveness of the AF-EduCare and AF-EduApp approach to improve atrial fibrillation knowledge and risk factor awareness in patients with atrial fibrillation: a randomized controlled trial

AIMS

Developing an integrated care pathway for atrial fibrillation (AF) patients is of pivotal importance, given the different treatment strategies. Moreover, knowledge about the condition is an important factor in engaging patients in their care. Patient education formed the core of the integrated AF-EduCare/AF-EduApp approach. The main aim of this manuscript is to report the impact of this approach on AF and risk factor (RF)-related knowledge and self-care awareness.

METHODS AND RESULTS

Atrial fibrillation patients (n = 1232) were randomized to standard care (SC) or three educational interventions: in-person, online, or app-based education. Patients in the intervention groups received targeted education based on their responses to the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) and a Self-Care Questionnaire (SCQ) presented at different time points. Patients who received educational follow-up reached a significantly higher knowledge score (in-person: 86.5 ± 13.2%; online: 82.5 ± 19.3%; app: 80.1 ± 15.0%) than the SC group (65.3 ± 16.6%) after 12/18 months (P < 0.001). The knowledge rapidly improved with the first sessions (i.e. 3 months) and remained sustained in all education groups. Patients with RF at baseline showed a slight but significant increase in awareness about their RF through education [e.g. no knowledge of last measured systolic blood pressure compared between education vs. SC: odds ratio of 0.45 (P = 0.012)], a change that was not seen in SC patients. Nevertheless, patients keep under-estimating the presence of their own RFs compared with objective documentation in their medical record (e.g. hypertension).

CONCLUSION

The JAKQ and SCQ are good instruments to provide targeted education to AF patients in daily clinical care. Knowledge level increases clinically significantly, but the impact on awareness about personal risk factors remains unsatisfactory.

REGISTRATION

ClinicalTrials/gov: NCT03707873NCT03788044.

Atrial fibrillation ablation timing: where is the sweet spot?

Convincing evidence for the efficacy of ablation as first-line therapy in paroxysmal AF (PAF) and its clear superiority to medical therapy for rhythm control in both PAF and persistent AF (PsAF) has generated considerable interest in the optimal timing of ablation. Based on this data, there is a widespread view that the principle of 'the earlier the better' should be generally applied. However, the natural history of AF is highly variable and non-linear, and for this reason, it is difficult to be emphatic that all patients are best served by ablation early after their initial AF episodes. Sufficient evidence exists to indicate a conservative approach is reasonable in patients with infrequent and non-progressive episodes (i.e. absence of progressive increase in burden culminating in PsAF) in whom symptoms remain mild and well-controlled. A conservative management phase should be marked by assiduous attention to risk factor modification, changes in frequency and duration of AF episodes, and patient preferences. If and when AF does begin to progress, accumulating evidence indicates that early ablation accompanied by ongoing attention to risk factors provides the best outcomes.

Emotions & Heart:Exploring the Impact of Negative Emotions on Cardiovascular Health

Negative emotions can have a significant impact on individuals, which then influences their cardiovascular system. However, the underlying pathophysiological mechanisms and clinical implications of this association remain inadequately defined. A narrative review of pertinent literature was conducted to examine the pathophysiology, clinical manifestations, and treatment related to the interplay between emotions and conditions such as takotsubo cardiomyopathy, atherosclerosis, acute plaque rupture, and cardiac arrhythmias. Negative emotions can instigate a chronic stress response, which in turn heightens sympathetic nervous system activity and increases vulnerability to cardiovascular diseases. This intricate relationship between emotional states and cardiovascular health underscores the necessity for targeted lifestyle interventions and clinical strategies aimed at mitigating the adverse effects of negative emotions.

Atrial Fibrillation in Heart Failure Due to Congenial Heart Disease

Atrial arrhythmia is the most common complication in the adult congenital heart disease population, and with an aging population, atrial fibrillation is rapidly increasing in prevalence-particularly in those with concomitant heart failure. There is much to be determined regarding the pathophysiology of atrial fibrillation in the adult congenital heart disease population, but it is likely linked to the congenital heart defects, shunts, surgical patches, and coexisting hemodynamic lesions associated with the congenital heart disease process and physiology. This review focuses on the management of atrial fibrillation and heart failure in patients with adult congenital heart disease.

Antithrombotic therapy in patients with atrial high-rate episodes (AHREs): Current evidence and open questions

With the increasing use of cardiac electronic implantable devices in recent years, the identification of asymptomatic atrial arrhythmias, including atrial high-rate episodes (AHREs) and device-detected subclinical atrial fibrillation (SCAF), has become common in clinical practice. AHREs have potentially important clinical implications because they are considered precursors of atrial fibrillation (AF). Although to a lesser extent than clinical AF, both AHREs and device-detected SCAF are associated with thromboembolic events, however routine use of anticoagulants in these conditions is not recommended. In addition, patients with AHREs are at increased risk of cardiovascular events, including myocardial infarction, heart failure, and cardiovascular hospitalization. The relationship between stroke and AHREs and the potential benefit of anticoagulant therapy in this setting is the subject of ongoing debate. In this review, we aimed to appraise the available evidence and current gaps in the risk stratification and management of patients with AHREs/device-detected SCAF.

Nonsevere hypertensive disorders of pregnancy and oral antihypertensive medications: an argument against use

Hypertensive disorders of pregnancy, including gestational hypertension and preeclampsia, affect approximately 13% of all pregnancies and are a major cause of maternal and neonatal morbidity and mortality worldwide. Although the treatment of preeclampsia with severe features has been well established on the basis of randomized controlled data, international society guidelines vary on the treatment of gestational hypertension and preeclampsia without severe features. The American College of Obstetricians and Gynecologists recommends against the use of antihypertensive agents for nonsevere hypertension (blood pressure of <160/110 mm Hg) in both gestational hypertension and preeclampsia without severe features given a lack of level 1 evidence in support of treatment and the theoretical risk of masking of disease progression or causing adverse fetal effects, such as growth restriction. However, with the publication of the Chronic Hypertension in Pregnancy trial, (CHAP) which demonstrated the benefit of treatment of nonsevere chronic hypertension, "indication creep" or the application of a treatment outside the population of proven benefit is being observed with the use of antihypertensive medication for the treatment of nonsevere hypertension in gestational hypertension and preeclampsia without severe features. The use of antihypertensive treatment in this population without a definitive trial and no clearly defined safety protocols is potentially dangerous and could, at worst, lead to maternal and fetal harm or, at best, provide benefit in ways that are hard to assess and, thus, interfere with efforts to generate definitive evidence to change practice guidelines, denying many pregnant patients optimal care. It is imperative that a definitive trial be performed performed prior to the widespread use of antihypertensive treatment for gestational hypertension or preeclampsia without severe features.

Elucidating the Linkage Between Obesity-Related Body Fat Indicators and Atrial Fibrillation: Supported by Evidence From Mendelian Randomization and Mediation Analyses

OBJECTIVES

To elucidating the linkage between obesity-associated body fat indicators and atrial fibrillation (AF) using Mendelian Randomization (MR) and mediation analysis.

METHODS

The study utilized three independent genome-wide association study (GWAS) datasets, with containing over 450 000 individuals each, to represent body fat indicators as the exposure variable. Additionally, two summary genetic datasets of AF were utilized as the clinical outcome. Single nucleotide polymorphisms (SNPs) with p-values less than 5 × 10-10 were identified as instrumental variables (IVs) for MR analysis. The primary analysis method employed was the inverse-variance weighting (IVW) model, supplemented by three additional models: MR-Egger regression, weighted median, and maximum likelihood. Sensitivity analysis was conducted, encompassing tests for heterogeneity and horizontal pleiotropy, utilizing Cochran's Q, MR-Egger intercept, and MR-PRESSO tests to validate the reliability of the findings. Furthermore, a mediation analysis was conducted to explore potential mediators involved in the pathogenesis of AF.

RESULTS

The IVW model demonstrated that per 1-SD increase in body fat indicators (body fat percentage, whole body fat mass, and trunk fat mass) is associated with an elevated risk of AF, with values of 63.1%, 55.0%, and 55.8% respectively. All three supplementary models arrived comparable conclusions with IVW model. The sensitivity analysis confirmed the absence of horizontal pleiotropy, thereby validating the reliability of the findings. Additionally, the mediation study indicates that hypertension and sleep apnea syndrome are identified as significant mediators during the pathogenesis of AF.

CONCLUSIONS

The study reveals that individuals with a higher body fat percentage tend to exhibit a heightened genetic predisposition for susceptibility to AF. Meanwhile, hypertension and sleep apnea syndrome have been identified as key mediators contributing to the pathogenesis of AF.

Bleeding Complications Following Paracentesis in Patients Taking Apixaban

Background Both ascites and thrombosis are common complications of liver disease. Abdominal paracentesis to drain ascites has a low reported risk of hemorrhage, but it is unknown how exposure to direct oral anticoagulants (DOACs) such as apixaban increases this risk. Objectives We aim to quantify the rate of major bleeding and identify additional risk factors for bleeding in patients on apixaban undergoing paracentesis. Methods We performed a retrospective cohort study for all patients exposed to apixaban within seven days prior to paracentesis at a single US academic hospital between January 1, 2016, and April 1, 2022. Abstracted data included the presence or absence of hemorrhagic complications, dosing and timing of apixaban administration, and patient comorbidities. Results We identified 365 paracenteses in 91 unique patients. There were 20 (5.5%) reported hemorrhages, nine (2.5%) of which were plausibly related to the procedure. Four (1.1%) patients suffered fatal hemorrhage. Patients taking 10 mg twice daily of apixaban (3/8, 38%), co-prescription of apixaban with more than one additional antiplatelet or anticoagulant (3/16, 19%), apixaban taken within six hours of the procedure (6/37, 16%), and inpatient status (8/158, 5.1%) were associated with bleeding. While internal medicine residents (3/38, 7.9%) had a higher rate of hemorrhage than interventional radiologists (6/289, 2.1%), this difference was negligible when restricted to inpatients (3/38 versus 5/100). Conclusions The rate of bleeding after paracentesis for patients taking apixaban was much higher than historical estimates. Apixaban exposure, especially on high doses, within six hours of the procedure or on additional anticoagulant medications, significantly increases the rate of hemorrhagic complications of paracentesis.

Safe and effective anticoagulation use: case studies in anticoagulation stewardship

Anticoagulant use is prevalent and associated with significant potential for harm. Anticoagulation stewardship practice has emerged to address care gaps and promote safe, effective, and cost-conscious anticoagulation use across health care systems. We present 4 patient cases describing common challenges in anticoagulation management: inappropriate dosing of direct oral anticoagulants, the diagnosis and management of heparin-induced thrombocytopenia, periprocedural anticoagulation management, and heavy menstrual bleeding on anticoagulation. We discuss available examples of successful stewardship programs that can address the challenges of each case, demonstrating how an investment in anticoagulation stewardship can improve patient outcomes.

Increasing Very Low-Dose Edoxaban Prescription: Effectiveness and Safety Data of Korean AF Patients

BACKGROUND AND OBJECTIVES

Evidence remains limited on the real-world prescription of very low-dose oral anticoagulation among frail patients with atrial fibrillation (AF). We described the practice patterns, effectiveness, and safety of very low-dose edoxaban (15 mg once daily).

METHODS

Patients with AF prescribed edoxaban 15 mg once daily in 2 tertiary hospitals between 2016 and September 2022 were included. Baseline clinical characteristics and clinical outcomes of interest were thromboembolic and bleeding events.

RESULTS

A total of 674 patients were included (mean age 78.3±9.1, 49.7% aged ≥80 years, 49.3% women, median follow-up 1.0±1.2 years). Mean CHA2DS2-VASc score was 3.9±1.6, and the modified HAS-BLED score was 2.0±1.1. Between 2016 and 2022, the number of very low-dose edoxaban prescriptions increased. The main reasons for the prescription of very low-dose were low body weight (55.5% below 60 kg), anaemia (62.8%), chronic kidney disease (40.2%), active cancer (15.3%), concomitant anti-platelet use (26.7%), and prior major bleeding (19.7%). During a median follow-up duration of 8 (interquartile range 3-16) months, overall thromboembolic and bleeding events occurred in 16 (2.3%) and 88 (13.1%) patients, respectively. Compared to the expected event rates on the established risk scoring systems, patients receiving very low-dose edoxaban demonstrated a 61% reduction in ischemic stroke, a 68% reduction of ischemic stroke/transient ischemic attack/systemic embolism, whereas a 49% increase in major bleeding.

CONCLUSIONS

The prescription of very low-dose edoxaban was increased over time, attributable to various clinical factors. The use of very low-dose edoxaban reduced the expected risk of thromboembolic events.

Anticoagulants: From chance discovery to structure-based design

Taking a historical perspective, we review the discovery, pharmacology, and clinical evaluation of the old and new anticoagulants that have been approved for clinical use. The drugs are discussed chronologically, starting in the 1880s, and progressing through to 2024. The innovations in technology used to develop novel anticoagulants came in fits and starts and reflected the advances in science and technology over these decades, whereas the shift from anecdote to evidence-based use of anticoagulants was delayed until the principles of epidemiology and biostatistics were introduced into clinical trial design and to the approval process. Hirudin, heparin, and vitamin K antagonists were discovered by chance, and were used clinically before their mechanism of action was elucidated and before their net clinical benefits were evaluated in randomized clinical trials. Subsequent anticoagulants were designed based on a better understanding of the structure and function of coagulation proteins, including antithrombin, thrombin, and factor Xa, and underwent more rigorous preclinical and clinical evaluation before regulatory approval. By simplifying oral anticoagulation, the direct oral anticoagulants have revolutionized anticoagulation care and have enhanced the uptake of anticoagulation, but bleeding has not been eliminated and there is a need for more effective and convenient anticoagulants for thrombosis triggered by the contact pathway of coagulation. The newly developed factor XIa and XIIa inhibitors have the potential to address these unmet clinical needs and are undergoing clinical evaluation for several indications. SIGNIFICANCE STATEMENT: Anticoagulant therapy is the cornerstone of treatment and prevention of thrombosis, which remains a leading cause of morbidity and mortality worldwide. Elucidation of the structure and function of coagulation enzymes, their cofactors, and inhibitors, coupled with advances in structure-based design led to the discovery of more convenient, safer, and more effective anticoagulants that have revolutionized the management of thrombotic disorders.

[Catheter ablation in patients with heart failure-who benefits?]

Atrial fibrillation (AF) ablation is associated with a lower likelihood of death and surgical heart failure (HF) interventions in patients with HF. This effect is mainly driven by reduced all cause and cardiovascular death following ablation. Ablation also results in improved left ventricular (LV) function, decreased AF burden and AF regression. The accumulated evidence contributed substantially to a class 1 indication for AF ablation in patients with AF and HF with reduced ejection fraction in the 2023 ACC/AHA/ACCP/HRS guidelines. Risk scores like the CASTLE-HTx risk score may help to identify patients with HF who will particularly benefit from catheter ablation. The absolute benefit of catheter ablation is more pronounced in high-risk patients and is sustained over time. Catheter ablation should be considered as first-line therapy with a definitive class 1 indication for many patients with HF, particularly those with advanced HF.

Atrial Fibrillation in Patients with Breast Cancer: A Literature Review

In addition to traditional risk factors, patients with breast cancer are at an increased risk of atrial fibrillation due to cancer itself and certain cancer therapies. Atrial fibrillation in these patients adds to their morbidity and mortality. The precise mechanisms leading to the increased atrial fibrillation in patients with breast cancer are not well understood. The main goal of atrial fibrillation management in this population is to facilitate uninterrupted cancer treatment while addressing the arrhythmia and other cardiovascular sequelae of cancer treatment. Rhythm control is often challenging to implement in patients with breast cancer during active antineoplastic therapy because of the need for uninterrupted anticoagulation, potential drug-drug interactions between cancer treatments and antiarrhythmic medications, and the increased likelihood of atrial fibrillation recurrence. Prevention of thromboembolism and anticoagulation can also be challenging in patients with breast cancer as a result of the increased risk of cancer-related procoagulant state and coagulopathies. The integration of a cardio-oncology team and a multidisciplinary approach are crucial for better outcomes. The therapeutic interventions should be tailored toward individual patients' profiles through a shared decision-making approach. The precise mechanisms leading to the increased atrial fibrillation in patients with breast cancer are not well understood, highlighting the gaps in our knowledge. More research is required to reduce these gaps, refine risk stratification, and optimize treatment strategies in these patients.

Direct Oral Anticoagulants Versus Warfarin in Patients With Isolated Heparin-Induced Thrombocytopenia or Heparin-Induced Thrombocytopenia With Thrombosis

No existing studies compare oral anticoagulants to treat heparin-induced thrombocytopenia with or without thrombosis (HIT/HITT). This retrospective study evaluated thrombotic and bleeding outcomes in adults treated for HIT/HITT with a direct oral anticoagulant (DOAC) or warfarin between 2012 and 2023 within the Ochsner Health System. Patients with mechanical heart valves, valvular atrial fibrillation, antiphospholipid syndrome, active malignancy, or venous thromboembolism (VTE) within the previous 6 months were excluded. The primary outcome was a composite of new or progressive VTE or arterial thromboembolism. Secondary outcomes included major and clinically relevant non-major bleeding, duration of hospitalization, time to platelet recovery, and incidence of skin necrosis, gangrene, and amputation. Forty-nine patients receiving a DOAC and 30 patients receiving warfarin were included. Baseline characteristics were similar between cohorts. There were non-statistically significant increased rates of both the primary outcome (8.9% vs. 4.3%, p = 0.65) and the composite bleeding outcome (32.7% vs. 23.3%, p = 0.37) in the DOAC cohort. Larger, prospective studies are needed to confirm these findings.

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.

Cost Effectiveness of Catheter Ablation Versus Antiarrhythmic Drugs for Atrial Fibrillation: A Systematic Review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and is associated with substantial morbidity and mortality. Current international guidelines recommend antiarrhythmic drugs or catheter ablation (CA) as rhythm-control strategies for AF. This study aimed to comprehensively assess economic evaluations (EEs) of the treatment of AF by country income level.

METHODS

Seven electronic databases were systematically searched for EE literature until March 30, 2024, with no constraints on time or language. Two independent reviewers selected the studies, extracted the data, and assessed the quality of the data. Full EEs comparing CA with antiarrhythmic drugs for rhythm-control treatment were included; surgical or rate-control treatments were excluded. The quality of the included articles was assessed using the ECOBIAS checklist. Costs were converted to purchasing power parity US dollars for 2023. A random-effects meta-analysis was applied to pool incremental net benefit (INB) based on a heterogeneity test and its degree (I2 > 25% or Cochran's Q test < 0.1). We also explored heterogeneity and potential publication bias and conducted sensitivity and subgroup analyses.

RESULTS

In total, 27 studies across nine countries were eligible, predominantly from high-income countries (n = 25), with a smaller subset from upper-middle-income countries (n = 2). Because of the heterogeneity among the studies, a random-effects model was selected over a fixed-effects model to pool INBs. Most studies (n = 21) favored CA as the cost-effective intervention, yielding an INB of $US23,796 (95% confidence interval [CI] 15,341-32,251) in high-income countries. However, heterogeneity was substantial (I2 = 99.67%). In upper-middle-income countries, the estimated INB was $US18,330 (95% CI - 11,900-48,526). The publication bias results showed no evidence of asymmetrical funnel plots.

CONCLUSION

In this meta-analysis, CA emerged as a cost-effective rhythm-control treatment for AF when compared with antiarrhythmic drugs, particularly in high-income countries. However, economic evidence for upper-middle-income countries is lacking, and no primary evaluations were found for low-middle-income and low-income countries. Further EEs are necessary to expand the understanding of AF treatment globally.

Early vs later non-vitamin K antagonist oral anticoagulants in patients with acute ischemic stroke and atrial fibrillation: A meta-analysis and systematic review of randomized trials

BACKGROUND

There are conflicting published data on the optimal timing of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with acute ischemic stroke.

OBJECTIVE

To compare the efficacy and safety of early initiation of NOACs with later initiation of NOACs in those patients, we conducted a meta-analysis of phase 3 or phase 4 randomized controlled trials.

METHODS

We systematically searched the Cochrane Library, PubMed, and Embase databases. A random effects model was selected to pool the effect measurement estimates (risk ratios [RRs] and 95% confidence intervals [CIs]).

RESULTS

Three randomized controlled trials with 6442 enrolled patients with AF and acute ischemic stroke were included. Compared with later NOAC therapy, early NOAC therapy was associated with nonsignificant reductions in the risk of primary outcomes (RR, 0.82; 95% CI, 0.65-1.05). Subgroup analysis found that in reducing risk of primary outcomes, early anticoagulation may benefit female patients more than male patients (0.54 [0.35-0.83] vs 0.97 [0.63-1.50]; P for interaction, .06). Numerically lower rates of recurrent ischemic stroke (RR, 0.80; 95% CI, 0.56-1.15), death (RR, 0.96; 95% CI, 0.81-1.15), and systemic embolism (RR, 0.43; 95% CI, 0.16-1.11) were observed in early initiation of NOACs in comparison with later initiation of NOACs. There was no difference in major bleeding (RR, 0.98; 95% CI, 0.55-1.74), symptomatic intracranial hemorrhage (RR, 0.93; 95% CI, 0.43-1.96), or major extracranial bleeding (RR, 0.73; 95% CI, 0.28-1.95) between groups.

CONCLUSION

In AF patients with acute ischemic stroke, early initiation of NOACs is not inferior to later initiation of NOACs in reducing composite events, without increased hazard of bleeding, especially in female patients.

Sacubitril-Valsartan Lowers Atrial Fibrillation Recurrence and Left Atrial Volume Post-catheter Ablation: Systematic Review and Meta-Analysis

INTRODUCTION

In patients with atrial fibrillation (AF) who have undergone catheter ablation, the comparative effectiveness of sacubitril-valsartan (SV) versus ACE inhibitors (ACEi) or angiotensin-receptor blockers (ARB) in preventing AF recurrence remains unclear. The purpose of the present systematic review and meta-analysis is to determine whether SV offers superior outcomes in this clinical setting.

METHODS

This study systematically reviewed PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating SV's efficacy in preventing AF recurrence after catheter ablation. Outcomes included AF recurrence and structural remodeling assessed via left ventricular ejection fraction (LVEF) and left atrial volume index (LAVi), with statistical analyses performed using Review Manager 5.1.7 and heterogeneity assessed via I2 statistics.

RESULTS

The analysis comprised 642 patients from three RCTs and one PMC (319 SV-treated). SV significantly reduced AF recurrence [risk ratios (RR) 0.54; 95% confidence intervals (CI) 0.41-0.70; p < 0.00001; I2 = 0%), a trend also observed when considering RCTs exclusively (RR 0.58; 95% CI 0.41-0.84; p = 0.004; I2 = 0%). Moreover, SV demonstrated a notable reduction in LAVi [mean deviation (MD) -5.34 mL/m2; 95% CI -8.77 to -1.91; p = 0.002; I2 = 57%] compared with ARB, alongside a significant improvement in LVEF (MD 1.83%; 95% CI 1.35-2.32; p < 0.00001; I2 = 0%). Subgroup analyses among patients with hypertension and LVEF < 50% also indicated lower AF recurrence with SV.

CONCLUSION

SV therapy exhibited superior efficacy in reducing AF recurrence compared with ACEi or ARB and demonstrated superior outcomes in attenuating atrial structural remodeling after catheter ablation. These findings underscore the potential of SV as a therapeutic option for patients with AF undergoing catheter ablation, highlighting its efficacy in mitigating AF recurrence and structural remodeling.

REGISTRATION

PROSPERO identifier number CRD42024497958.

Analysis of The 2024 ESC/EACTS Guidelines For The Management Of Atrial Fibrillation

The 2024 European Society of Cardiology guidelines for atrial fibrillation (AF) emphasize a patient-centered approach to management, structured around the AF-CARE pathway: Comorbidity and risk factor management (C), Avoiding stroke and thromboembolism (A), Reducing symptoms through rate and rhythm control (R), and Evaluation and dynamic reassessment (E). This framework ensures that comorbidities such as hypertension, heart failure, diabetes, and obesity are effectively managed to prevent disease progression and improve outcomes. A key principle of the guidelines is shared decision making involving patients, families, caregivers, and healthcare teams to ensure individualized care that reflects patient preferences. The guidelines also stress healthcare equity, advocating for the elimination of disparities related to sex, ethnicity, disability, and socioeconomic status. For diagnosis, electrocardiographic confirmation of clinical AF is essential, followed by risk stratification using the CHA₂DS₂-VASc score to guide anticoagulation therapy. Direct oral anticoagulants are preferred for most patients because of their good safety profile. Stroke prevention is prioritized, with rhythm control as first-line treatment for suitable patients. For those with persistent symptoms despite medications, catheter ablation is recommended. Rate control strategies, including beta-blockers, digoxin, and calcium channel blockers, are used to manage heart rate and symptoms. Ongoing education for patients, families, and providers supports informed decision making and dynamic reassessment, optimizing patient outcomes and quality of life.

Exercise-based cardiac rehabilitation for patients with atrial fibrillation: a narrative review

The role of physical activity (i.e. any bodily movement that requires energy expenditure) and exercise (i.e. planned, structured, and repetitive physical activity to improve/maintain fitness) in the primary and secondary prevention of atrial fibrillation (AF) is increasingly recognized. Physical activity has been associated with lower risks to develop AF and associated complications (e.g. stroke, heart failure, and myocardial infarction). Exercise-based cardiac rehabilitation (ExCR) is increasingly examined in the treatment of AF and sometimes combined with rhythm control strategies (e.g. catheter ablation). Nonetheless, several important clinical, practical, and mechanistic questions remain not fully understood. This state-of-the-art review first provides a contemporary update on the evidence base for the clinical effects of ExCR in AF. Despite the ongoing need for high-quality studies, existing randomized controlled trials and cohort studies suggest ExCR reduces AF burden, lowers risks for major adverse cardiovascular events, and improves health-related quality of life. Second, to facilitate implementation of ExCR, we have observed comparable effects of distinct exercise protocols (e.g. type of training and centre-/home-based) and discussed similarity of effectiveness across patient characteristics (e.g. age, sex, and AF subtype). Critically, we have discussed potential barriers that may prohibit the uptake of ExCR for patients with AF, categorized at clinician- (e.g. referral and training), patient- (e.g. motivation, transportation, and psychosocial factors), and system-levels (e.g. insurance and resources). Third, we have summarized the potential mechanisms underlying these effects of ExCR, classified by their potential role in reducing AF burden (e.g. atrial/ventricular function, autonomic balance, and inflammation) and lowering risks for adverse events (e.g. modifiable risk factors, vascular function, and thrombogenesis). Based on the increasing evidence for clinical benefits, e.g. improved health-related quality of life and better clinical outcomes, we advocate stronger focus on regular physical activity and referral to multidisciplinary ExCR for sustainable lifestyle changes within the ESC AF-CARE pathway for the prevention and treatment of AF.

Risk of Bleeding, Thrombosis and Death among Atrial Fibrillation Patients Treated with Oral Anticoagulants Across Estimated Glomerular Filtration Rates

There are limited data about the clinical benefits and harm of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) and chronic kidney disease using CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine equation for glomerular filtration rate (GFR) estimation in nuanced GFR stratification. We conducted a retrospective study in 12 centers in China and included 9,510 patients with AF. We grouped patients into the following estimated GFR (eGFR) categories: ≥60 (n = 7,616), 45 to 59 (n = 1,139), 30 to 44 (n = 474), and <30 (n = 281) ml/min/1.73 m2. Logistic regression was used to the compare risks of major bleeding, minor bleeding, total bleeding, thrombosis, and all-cause deaths in patients with AF with eGFR 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and ≥60 ml/min/1.73 m2 after taking OACs. Patients with AF treated with OACs with eGFR 45 to 59, 30 to 44, and <30 ml/min/1.73 m2 had a significantly increased risk of all-cause deaths compared with eGFR ≥60 ml/min/1.73 m2 (adjusted odds ratio [aOR] 1.326, 95% confidence interval [CI] 1.049 to 1.665, p = 0.016; aOR 1.634, 95% CI 1.197 to 2.200, p = 0.002; aOR 2.492, 95% CI 1.766 to 3.471, p <0.001; respectively). Higher eGFR was associated with a significantly lower risk of all-cause deaths (aOR 0.990, 95% CI 0.986 to 0.994, p <0.001) and major bleeding (aOR 0.988, 95% CI 0.979 to 0.998, p = 0.018). Direct OACs remarkably reduced risk of major bleeding in those with eGFR 30 to 44 ml/min/1.73 m2 compared with warfarin. In conclusion, in patients with AF treated with OACs, patients with eGFR 45 to 59, 30 to 44, and <30 ml/min/1.73 m2 had a significantly increased risk of all-cause deaths compared with eGFR ≥60 ml/min/1.73 m2, and the risk of all-cause deaths increased with decreasing eGFR. Direct OACs are at least safe alternatives to warfarin in patients with AF with eGFR 30 to 44 ml/min/1.73 m2.

Metoprolol vs diltiazem for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysis of adverse events

BACKGROUND

Intravenous (IV) diltiazem and metoprolol are commonly used to achieve rate control for atrial fibrillation with RVR (Afib with RVR), and are both recommended as first-line by current guidelines. While prior studies investigated the efficacy of these medications, there is little evidence available regarding the risk of adverse events (AEs) with their use.

METHODS

We identified randomized controlled trials (RCT) and observational studies reporting rates of AEs following administration of IV diltiazem and metoprolol for Afib with RVR by searching PubMed, SCOPUS, EMBASE, and Cochrane Library. Our primary outcome was the incidence of AEs and specifically hypotension and bradycardia, which were examined individually as secondary outcomes. We performed random-effects meta-analysis to identify rates of each AE. We used moderator analysis and meta-regressions to evaluate risk factors. We used the Cochrane Risk-of-Bias 2 tool and the Newcastle-Ottawa Scale to assess study quality.

RESULTS

We reviewed 13 studies and included 1660 patients, 888 (53 %) treated with metoprolol and 772 (47 %) with diltiazem. Metoprolol was associated with a 26 % lower risk of AE (total incidence 10 %) compared to diltiazem (total incidence 19 %), (RR 0.74, 95 % CI 0.56-0.98, p = 0.034) with a prediction interval of 0.50-1.10. Patients with higher initial heart rates faced higher rates of AEs (Correlation Coefficient 0.11, 95 % CI 0.03-0.19, p = 0.006). There was no difference with respect to rates of bradycardia (RR 0.44, 95 % CI 0.15-1.30, p = 0.14) or hypotension (RR 0.80, 95 % CI 0.61-1.04, p = 0.10).

CONCLUSION

Afib with RVR treated with metoprolol had lower rates of AE (bradycardia and/or hypotension) compared to those treated with diltiazem. We found no difference in rates of hypotension or bradycardia when individually assessed. Existing data are limited by small sample sizes, variability in dosing, and limited representation of important patient subgroups.

Prevention of New-Onset Heart Failure in Atrial Fibrillation: The Role of Pharmacological Management

Atrial fibrillation (AF) is the most common type of chronic arrythmia, with a lifetime prevalence of one in every three to five individuals above the age of 45 years. The higher heart rate, abnormal rhythm and inflammation caused by AF lead to changes in the function and structure of the heart. This, over time, can culminate in heart failure. In patients with AF, the lifetime prevalence of new-onset heart failure is twice that of stroke. The development of new-onset heart failure in AF is associated with high mortality. Despite the emphasis that AF guidelines put on preventing cardiovascular comorbidities, there is limited evidence regarding pharmacological therapies to prevent incident heart failure in individuals with AF. Specifically, the association between the use of rate control agents and incident heart failure in this population is unknown. Whilst rhythm control may reduce the risk of heart failure, the comparative effect of each pharmacological agent is not clear. In select subgroups of patients with AF, the choice of direct-acting oral anticoagulants and their optimal dosing has been attributed to a lower risk of new-onset heart failure. Future research is needed to identify an evidence-based approach to minimizing the development of heart failure in patients with AF.

Catheter ablation for atrial fibrillation in patients with significant mitral regurgitation: A systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) is commonly associated with cardiac structural abnormalities including mitral regurgitation (MR). Contemporary guidelines recommend consideration of early rhythm control strategies including catheter ablation (CA) for AF. However, the long-term efficacy of CA is highly variable across studies and patient populations, and the effect of coexisting MR on AF recurrence remains unclear.

OBJECTIVE

A systematic review and meta-analysis was performed to determine the impact of significant MR (defined as ≥moderate) on AF recurrence rate after CA and whether CA for AF is associated with significant changes in the severity of MR.

METHODS

A systematic search of PubMed, Embase, Web of Science, and Cochrane databases for all English-language studies published to December 31, 2023, was performed.

RESULTS

A total of 17 studies (N = 2624 patients) were retained for meta-analysis. The pooled recurrence proportion of AF after CA in patients with baseline significant MR was 36% (95% CI, 27%-46%) compared with 27% (14%-41%) in patients without. The pooled hazard ratio (95% CI) for AF recurrence after CA in the presence of significant MR was 2.47 (1.52-4.01; P < .001; Egger test P value, .0583). The pooled proportion of patients who witnessed MR improvement to nonsignificant (ie,

CONCLUSION

Baseline significant MR was independently predictive of AF recurrence rate after CA. Despite the increased AF recurrence rates after CA associated with significant MR, CA with maintenance of sinus rhythm appeared to improve the severity of MR, suggesting a possible induction of reverse positive atrial and mitral valvular remodeling.

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Key Words

• Atrial fibrillation
• Catheter ablation
• Mitral regurgitation
• Pulmonary vein isolation
• Review

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MESH Headings

• Humans
• Atrial Fibrillation/surgery
• Atrial Fibrillation/complications
• Atrial Fibrillation/physiopathology
• Catheter Ablation/methods
• Mitral Valve Insufficiency/complications
• Mitral Valve Insufficiency/physiopathology
• Recurrence

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Affiliation(s)

Ross A Okazaki Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
Lillian C Flashner Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
Scott Kinlay Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
Adelqui O Peralta Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
Peter S Hoffmeister Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
Hirad Yarmohammadi Department of Medicine, Columbia University, New York, New York
Jacob Joseph Department of Medicine, Brown University, Providence, Rhode Island; Department of Medicine, VA Providence Healthcare System, Providence, Rhode Island
Matthew F Yuyun Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.

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