Follow-up management of patients receiving direct oral anticoagulants

Over the last years, direct oral anticoagulants (DOACs) have radically changed and simplified the therapeutic approach and management of patients on anticoagulant therapy. For these patients, international guidelines recommend to set up a regular follow-up (every 1-6 months) to re-enforce education, to ensure adequate adherence and persistence to treatment. In real-life setting, the application of the suggested follow-up regimens and incidence rates of thrombotic and bleeding complications related to the intensity of follow-up strategies has not been described. We conducted a multicentre, retrospective study at 4 Italian Thrombosis Centres to describe follow-up strategies of patients on DOACs treatment and to assess the incidence of bleeding and thrombotic complications. We enrolled 534 patients, with median follow-up 24 months: 52.1% had < 3 visits/year (group 1), while 47.9% required ≥ 3 visits/year (group 2). Mean age and gender were similar between the 2 groups, while severe anaemia (4.4% and 1.2%, p 0.03) and creatinine clearance < 50 mL/min were more common in group 2 (26.8% and 17.8%, p 0.02). The incidence of thromboembolic events was 3.9% in group 2 and 1.1% in group 1 (p 0.03). Major bleeding rates were non-significantly higher in group 2, whereas non-major bleeding rates occurred significantly more frequently in group 2 (26.6% and 18.7%, respectively, p 0.03). A tailored follow-up program is of critical importance to correctly manage patients on DOACs. A less intense follow-up management is feasible and safe for a substantial proportion of patients, provided they are carefully identified at specialized centres.

Small Conductance Ca2 +-Activated K+ (SK) Channel mRNA Expression in Human Atrial and Ventricular Tissue: Comparison Between Donor, Atrial Fibrillation and Heart Failure Tissue

In search of more efficacious and safe pharmacological treatments for atrial fibrillation (AF), atria-selective antiarrhythmic agents have been promoted that target ion channels principally expressed in the atria. This concept allows one to engage antiarrhythmic effects in atria, but spares the ventricles from potentially proarrhythmic side effects. It has been suggested that cardiac small conductance Ca²⁺-activated K⁺ (SK) channels may represent an atria-selective target in mammals including humans. However, there are conflicting data concerning the expression of SK channels in different stages of AF, and recent findings suggest that SK channels are upregulated in ventricular myocardium when patients develop heart failure. To address this issue, RNA-sequencing was performed to compare expression levels of three SK channels (KCNN1, KCNN2, and KCNN3) in human atrial and ventricular tissue samples from transplant donor hearts (no cardiac disease), and patients with cardiac disease in sinus rhythm or with AF. In addition, for control purposes expression levels of several genes known to be either chamber-selective or differentially expressed in AF and heart failure were determined. In atria, as compared to ventricle from transplant donor hearts, we confirmed higher expression of KCNN1 and KCNA5, and lower expression of KCNJ2, whereas KCNN2 and KCNN3 were statistically not differentially expressed. Overall expression of KCNN1 was low compared to KCNN2 and KCNN3. Comparing atrial tissue from patients with AF to sinus rhythm samples we saw downregulation of KCNN2 in AF, as previously reported. When comparing ventricular tissue from heart failure patients to non-diseased samples, we found significantly increased ventricular expression of KCNN3 in heart failure, as previously published. The other channels showed no significant difference in expression in either disease. Our results add weight to the view that SK channels are not likely to be an atria-selective target, especially in failing human hearts, and modulators of these channels may prove to have less utility in treating AF than hoped. Whether targeting SK1 holds potential remains to be elucidated.

Burden of major gastrointestinal bleeding among oral anticoagulant-treated non-valvular atrial fibrillation patients

BACKGROUND

Gastrointestinal (GI) bleeding is the most common type of major bleeding associated with oral anticoagulant (OAC) treatment. Patients with major bleeding are at an increased risk of a stroke if an OAC is not reinitiated.

METHODS

Non-valvular atrial fibrillation (NVAF) patients initiating OACs were identified from the Centers for Medicare and Medicaid Services (CMS) Medicare data and four US commercial claims databases. Patients who had a major GI bleeding event (hospitalization with primary diagnosis of GI bleeding) while on an OAC were selected. A control cohort of patients without a major GI bleed during OAC treatment was matched to major GI bleeding patients using propensity scores. Stroke/systemic embolism (SE), major bleeding, and mortality (in the CMS population) were examined using Cox proportional hazards models with robust sandwich estimates.

RESULTS

A total of 15,888 patients with major GI bleeding and 833,052 patients without major GI bleeding were included in the study. Within 90 days of the major GI bleed, 58% of patients discontinued the initial OAC treatment. Patients with a major GI bleed had a higher risk of stroke/SE [hazard ratio (HR): 1.57, 95% confidence interval (CI): 1.42-1.74], major bleeding (HR: 2.79, 95% CI: 2.64-2.95), and all-cause mortality (HR: 1.29, 95% CI: 1.23-1.36) than patients without a major GI bleed.

CONCLUSION

Patients with a major GI bleed on OAC had a high rate of OAC discontinuation and significantly higher risk of stroke/SE, major bleeding, and mortality after hospital discharge than those without. Effective management strategies are needed for patients with risk factors for major GI bleeding.

Relation of Left Atrial Enlargement to Subsequent Thromboembolic Events in Nonvalvular Atrial Fibrillation Patients With Low to Borderline Embolic Risk

The current thromboembolic risk stratification of non-valvular atrial fibrillation (NVAF) does not include parameters from transthoracic echocardiography (TTE). We hypothesized that left atrial enlargement (LAE) on TTE could discriminate who require anticoagulation therapy among NVAF patients with low/borderline clinical embolic risk. This single-center cohort study included 6,602 patients with NVAF (median age, 56 years, 70.0% male) with a low to borderline clinical embolic risk (CHA₂DS₂-VASc score: 0 to 1 in males, 1 to 2 in females). LAE was classified as mild (≥41 mm in males; ≥39 mm in females) or moderate-severe (≥47 mm in males; ≥43 mm in females). The main study outcome was thromboembolic event (ischemic stroke and systemic embolism). Mild and moderate-severe LAE was diagnosed in 26.1% and 32.9% of the cohort, respectively. The patients with moderate-severe LAE showed a higher prevalence of baseline comorbidities and valvular heart disease and had a higher incidence of thromboembolic events than patients with mild or no LAE at 2 years of follow-up (2.5% vs 1.3% vs 1.1%, respectively, p < 0.001). After multivariable adjustment, patients with moderate-severe LAE were at a higher risk of thromboembolic event (hazard ratio, 2.54; 95% CI, 1.65 to 3.90; p < 0.001) compared to those with no LAE. This result persisted in a subgroup analysis of anticoagulant-naïve patients. The rate of thromboembolic events in patients with low clinical embolic risk and moderate-severe LAE was not different to those with high clinical embolic risk without LAE. In conclusion, Moderate-severe LAE on TTE was a significant predictor of thromboembolic events in NVAF patients at low/borderline clinical embolic risk.

Prognostic Value of Pre-operative Atrial Fibrillation in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation

Limited data are available regarding the independent prognostic role of preoperative atrial fibrillation (AF) after transcatheter mitral valve repair with MitraClip. We sought to evaluate the impact of preoperative AF in patients with heart failure (HF) and concomitant secondary mitral regurgitation (MR) after MitraClip treatment. The study included 605 patients with significant secondary MR from a multicenter international registry. Patients were stratified into 2 groups according to the presence or absence of preoperative AF. Primary end point was 5-year overall death, secondary end points were 5-year cardiac death and first re-hospitalization for HF. To account for baseline differences, patients were propensity score matched 1:1. The overall prevalence of preoperative AF was 44%. At 5-year Kaplan-Meier analysis, compared with patients without AF, those with AF had significantly more adverse events in term of overall death (67% vs 43%; HR 1.84, log-rank p <0.001) and cardiac death (56% vs 29%; HR 2.11, log-rank p <0.001) and re-hospitalization for HF (63% vs 52%; HR 1.33, log-rank p = 0.048). Multivariate analysis identified AF as independent predictor of worse outcome in term of primary end point (HR 1.729, 95% C.I. 1.060 to 2.821; p = 0.028). After propensity score matching, patients with AF had higher rates of death and cardiac mortality but similar rates of re-hospitalization for HF. In conclusion, in patients with HF undergoing MitraClip treatment for secondary MR, preoperative AF is common and an unfavourable predictor of 5-year death and cardiac death. However, AF did not affect the frequency of re-hospitalization for HF.

Atrial high‑rate episodes and risk of major adverse cardiovascular events in patients with dual chamber permanent pacemakers: a retrospective study

Patients with atrial high-rate episodes (AHRE) are at higher risk of major adverse cardiovascular events (MACE). The cutoff threshold for AHRE duration for MACE, with/without history of atrial fibrillation (AF) or myocardial infarction (MI), is unknown. A total of 481 consecutive patients with/without history of AF or MI receiving dual-chamber pacemaker implantation were included. The primary outcome was a composite endpoint of MACE after AHRE ≥ 5 min, ≥ 6 h, and ≥ 24 h. AHRE was defined as > 175 bpm (MEDTRONIC) or > 200 bpm (BIOTRONIK) lasting ≥ 5 min. Cox regression analysis with time-dependent covariates was conducted. Patients' mean age was 75.3 ± 10.7 years and 188 (39.1%) developed AHRE ≥ 5 min, 115 (23.9%) ≥ 6 h, and 83 (17.3%) ≥ 24 h. During follow-up (median 39.9 ± 29.8 months), 92 MACE occurred (IR 5.749%/year, 95% CI 3.88-5.85). AHRE ≥ 5 min (HR 5.252, 95% CI 2.575-10.715, P < 0.001) and ≥ 6 h (HR 2.548, 95% CI 1.284-5.058, P = 0.007) was independently associated with MACE, but not AHRE ≥ 24 h. Patients with history of MI (IR 17.80%/year) had higher MACE incidence than those without (IR 3.77%/year, p = 0.001). Significant differences were found between MACE patients with/without history of AF in AHRE ≥ 5 min but not AHRE ≥ 6 h or ≥ 24 h. Patients with dual-chamber pacemakers who develop AHRE have increased risk of MACE, particularly after history of AF or MI.

Individualized education focusing on self-management improved the knowledge and self-management behaviour of elderly people with atrial fibrillation: A randomized controlled trial

AIM

This study examined the effect of an individualized educational intervention on the knowledge, attitudes and self-management ability after 12 weeks for outpatients with atrial fibrillation.

METHODS

A randomized control-group pretest-post-test experimental design was used. Elderly outpatients with atrial fibrillation aged over 65 years were recruited from a university hospital in Korea. The experimental group received a 50-min individualized education on self-management, one telephone counselling after 8 weeks and maintenance of a self-management diary for 12 weeks. Data were collected from November 2017 to April 2018 and analysed using SPSS 22.0 for descriptive statistics and hypothesis testing.

RESULTS

The participants' mean age was 71.9 (4.6) years. Compared to the control group (n = 29), the experimental group (n = 31) showed a significantly greater improvement in knowledge regarding atrial fibrillation and stroke prevention (t = -2.27, p = .027) and self-management behaviours (t = -8.02, p < .001). There were no significant group differences in attitudes towards atrial fibrillation.

CONCLUSION

The findings suggest that education for elderly people with atrial fibrillation should be individualized, focusing on self-management in daily life to prevent cardiovascular complications. Future research is needed to confirm the long-term effects of such education programmes.

The Risk of Falling and Consequences of Falling in Patients with Atrial Fibrillation Receiving Different Types of Anticoagulant

OBJECTIVE

Our objective was to investigate the predictors of falls requiring a visit to the emergency department in patients with nonvalvular atrial fibrillation (AF) receiving different types of anticoagulants and to investigate the clinical consequences of falling in the same population.

METHODS

A total of 1217 patients with nonvalvular AF from two institutions were retrospectively evaluated. Each patient underwent a physical examination, and clinical histories and medication profiles were taken from each patient at baseline.

RESULTS

The median age of our cohort was 71 years; 52.3% were males, and 86.1% of patients were receiving anticoagulation at study baseline. The 5-year freedom-from-falling rate was 81.6%. The use and type of anticoagulation was not significantly associated with the risk of falling (P = 0.222), whereas higher Morse Fall Scale (MFS), CHA₂DS₂-VAS_C (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category), and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [> 65 years], drugs/alcohol concomitantly) scores were significantly associated with a higher hazard of the first fall in univariate analyses. In the multivariate Cox regression model, MFS, older age, osteoporosis, higher levels of high-density lipoprotein cholesterol, higher diastolic blood pressure, and use of amiodarone, diuretics, or short- and medium-acting benzodiazepines were mutually independent predictors of the first fall. Of 163 patients, 93 (57%) had a bone fracture during the fall. Type of anticoagulation significantly affected survival after the first fall (P < 0.001): patients inadequately anticoagulated with warfarin had worse survival rates, and patients receiving apixaban and dabigatran had the best survival rates after the first fall.

CONCLUSION

Older patients who had comorbidities and were taking amiodarone, diuretics, or short- or medium-acting benzodiazepines had the highest risk of falls. The type and quality of anticoagulation did not seem to affect the risk of falling but did significantly affect survival after the first fall.

Decentralising atrial fibrillation screening to overcome socio-demographic inequalities in uptake in STROKESTOP II

OBJECTIVE

In the first STROKESTOP atrial fibrillation screening study, participation was influenced by socio-demographic and geographic factors. To improve uptake in the second study, two screening sites were added, closer to low-income neighbourhoods which had very low participation in the first study. This paper aims to analyse the geographic and socio-demographic disparities in uptake in the second trial and compare the results with the first trial.

METHODS

Inhabitants of the Stockholm region born in 1940 and 1941 were randomised 1:1 to be invited to screening or serve as controls. Medical history, blood samples and single-lead-ECG were collected. Invitee's residential parish was used for geo-mapping analysis of the geographical disparities in participation, using hierarchical Bayes methods. Individual data for participants and non-participants were obtained for the socioeconomic variables: educational level, disposable income, immigrant and marital status.

RESULTS

Higher participation was observed in those with higher education, high income, among non-immigrants and married individuals. Participation between the first and second studies improved significantly, where additional screening sites were introduced. These improvements were generally significant, in each population group according to socio-demographic characteristics.

CONCLUSION

Decentralisation of screening sites in an atrial fibrillation screening program yielded a significantly positive impact on screening uptake. Adding local screening sites in areas with low uptake had beneficial impact on participation across a wide spectrum of socio-demographic groups. Decentralised screening substantially increased the screening uptake in deprived areas.

Comparison of the ATRIA, CHA2DS2-VASc, and Modified Scores ATRIA-HSV, CHA2DS2-VASc-HS, for the Prediction of Coronary Artery Disease Severity

Many parameters included in the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) and CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, sex category) scores also predict coronary artery disease (CAD). We modified the ATRIA score (ATRIA-HSV) by adding hyperlipidemia, smoking, and vascular disease and also male sex instead of female. We evaluated whether the CHA₂DS₂-VASc, CHA₂DS₂-VASc-HS, ATRIA, and ATRIA-HSV scores predict severe CAD. Consecutive patients with coronary angiography were prospectively included. A ≥50% stenosis in ≥1epicardial coronary artery (CA) was defined as severe CAD. Patient with normal CA (n = 210) were defined as group 1, with <50% CA stenosis (n = 178) as group 2, and with ≥50% stenosis (n = 297) as group 3. The mean ATRIA, ATRIA-HSV, CHA₂DS₂-VASc, and CHA₂DS₂VASc-HS scores increased from group 1 to group 3. A correlation was found between the Synergy between PCI with Taxus and Cardiac Surgery score and ATRIA (r = 0.570), ATRIA-HSV (r = 0.614), CHA₂DS₂-VASc (r = 0.428), and CHA₂DS₂-VASc-HS (r = 0.500) scores (Ps < .005). Pairwise comparisons of receiver operating characteristics curves showed that ATRIA-HSV (>3 area under curve [AUC]: 0.874) and ATRIA (>3, AUC: 0.854) have a better performance than CHA₂DS₂-VASc (>1, AUC: 0.746) and CHA₂DS₂-VASc-HS (>2, AUC: 0.769). In conclusion, the ATRIA and ATRIA-HSV scores are simple and may be useful to predict severe CAD.

Atrial fibrillation self screening, management and guideline recommended therapy (AF SELF SMART): A protocol for atrial fibrillation self-screening in general practice

BACKGROUND

Opportunistic screening for silent atrial fibrillation (AF) is recommended to reduce stroke, but screening rates are sub-optimal in general practice. We hypothesize that patient self-screening in the waiting room may improve screening and detection of AF.

METHODS AND ANALYSES

This proof-of-concept study tests a purpose-designed AF self-screening station and customised software which seamlessly integrates with general practice electronic medical records and workflow. The self-screening station records a lead-1 ECG. The software automatically (1) identifies eligible patients (aged ≥65 years, no AF diagnosis) from the practice appointment diary; (2) sends eligible patients an automated SMS reminder prior to their appointment; (3) creates individualised QR code to scan at self-screening station; and (4) imports the ECG and result directly into the patients' electronic medical record. Between 5 and 8 general practices in New South Wales, Australia, will participate with an aim of 1500 patients undertaking self-screening. The main outcome measures will be the proportion of eligible patients that undertook self-screening, incidence of newly-diagnosed AF, and patient and staff experience of the self-screening process. De-identified data will be collected using a clinical audit tool, and qualitative interviews will determine patient and staff acceptability.

ETHICS AND DISSEMINATION

Ethics approval was received from the University of Sydney Human Research Ethics Committee in June 2019 (Project no: 2019/382) and the University of Notre Dame Human Research Ethics Committee (Project no: 019145S) in October 2019. Results will be disseminated through various forums, including peer-reviewed publication and conference presentations.Trial registration numberACTRN12620000233921.

Atrial fibrillation after orthotopic heart transplantatation: Pathophysiology and clinical impact

BACKGROUND

Atrial fibrillation (AF) is a well-established post-cardiac surgery complication. Orthotopic heart transplantation (OHT) represents a peculiar condition where surgical thoracic veins isolation and autonomic denervation occur. This study aims at investigating AF incidence in OHT in order to define its risk factors and to evaluate its prognostic impact.

METHODS

278 patients affected by OHT were recruited in our Cardiac Surgery Unit and retrospectively analyzed, using clinical, surgical and instrumental data.

RESULTS

The patients cohort showed 45 post-operative (16.5%) and 20 late AF cases (7.2%). Only paroxysmal AF episodes were observed. Elderly donors and acute rejection resulted as risk factors in patients with post-operative AF episodes, who presented higher all-cause mortality at 11 years post-OHT (p < 0.001, Kaplan Meier analysis). The majority of late AF episodes occurred during hospitalization, due to renal failure or infections and more frequently in male patients; no significant correlation was observed with acute or chronic rejection or other characteristics.

CONCLUSION

Pulmonary vein isolation and vagal denervation lead to low AF incidence in OHT recipients. Acute rejection and graft status are the main risk factors for post-operative AF episodes, while other systemic conditions act as late AF triggers. The occurrence of AF episodes is associated with poor outcome and AF should be considered as a marker of clinical frailty.

Atrial Fibrillation and Stroke

Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.

Evaluation of Index of Cardio-Electrophysiological Balance in Patients With Atrial Fibrillation on Antiarrhythmic-Drug Therapy

BACKGROUND

Index of cardio-electrophysiological balance (iCEB) has been described as a novel risk marker for predicting malignant ventricular arrhythmia. There remains limited evidence on the effects of amiodarone and propafenone used for sinus rhythm maintenance on iCEB in patients with atrial fibrillation (AF). The aim of this study was to evaluate iCEB in patients with AF on antiarrhythmic-drug therapy.

METHODS

A total of 108 patients with AF (68 patients using amiodarone and 40 patients using propafenone) and 50 healthy subjects were included in the study. All groups underwent a standard 12-lead surface electrocardiogram. QRS duration, QT, T wave peak-to-end (Tp-e) intervals, iCEB (QT/QRS) and iCEBc (heart rate-corrected QT (QTc)/QRS) rates were calculated from the electrocardiogram and compared between groups.

RESULTS

QT, Tp-e intervals and Tp-e/QT ratio were significantly longer in the amiodarone group than the propafenone and control groups (P < 0.001, for all). iCEB was similar in the amiodarone and control groups (4.4 ± 0.6 and 4.2 ± 0.4; P > 0.05), while iCEB values in the propafenone group were significantly lower than the amiodarone group and control groups (3.9 ± 0.5; P < 0.001). There was a significantly difference in iCEBc values among the amiodarone, control and propafenone groups (4.8 ± 0.6, 4.6 ± 0.4 and 4.3 ± 0.6; P < 0.001, respectively).

CONCLUSIONS

In this study, higher iCEBc parameters were observed in patients using amiodarone, while iCEBc values were lowest among patients with AF using propafenone. Further studies are needed to determine whether these electrophysiological changes are associated with ventricular arrhythmias for patients with AF on antiarrhythmic-drug therapy.

Correlation between the elevated uric acid levels and circulating renin-angiotensin-aldosterone system activation in patients with atrial fibrillation

Background

The aim of the present study was to investigate the correlation between the elevated uric acid (UA) levels and activation of the circulating renin-angiotensin-aldosterone system (RAAS) in patients with atrial fibrillation (AF).

Methods

A total of 233 outpatients and inpatients of the Cardiology Department from January 1, 2019, to December 31, 2019, were selected and divided into the sinus rhythm group (SR) with 84 cases, the paroxysmal AF group (pAF) with 76 cases, and the persistent AF group (PAF) with 73 patients. The general clinical data and the serum levels of UA of the enrolled patients were collected, and the radioimmunoassay was adopted to detect the levels of renin (Renin), angiotensin II (Ang II), and aldosterone (Ald).

Results

Renin, AngII, Ald, and UA in the PAF group were significantly higher than those in the pAF group, and the levels of the above indicators in the pAF group were significantly higher than those in the SR group (P<0.001). The left atrium anteroposterior diameter (LAD) and the left ventricular end-diastolic diameter (LVEDD) were significantly increased in the PAF group (P<0.001). The Pearson correlation analysis showed that the levels of the high sensitivity C-reactive protein (hsCRP), AngII Renin, Ald, LVEDD, and LAD were positively correlated with the serum levels of UA (r=0.174, 0.273, 0.34, 0.385, 0.138, respectively, P<0.05 in all). The left ventricular ejection fraction (LVEF) was negatively correlated with the UA level (r=-0.177, P<0.05). Multiple linear regression analysis showed that UA (β=0.103) and LAD (β=2.162) were independent risk factors for Renin. The independent risk factor for Ang II was UA (β=0.167). The independent risk factor for Ald was UA (β=0.283) and LAD (β=8.721) (P<0.05).

Conclusions

Elevated UA might cause excessive activation of the RAAS, aggravate the oxidative stress, and participate in the atrial remodeling, thereby promoting the occurrence and persistence of AF.

Inappropriate direct oral anticoagulant prescriptions in patients with non-valvular atrial fibrillation: cross-sectional analysis of the French CACAO cohort study in primary care

Background

Direct oral anticoagulants (DOACs) account for an increasing proportion of prescriptions in patients with non-valvular atrial fibrillation (NVAF) in primary care. Inappropriate dosing of DOACs is a common problem, with under-dosing being a particular issue. However, conflicting results have been reported about the factors independently associated with inappropriate dosing.

Aim

To describe inappropriate prescriptions of DOACs among patients in the CACAO French nationwide general practice cohort, and to identify the factors independently associated with inappropriate DOAC doses.

Design and setting

Cross-sectional baseline analysis of the CACAO French national multicentre prospective cohort of adult patients in primary care receiving an oral anticoagulant who were recruited between April and October 2014.

Method

A total of 1111 patients from the CACAO cohort who received a DOAC for NVAF were included in this study. Inappropriate prescriptions of DOACs were described (inappropriate dosage, contraindications, non-indications, interactions, and non-compliance with the precautions for use). Multivariate logistic models were used to investigate factors associated with inappropriate DOAC dosing (under-dosing and over-dosing).

Results

Overall, 438 patients (39.4%) received at least one inappropriate DOAC prescription. The most common inappropriate prescription was inappropriate dosage (n = 374, 33.7%), particularly under-dosing (n = 348, 31.3%). Multivariate analysis revealed that factors independently associated with under-dosing were older age, prescription of apixaban or dabigatran, and a CHA2DS2-VASc score ≥2 vs. a score = 1. Factors with over-dosing were kidney failure, a HAS-BLED score ≥3, and older age.

Conclusion

The appropriateness of DOAC prescribing for NVAF can be improved, especially in older patients, and in patients with kidney failure, a higher risk of ischaemic stroke, and/or a higher risk of bleeding. GPs have a key role in increasing the proportion of appropriate DOAC prescriptions via informational, educational, and/or management strategies.

A Review on the State of the Art in Atrial Fibrillation Detection Enabled by Machine Learning

Atrial Fibrillation (AF) the most commonly occurring type of cardiac arrhythmia is one of the main causes of morbidity and mortality worldwide. The timely diagnosis of AF is an equally important and challenging task because of its asymptomatic and episodic nature. In this paper, state-of-the-art ECG data-based machine learning models and signal processing techniques applied for auto diagnosis of AF are reviewed. Moreover, key biomarkers of AF on ECG and the common methods and equipment used for the collection of ECG data are discussed. Besides that, the modern wearable and implantable ECG sensing technologies used for gathering AF data are presented briefly. In the end, key challenges associated with the development of auto diagnosis solutions of AF are also highlighted. This is the first review paper of its kind that comprehensively presents a discussion on all these aspects related to AF auto-diagnosis in one place. It is observed that there is a dire need for low energy and low cost but accurate auto diagnosis solutions for the proactive management of AF.

Relationships between paroxysmal atrial fibrillation, total oxidant status, and DNA damage

INTRODUCTION

Structural and electrophysiological changes play a critical role in the development of atrial fibrillation (AF). Although the pathophysiology of paroxysmal AF (PAF) has not been fully elucidated, oxidative stress (OS) and DNA damage appear to be important triggers. Thus far, no studies have investigated the relationships among total oxidant status (TOS), DNA damage, and PAF. The goal of this study was to assess TOS and DNA damage in patients with PAF.

METHODS

This cross-sectional study included 56 patients with PAF and 31 healthy controls. OS was assessed based on TOS, total antioxidant capacity (TAC), and oxidative stress index (OSI). The level of DNA damage was assessed using 8-hydroxy-2'-deoxyguanosine (8-OHdG).

RESULTS

There were no significant differences between the groups in terms of baseline characteristics. However, patients with PAF had significantly higher high-sensitivity C-reactive protein (p=0.018), TOS (p=0.001), OSI (p=0.001), and 8-OHdG (p=0.019) levels, compared with the control group. Multivariate logistic regression analysis showed that serum TOS level (odds ratio: 1.608; 95% confidence interval [CI]: 1.188-2.176, p=0.002) was the only independent predictor of PAF. TOS ≥12.2 predicted PAF with a sensitivity of 82% and specificity of 76% (AUC: 0.785, 95% CI: 0.687-0.883, p<0.001).

CONCLUSION

We found that TOS and DNA damage were significantly greater in patients with PAF than in the control group. Therefore, we propose that TOS and DNA damage can be used to detect patients at higher risk of AF.

[Observational study of the prevalence of non-valvular atrial fibrillation and ischemic stroke and the factors associated with non-valvular atrial fibrillation in hypertensive patients: about 2887 cases]

Introduction

high blood pressure (HBP), atrial fibrillation (AF) and ischemic stroke are three public health problems. The purpose of this study was to determine the prevalence of AF and ischemic stroke in hypertensive patients and the factors associated with the occurrence of non-valvular AF in these patients.

Methods

we used data collected in the Department of Cardiology at the University Hospital of Sfax as a part of National Tunisian Registry of Hypertension. We examined the associations between different socio-demographic, clinical, paraclinical, and therapeutic variables and AF in hypertensive patients using logistic regression models.

Results

our sample consisted of 2887 patients with a sex ratio of 0.95. The average age of patients was 65 years (±11). AF was found in 230 patients (8%), while ischemic stroke was found in 152 patients (5.3%). Multivariate analysis highlighted that independent factors associated with an increase in the prevalence of AF were: advanced age (p = 0,001, Odds Ratio (OR) = 1,647, 95% confidence interval ( CI): 1,1227-2,213), the detection of left ventricular hypertrophy (LVH) on cardiac ultrasound (p= 0,004, OR= 2,140, 5%CI 9: 1,281-3,576), and left ventricular ejection fraction (LVEF) < 50% (p<0,001, OR=4,677, 95% CI: 2,715 and 8.057).

Conclusion

this study confirms that there is a direct and independent relationship between high blood pressure, advanced age, LVH and AF. AF in patients with high blood pressure is a disease progression leading to an increased risk of ischemic stroke. Optimal high blood pressure control is a priority in hypertensive patients, especially in the elderly, aiming at preventing the risk of AF and ischemic stroke.

Opportunistic atrial fibrillation screening and detection in "self-service health check-up stations": a brief overview of current technology potential and possibilities

Up to a fifth of patients who suffer a stroke had undiagnosed atrial fibrillation (AF). About 30% of AF patients are asymptomatic and remain undiagnosed, so there are no obvious (to the patient) forewarnings. Opportunistic screening for AF applied to the above clinical situation can save lives, since the strokes that occur as a result of AF are often large, severely debilitating or fatal. Today, anyone can buy a good, FDA-approved mobile electrocardiogram (ECG) device/smartwatch for AF detection on Amazon for €100-400, but not very many asymptomatic AF patients, particularly older patients, will do so on their own. In this article, we introduce the concept and potential benefits of opportunistic AF screening and detection in a community setting using the latest generation of affordable digital ECG capture and interpretation solutions integrated into easy-to-use "self-service health check-up stations" installed in public spaces, such as supermarkets and pharmacies. A comprehensive trial of the proposed self-service health check-up stations for AF screening is needed to produce more evidence to convince decision makers to fully buy into the idea of a nation-wide screening programme using these kiosks.

Healthcare resource utilization and costs of rivaroxaban versus warfarin among non-valvular atrial fibrillation (NVAF) patients with obesity in a US population

AIM

To assess the real-world healthcare resource utilization (HRU) and costs of patients with non-valvular atrial fibrillation (NVAF) and obesity newly initiated on rivaroxaban or warfarin in the US.

METHODS

This retrospective study used IQVIA PharMetrics Plus data (01/2010-09/2019) to evaluate patients (≥18 years) with NVAF and obesity (body mass index ≥30 kg/m²) initiated on rivaroxaban or warfarin (on or after 01/2013). Inverse probability of treatment weighting (IPTW) was used to adjust for confounding between cohorts. HRU and costs were assessed post-treatment initiation. Weighted cohorts were compared using Poisson regression models and cost differences, with 95% confidence intervals (CIs) and p values generated using non-parametric bootstrap procedures.

RESULTS

After IPTW, 10,555 and 5,080 patients were initiated on rivaroxaban and warfarin, respectively (mean age: 59 years). At 12 months follow-up, the rivaroxaban cohort had lower all-cause HRU, including fewer hospitalizations (rate ratio [RR]: 0.80, 95% CI: 0.74, 0.87), emergency room visits (RR: 0.89, 95% CI: 0.83, 0.97), and outpatient visits (RR: 0.72, 95% CI: 0.69, 0.77; all p < .05). Medical costs were also reduced in the rivaroxaban cohort (mean difference: -$6,759, 95% CI: -$9,814, -$3,311) due to reduced hospitalization costs (mean difference: -$5,967, 95% CI: -$8,721, -$3,327), resulting in lower total all-cause healthcare costs compared to the warfarin cohort (mean difference: -$4,579, 95% CI: -$7,609, -$1,052; all p < .05). The rivaroxaban cohort also had lower NVAF-related HRU and medical costs driven by lower hospitalization at 12 months post-treatment initiation. HRU and cost reductions associated with rivaroxaban persisted up to 36 months of follow-up.

LIMITATIONS

Claims data may have contained inaccuracies and obesity was classified based on ICD diagnosis codes given that patient BMI values were not available.

CONCLUSIONS

Rivaroxaban was associated with reduced HRU and costs compared to warfarin among NVAF patients with obesity in a real-world US setting.

[Diagnosis, Prevention and Treatment of Cardiovascular Disease in People with Diabetes and Prediabetes]

Diagnosis, Prevention and Treatment of Cardiovascular Disease in People with Diabetes and Prediabetes Abstract. Diabetes is associated with an increased cardiovascular risk. In addition to optimizing glycemia, timely diagnosis and stringent control of cardiovascular risk factors is essential for individuals with diabetes. Therapeutic options include lifestyle-optimization, individualized drug therapy and targeted treatment of concomitant or secondary cardiovascular disease. Cardiovascular disease occurs more often in individuals with diabetes and includes heart failure, atrial fibrillation, coronary heart disease and sudden cardiac death. The correct choice of antidiabetic drugs and interventions can control cardiovascular risk factors, reduce cardiovascular risk and treat concomitant or secondary diseases in a targeted manner. This review is intended to provide guidance on diagnosis, treatment and choice of therapy for individuals with type 2 diabetes without and with concomitant or secondary cardiovascular disease.

Predicting spontaneous conversion to sinus rhythm in symptomatic atrial fibrillation: The ReSinus score

The optimal management of patients presenting to the Emergency Department with hemodynamically stable symptomatic atrial fibrillation remains unclear. We aimed to develop and validate an easy-to-use score to predict the individual probability of spontaneous conversion to sinus rhythm in these patients METHODS: This retrospective cohort study analyzed 2426 cases of first-detected or recurrent hemodynamically stable non-permanent symptomatic atrial fibrillation documented between January 2011 and January 2019 in an Austrian academic Emergency Department atrial fibrillation registry. Multivariable analysis was used to develop and validate a prediction score for spontaneous conversion to sinus rhythm during Emergency Department visit. Clinical usefulness of the score was assessed using decision curve analysis RESULTS: 1420 cases were included in the derivation cohort (68years, 57-76; 43% female), 1006 cases were included in the validation cohort (69years, 58-76; 47% female). Six variables independently predicted spontaneous conversion. These included: duration of atrial fibrillation symptoms (<24hours), lack of prior cardioversion history, heart rate at admission (>125bpm), potassium replacement at K⁺ level ≤3.9mmol/l, NT-proBNP (<1300pg/ml) and lactate dehydrogenase level (<200U/l). A risk score weight was assigned to each variable allowing classification into low (0-2), medium (3-5) and moderate (6-8) probability of spontaneous conversion. The final score showed good calibration (p=0.44 and 0.40) and discrimination in both cohorts (c-indices: 0.74 and 0.67) and clinical net benefit CONCLUSION: The ReSinus score, which predicts spontaneous conversion to sinus rhythm, was developed and validated in a large cohort of patients with hemodynamically stable non-permanent symptomatic atrial fibrillation and showed good calibration, discrimination and usefulness REGISTRATION: NCT03272620.

Investigation of the Effect of HATCH Score and Coronary Artery Disease Complexity on Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery

OBJECTIVE

Postoperative atrial fibrillation (PoAF) is the most frequently encountered rhythm problem after coronary artery bypass graft (CABG) surgery. This situation decreases the capacity of the patients with respect to functional exercise and creates a risk for stroke. In this study, we aimed to determine the effect of coronary artery disease extensiveness and HATCH score on PoAF in patients undergoing CABG surgery with cardiopulmonary bypass.

SUBJECTS AND METHODS

Patients who underwent CABG between December 2014 and December 2018 were included retrospectively. Preoperative demographic characteristics, laboratory parameters, and operative parameters of the patients were recorded retrospectively.

RESULTS

Of the 352 patients, 274 had HATCH scores ≤2 (71.1% male, mean age: 61.7 ± 12.4 years), and 78 had HATCH scores >2 (69.2% male, mean age: 65.9 ± 11.7 years). Significant differences were found between the 2 groups in terms of the age (p = 0.014), presence of hypertension (p = 0.012), PoAF (p < 0.001), and SYNTAX (synergy between percutaneous coronary intervention with taxus and cardiac surgery) score I (p = 0.001). A HATCH score >2 and SYNTAX score I were identified as independent predictors of PoAF (OR: 1.022, 95% CI: 1.004-1.128, p = 0.032, and OR 1.098, 95% CI 1.035-1.164, p = 0.002, respectively). For predicting PoAF, the cutoff level in the ROC curve analysis was 19.7 for SYNTAX score (AUC 0.647, 95% CI 0.581-0.714, p < 0.001, 72.2% sensitivity and 66.4% specificity), and the cutoff level for HATCH score was 2 (AUC 0.656, 95% CI 0.595-0.722, p < 0.001, 69.4% sensitivity and 56.8% specificity) Conclusions: HATCH and SYNTAX scores are predictors of PoAF.

Acceleration of opportunistic atrial fibrillation screening for elderly patients in routine primary care

Cardio-embolic ischemic stroke caused by atrial fibrillation is more severe compared with other types of stroke, such as lacunar infarction and atherothrombotic infarction in patients without atrial fibrillation. Therefore, it is important to prevent cardio-embolic ischemic stroke by detecting atrial fibrillation early in at-risk patients and administering appropriate anticoagulation therapy. This prospective observational study aimed to evaluate the effectiveness of opportunistic atrial fibrillation screening at 12 primary clinics in Japan. The study included a 12-month pre-campaign period and a 12-month campaign period. During the campaign period, an awareness campaign was conducted to encourage physicians to be mindful of screening patients aged ≥65 years for atrial fibrillation by checking their pulses and performing subsequent electrocardiography when an irregular pulse was detected. The primary outcome was the proportion of patients with newly diagnosed atrial fibrillation. A sub-analysis focusing on first-time outpatients was performed. There were 9921 and 10,282 patients with no history of atrial fibrillation in the pre-campaign and campaign periods, respectively. In the whole population, the proportion of patients with newly diagnosed atrial fibrillation was 0.9% throughout the pre-campaign and campaign periods. In the sub-analysis limited to first-time outpatients, the detection proportion increased from 1.6% to 1.9% during the campaign period. In terms of age stratification, a large increase in detection was observed, especially among patients aged 65–74 years (detection increased from 0.9% to 1.5%) and ≥85 years (detection increased from 2.9% to 3.3%) during the campaign period. Our findings suggest the feasibility of opportunistic atrial fibrillation screening in routine primary care practice in Japan. Of note, our findings suggest that opportunistic atrial fibrillation screening targeting first-time outpatients may be of clinical value.

One-year clinical outcome of patients with nonvalvular atrial fibrillation: Insights from KERALA-AF registry

BACKGROUND

We report patient characteristics, treatment pattern and one-year clinical outcome of nonvalvular atrial fibrillation (NVAF) from Kerala, India. This cohort forms part of Kerala Atrial Fibrillation (KERALA-AF) registry which is an ongoing large prospective study.

METHODS

KERALA-AF registry collected data of adults with previously or newly diagnosed atrial fibrillation (AF) during April 2016 to April 2017. A total of 3421 patients were recruited from 53 hospitals across Kerala state. We analysed one-year follow-up outcome of 2507 patients with NVAF.

RESULTS

Mean age at recruitment was 67.2 years (range 18-98) and 54.8% were males. Main co-morbidities were hypertension (61.2%), hyperlipidaemia (46.2%) and diabetes mellitus (37.2%). Major co-existing diseases were chronic kidney disease (42.1%), coronary artery disease (41.6%), and chronic heart failure (26.4%). Mean CHA₂DS₂-VASc score was 3.18 (SD ± 1.7) and HAS-BLED score, 1.84 (SD ± 1.3). At baseline, use of oral anticoagulants (OAC) was 38.6% and antiplatelets 32.7%. On one-month follow-up use of OAC increased to 65.8% and antiplatelets to 48.3%. One-year all-cause mortality was 16.48 and hospitalization 20.65 per 100 person years. The main causes of death were cardiovascular (75.0%), stroke (13.1%) and others (11.9%). The major causes of hospitalizations were acute coronary syndrome (35.0%), followed by arrhythmia (29.5%) and heart failure (8.4%).

CONCLUSIONS

Despite high risk profile of patients in this registry, use of OAC was suboptimal, whereas antiplatelets were used in nearly half of patients. A relatively high rate of annual mortality and hospitalization was observed in patients with NVAF in Kerala AF Registry.

Demonstration of the potential of white-box machine learning approaches to gain insights from cardiovascular disease electrocardiograms

We present the results from a white-box machine learning approach to detect cardiac arrhythmias using electrocardiographic data. A C5.0 is trained to recognize four classes using common features. The four classes are (i) atrial fibrillation and atrial flutter, (ii) tachycardias (iii), sinus bradycardia and (iv) sinus rhythm. Data from 10,646 subjects, 83% of whom have at least one arrhythmia and 17% of whom exhibit a normal sinus rhythm, are used. The C5.0 is trained using 10-fold cross-validation and is able to achieve a balanced accuracy of 95.35%. By using the white-box machine learning approach, a clear and comprehensible tree structure can be revealed, which has selected the 5 most important features from a total of 24 features. These 5 features are ventricular rate, RR-Interval variation, atrial rate, age and difference between longest and shortest RR-Interval. The combination of ventricular rate, RR-Interval variation and atrial rate is especially relevant to achieve classification accuracy, which can be disclosed through the tree. The tree assigns unique values to distinguish the classes. These findings could be applied in medicine in the future. It can be shown that a white-box machine learning approach can reveal granular structures, thus confirming known linear relationships and also revealing nonlinear relationships. To highlight the strength of the C5.0 with respect to this structural revelation, the results of further white-box machine learning and black-box machine learning algorithms are presented.

General management of pulmonary arterial hypertension associated with adult congenital heart disease

Over the past 15 years there have been significant improvements in the treatment of pulmonary arterial hypertension due to congenital heart disease. Patients now live for several decades, but morbidity and mortality remain high. This article describes the holistic management of this patient group with an emphasis on both the physical and psychosocial aspects of care, taking into account the consequences of chronic cyanosis, avoiding complications and improving quality of life.

Toward Regulatory Effects of Curcumin on Transforming Growth Factor-Beta Across Different Diseases: A Review

Immune response, proliferation, migration and angiogenesis are juts a few of cellular events that are regulated by transforming growth factor-β (TGF-β) in cells. A number of studies have documented that TGF-β undergoes abnormal expression in different diseases, e.g., diabetes, cancer, fibrosis, asthma, arthritis, among others. This has led to great fascination into this signaling pathway and developing agents with modulatory impact on TGF-β. Curcumin, a natural-based compound, is obtained from rhizome and roots of turmeric plant. It has a number of pharmacological activities including antioxidant, anti-inflammatory, anti-tumor, anti-diabetes and so on. Noteworthy, it has been demonstrated that curcumin affects different molecular signaling pathways such as Wnt/β-catenin, Nrf2, AMPK, mitogen-activated protein kinase and so on. In the present review, we evaluate the potential of curcumin in regulation of TGF-β signaling pathway to corelate it with therapeutic impacts of curcumin. By modulation of TGF-β (both upregulation and down-regulation), curcumin ameliorates fibrosis, neurological disorders, liver disease, diabetes and asthma. Besides, curcumin targets TGF-β signaling pathway which is capable of suppressing proliferation of tumor cells and invading cancer cells.

Factors leading to high morbidity and mortality of COVID-19 in patients with type 2 diabetes

Coronavirus disease 2019 (COVID-19) is a recent pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus. Diabetes (mostly type 2 diabetes mellitus, T2DM) and hyperglycemia are among the major comorbidities in patients with COVID-19 leading to poor outcomes. Reports show that patients with diabetes and COVID-19 are at an increased risk for developing severe complications including acute respiratory distress syndrome, multi-organ failure, and death. Here we explore potential mechanistic links that could explain the observed higher morbidity and mortality in this patient population. Patients with T2DM have an underlying increased level of inflammation associated with obesity and insulin resistance in addition to other comorbidities including hypertension, obesity, cardiovascular disease, dyslipidemia, and being older. We review evidence that T2DM with hyperglycemia are among factors that lead to elevated expression of angiotensin-converting enzyme 2 (ACE2) in lungs and other tissues; ACE2 is the cellular "receptor" and port of viral entry. The preexisting chronic inflammation with augmented inflammatory response to the infection and the increasing viral load leads to extreme systemic immune response ("cytokine storm") that is strongly associated with increased severity of COVID-19. Based on the available evidence, it is recommended by a panel of experts that safe but stringent control of blood glucose, blood pressure, and lipids be carried out in patients with T2DM, measures that could potentially serve to decrease the severity of COVID-19 should these patients contract the viral infection. Once the infection occurs, then attention should be directed to proper glycemic control with use of insulin and frequent monitoring of blood glucose levels.

Atrial Thrombosis Caused by a Dislocated Left Atrial Appendage Closure Device After Mitral Valve Replacement

A patient with a left atrial appendage occlusion device underwent mitral valve replacement. Later, the patient developed a left atrial thrombosis with thromboembolic myocardial infarction caused by a dislocation of the occlusion device. Exclusion of the device and non-device-based appendage occlusion may have prevented the patient from experiencing postoperative complications (Level of Difficulty: Intermediate.).

Association of anticoagulant-related bleeding events with cancer detection in atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

A bleeding episode may herald cancer in the general population. Oral anticoagulants (OACs), the mainstay treatment for atrial fibrillation (AF), are known to increase the risk of bleeding, and may thus promote an earlier diagnosis of cancer. Data regarding the association of bleeding episodes with cancer in patients with AF on OACs are scarce.

METHODS

In this systematic review and meta-analysis, we searched electronic databases (Medline, Scopus, and Central) and gray literature sources for studies of patients with nonvalvular AF under any OAC, from inception until 14 October 2020. The primary outcome was the association of bleeding occurrences with the detection of cancer. A subgroup analysis was performed according to OAC type [NOAC (non-vitamin K oral anticoagulant) versus VKA (vitamin K antagonist)].

RESULTS

Overall, 4 studies were included, accounting for a total of 144,362 patients with AF receiving OAC. During follow-up, 816 (0.57%) cases of cancer were confirmed. The presence of a bleeding event, either major or minor, was associated with a higher risk for cancer detection (odds ratio [OR] 8.79, 95% confidence interval [CI] 4.98-15.51, and I² 85%). Heterogeneity was explained after studies were stratified by the type of OAC (NOACs: OR 6.12, 95% CI 4.47-8.37, I² 0%, VKAs: OR 15.16, 95% CI 12.61-18.23, and I² 0%).

CONCLUSION

The detection of a bleeding event could be an alerting sign of cancer in patients with AF on OACs, particularly in patients receiving VKAs. REGISTRATION NUMBER (DOI): available in https://doi.org/10.17605/OSF.IO/3948R, DOI: 10.17605/OSF.IO/3948R.

An effective frequency-domain feature of atrial fibrillation based on time-frequency analysis

Background

Atrial fibrillation is a type of persistent arrhythmia that can lead to serious complications. Therefore, accurate and quick detection of atrial fibrillation by surface electrocardiogram has great importance on further treatment. The practical electrocardiogram signals contain various interferences in different frequencies, such as myoelectricity interference, power interference and so on. Detection speed and accuracy largely depend on the atrial fibrillation signal features extracted by the algorithm. But some of the discovered atrial fibrillation features are not well distinguishable, resulting in poor classification effect.

Methods

This paper proposed a high distinguishable frequency feature—the frequency corresponding to the maximum amplitude in the frequency spectrum. We used the R–R interval detection method optimized with the mathematical morphology method and combined with the wavelet transform method for analysis. According to the two features—the maximum amplitude in the frequency spectrum and R–R interval irregular, we could recognize atrial fibrillation signals in electrocardiogram signals by decision tree classification algorithm.

Results

The data used in the experiment come from the MIT-BIH database, which is publicly accessible via the web and with ethical approval and consent. Based on the input of time-domain and frequency-domain features, we classified sinus rhythm signals and AF signals using the decision tree generated by classification and regression tree (CART) algorithm. From the confusion matrix, we got the accuracy was 98.9%, sensitivity was 97.93% and specificity was 99.63%.

Conclusions

The experimental results can prove the validity of the maximum amplitude in the frequency spectrum and the practicability and accuracy of the detection method, which applied this frequency-domain feature. Through the detection method, we obtained good accuracy of classifying sinus rhythm signals and atrial fibrillation signals. And the sensitivity and specificity of our method were pretty good by comparison with other studies.

Evaluating the cost-effectiveness of catheter ablation of atrial fibrillation

Background

The pursuit of a clearer understanding of the pathogenesis of atrial fibrillation (AFib) and the development of new technology has resulted in a surge of interest in the surgical ablation for AFib. Here, we report our 8-year experience in the surgical treatment and management of AFib alongside, evaluating the cost-effectiveness in southern Mainland China over a 1-year follow-up.

Methods

Data of 3,068 patients from March 2011 through June 2019 was retrospectively extracted from The Provincial National Cardiac Database of Xiangya Second Hospital. The activities considered (and costs calculated) were outpatient consultations, hospital admissions, and drug treatment. Quality of life (QoL) questionnaires were also carried out to assess whether concomitant AFib correction procedures increase risk in patients, or improve patient's QoL.

Results

A total of 3,068 patients completed the questionnaires at a minimum of one time-point during the follow-up. The total cost was combined to obtain incremental costs per quality-adjusted life-years (QALYs). The total costs of the AFib catheter ablation group were remarkably higher compared to surgery as usual group. The incremental cost-effectiveness ratio was $76,513,227 (¥542,287,667) per QALY, with an acceptability line graph for cost at 43%.

Conclusions

AFib is an extraordinarily costly and worrisome public health problem. Precision medicine is vital as it provides a platform for the clinical translation of targeted interventions that are designed to help treat and prevent AFib. Thus, to improve the QoL expectancy outcome(s), both therapeutic and surgical interventions should be aimed at addressing the underlying heart disease rather than restoring sinus rhythm.

Real-World Comparative Effectiveness and Safety of Non-Vitamin K Antagonist Oral Anticoagulants vs. Warfarin in a Developing Country

We aimed to compare effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) vs. warfarin for stroke prevention in nonvalvular atrial fibrillation (NVAF) in a developing country where anticoagulation control with warfarin is suboptimal. A real-world study was conducted among patients with NVAF in Thailand receiving NOACs and warfarin from 9 hospitals during January 2012 to April 2018. Propensity-score weighting was used to balance covariates across study groups. Cox regression models were used to compare the risk of thromboembolism, major bleeding, and net adverse clinical events across matched cohorts. A total of 2,055 patients; 605, 604, 441, and 405 patients receiving warfarin, rivaroxaban, dabigatran, and apixaban, respectively, were included. Median (interquartile range) time in therapeutic range (TTR) for warfarin users was 49.5% (26.6%-70.3%). Compared with warfarin, NOACs were associated with a significant reduction in major bleeding either when analyzed as a group (adjusted hazard ratio (HR) (95% confidence interval (CI)) of 0.46 (0.34-0.62) or by each agent. Compared with warfarin users with poor TTR, apixaban (adjusted HR 0.48, 95% CI 0.26-0.86, P = 0.013) and dabigatran (adjusted HR 0.44, 95% CI 0.21-0.90, P = 0.025) were associated with a lower risk of thromboembolism, in addition to markedly lower risk of major bleeding. In a healthcare system where anticoagulation control with warfarin is suboptimal, use of NOACs was associated with a profound reduction in major bleeding. The effectiveness and safety advantages of NOACs were more pronounced compared with warfarin users with low TTR.

Effectiveness and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in patients with left ventricular thrombus: A meta-analysis

BACKGROUND

Left ventricular thrombus (LVT) is a complication of multiple cardiovascular diseases. There has been an increasing trend of off-label using direct-acting oral anticoagulants (DOACs) for the treatment of patients with LVT. The effectiveness and safety of DOACs remain to be determined.

METHOD

We searched for publications (PubMed, MEDLINE, Web of Science, EMBASE, Scopus, and ClinicalTrials.gov) comparing DOACs with Vitamin K antagonists (VKAs) in patients with LVT. We estimated odds ratio (OR) and 95% confidence intervals (CIs) for stroke, systemic embolism, major bleeding events, and thrombus resolution as the effectiveness and safety outcomes. The subgroup analysis and meta-regression were also performed.

RESULTS

Nine retrospective observational studies with a total of 2028 participants were included. DOACs demonstrated a similar risk of stroke, systemic embolism, major bleeding events, and thrombus resolution (OR = 0.79, 95% CI: 0.50-1.23; OR = 1.22, 95% CI: 0.65-2.26; OR = 0.82, 95% CI: 0.47-1.42; OR = 1.34, 95% CI: 0.62-2.90, respectively).

CONCLUSIONS

There is no difference between DOACs and VKAs in patients with LVT from the perspectives of stroke, systemic embolism, major bleeding events, and thrombus resolution. Prospective randomized controlled trials with adequate sample sizes are urgently needed to confirm findings.

Evaluation of Left Atrial Appendage Isolation Using Cardiac MRI after Catheter Ablation of Atrial Fibrillation: Paradox of Appendage Reservoir

Objective

To assess the effect of left atrial appendage (LAA) isolation on LAA emptying and left atrial (LA) function using cardiac MRI in patients who underwent successful catheter ablation of atrial fibrillation (AF).

Materials and Methods

This retrospective study included 84 patients (mean age, 59 ± 10 years; 67 males) who underwent cardiac MRI after successful catheter ablation of AF. According to the electrical activity of LAA after catheter ablation, patients showed either LAA isolation or LAA normal activity. The LAA emptying phase (LAA-EP, in the systolic phase [SP] or diastolic phase), LAA emptying flux (LAA-EF, mL/s), and LA ejection fraction (LAEF, %) were evaluated by cardiac MRI.

Results

Of the 84 patients, 61 (73%) and 23 (27%) patients showed LAA normal activity and LAA isolation, respectively. Incidence of LAA emptying in SP was significantly higher in LAA isolation (91% vs. 0%, p < 0.001) than in LAA normal activation. LAA-EF was significantly lower in LAA isolation (40.1 ± 16.2 mL/s vs. 80.2 ± 25.1 mL/s, p < 0.001) than in LAA normal activity. Furthermore, LAEF was significantly lower in LAA isolation (23.7% ± 11.2% vs. 31.1% ± 16.6%, p = 0.04) than in LAA normal activity. Multivariate analysis demonstrated that the LAA-EP was independent from LAEF (p = 0.01).

Conclusion

LAA emptying in SP may be a critical characteristic of LAA isolation, and it may adversely affect the LAEF after catheter ablation of AF.

Atrial Fibrillation and Resistant Stroke: Does Left Atrial Appendage Morphology Matter? A Case Report

Introduction: Patients with atrial fibrillation (AF) can experience ischemic stroke despite adequate anticoagulant therapy. The secondary prevention strategy of these so-called “resistant strokes” is empirical. Since about 90% of patients with ischemic stroke due to atrial fibrillation have thrombus in left atrial appendage (LAA) we sought to explore the possibility that resistant stroke could have a LAA morphology resistant to anticoagulants.

Case Report: A 77 years old man affected by AF experienced two cardioembolic ischemic stroke while on anticoagulants. The study of LAA showed a windsock-like morphology in the proximal part while distally the LAA presented a cauliflower morphology with a large amount of pectinate muscles and blood stagnation. The precise characteristics of LAA were properly understood integrating images obtained by cardiac CT, transesophageal echocardiography, and selective angiography. A high risky LAA for thrombus formation was diagnosed and its occlusion (LAAO) as an add-on therapy to anticoagulants was proposed and performed. Six month follow-up was uneventfully.

Conclusion: The systematic study of LAA in patients with resistant-stroke could help to identify LAA malignant morphology. The efficacy on stroke recurrence of the combined therapy (anticoagulants plus LAAO) is worthy to be tested in randomized trials.

Safety and Efficacy of Single Versus Dual Antiplatelet Therapy After Left Atrial Appendage Occlusion

The optimal antiplatelet strategy after left atrial appendage (LAA) occlusion able to protect from device-related thrombosis, paying the lowest price in terms of bleeding increase, is unclear. In a real-world, observational study we performed a head-to-head comparison of single versus dual antiplatelet therapy (SAPT vs DAPT) in patients who underwent LAA occlusion. We included 610 consecutive patients, stratified according to the type of post-procedural antiplatelet therapy (280 on SAPT and 330 on DAPT). Primary outcome measure was the incidence of the net composite end point including Bleeding Academic Research Consortium classification 3-5 bleeding, major adverse cardiovascular events or device-related thrombosis at 1-year follow-up. The use of SAPT compared with DAPT was associated with similar incidence of the primary net composite end point (9.3% vs 12.7% p = 0.22), with an adjusted hazard ratio (HR) of 0.69, 95% confidence interval 0.41 to 1.15; p = 0.15) at multivariate analysis. However, SAPT significantly reduced Bleeding Academic Research Consortium classification 3-5 bleeding (2.9% vs 6.7%, p = 0.038; adjusted HR 0.37, 0.16 to 0.88; p = 0.024). The occurrence of ischemic events (major adverse cardiovascular events or device-related thrombosis) was not significantly different between the 2treatment strategies (7.8% vs 7.4%; adjusted HR 1.34, 0.70 to 2.55; p = 0.38). In patients who underwent LAA occlusion, post-procedural use of SAPT instead of DAPT was associated with reduction of bleeding complications, with no significant increase in the risk of thrombotic events. These hypothesis-generating findings should be confirmed in a specific, randomized study.

Exercise training in the treatment of paroxysmal atrial fibrillation: study protocol of the Cologne ExAfib Trial

INTRODUCTION

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia and is associated with a number of comorbidities such as coronary artery disease and heart failure. While physical activity is already implemented in current international guidelines for the prevention and treatment of AF, the precise role of different types of exercise in the management of AF remains to be elucidated. The primary aim of the Cologne ExAfib Trial is to assess the feasibility and safety of different exercise modes in patients diagnosed with paroxysmal AF. Secondary outcomes include assessments of physical function, AF burden, quality of life and inflammation, as well as morphological and cardiac adaptations.

METHODS AND ANALYSIS

The study opened for recruitment in September 2019. In the initial pilot phase of this four-armed randomised controlled trial, we aim to enrol 60 patients between 60 years and 80 years of age with paroxysmal AF. After screening and pretesting, patients are randomised into one of the following groups: high-intensity interval training (4×4 min at 75%-85% peak power output (PPO)), moderate-intensity continuous training (25 min at 55%-65% PPO), strength training (whole body, 3 sets of 6-12 repetitions at 70%-90% one repetition maximum [1RM]) or a usual-care control group. Training is performed two times per week for 12 weeks. If the feasibility and safety can be confirmed through the initial pilot phase, the recruitment will be continued and powered for a clinical endpoint.Feasibility and safety are assessed by measures of recruitment and completion, programme tolerance and adherence as well as reported adverse events, including hospitalisation rates. Secondary endpoints are assessed by measures of peak oxygen consumption and the 1RM of selected muscle groups, questionnaires concerning quality of life and AF burden, serum blood samples for the analysis of C reactive protein, interleukin-6, tumour necrosis factor alpha and N-terminal pro-brain natriuretic peptide concentrations and ultrasound for muscle and heart morphology as well as cardiac function.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the ethics committee of the German Sport University Cologne (No.: 175/2018). All procedures performed in studies involving human participants are in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Manuscripts will be written based on international authorship guidelines. No professional writers will be commissioned for manuscript drafting. The findings of this study will be published in peer-reviewed journals and presented at leading exercise and medicine conferences TRIAL REGISTRATION NUMBER: The study is registered both at the German and at the WHO trial registers (DRKS00016637); Pre-results.

Prognostic Value of Troponin in Patients with Atrial Fibrillation Admitted to an Emergency Department: Review and Meta-Analysis

Introduction

Elevated levels of cardiac troponin (cTn) indicate underlying heart disease and is known to predict adverse events in multiple conditions. Its role in atrial fibrillation (AF) in the acute setting is still not conclusive. We aimed to assess the prognostic value of c-Tn in patients with AF admitted to an emergency department (ED).

Methods

Systematic searches were conducted using PubMed and the Cochrane Library and the International Clinical Trials Registry Platform to identify studies from year 2009 to October 2019 reporting on the prognostic value of cTn on all-cause mortality or major adverse cardiac events (MACE) in adult patients with AF in the ED. We pooled hazard ratio (HR) and 95% confidence interval (CI) using fixed and random effects models according the heterogeneity. We planned to conduct a sensitivity and subgroup analyses.

Results

Five studies involving 5750 patients were identified. The mean follow-up ranged from 12 to 35 months. An increase in mortality was observed in the elevated cTn group compared to the controls, HR=2.7 (95% CI 1.55-4.72), P for effect<0.001, I2=80%). For MACE, the pooled HR was 2.17 (95%CI 1.60-2.94), P for effect<0.001, I2=0%). In the subgroup analysis we found no significant difference in type of troponin used and study design.

Conclusions

The elevation of cardiac troponin was significantly associated with higher mortality and major adverse cardiac events in patients with AF admitted to an ED. In this setting the use of c-Tn could provide prognostic information.

Continued versus interrupted direct oral anticoagulation for cardiac electronic device implantation: A systematic review

BACKGROUND

Many patients undergoing cardiac device implantation are taking direct oral anticoagulation (DOAC). Continuing DOAC during device implantation may increase periprocedural bleeding risk; however, interrupting DOACs may increase thromboembolic risk.

OBJECTIVE

To compare the incidence of clinically significant pocket hematoma and thromboembolism in patients who have their DOAC continued or interrupted for cardiac device implantation.

METHODS

We searched MEDLINE, EMBASE, and randomized controlled trial (CENTRAL) until December 2019 and included randomized controlled trials (RCTs) and observational studies that compared outcomes after continuing or interrupting DOAC during cardiac device implantation. Independently and in duplicate, reviewers screened titles, abstracts, and full text of potentially eligible studies. They then evaluated risk of bias and abstracted data. RCT data were pooled using a fixed-effect model. Quality of evidence was assessed using grading of recommendations assessment, development and evaluation (GRADE).

RESULTS

Two RCTs, representing 763 patients, and three observational studies met eligibility criteria. In RCTs, continuing DOAC for device implantation compared to interrupting DOAC resulted in no significant difference in clinically significant pocket hematoma (2.1% vs 1.8%; RR 1.15; 95% CI 0.44-3.05) or thromboembolism (0.03% vs 0.03%; RR 1.02; 95% CI 0.06-16.21). Quality of evidence for both outcomes was moderate due to imprecision. Observational studies showed similar results.

CONCLUSIONS

Continuing DOACs for device implantation results in little to no difference in the incidence of clinically significant pocket hematoma or thromboembolism. Given the ease of stopping and restarting DOACs, interrupting DOACs may be the preferred strategy for most patients. However, whenever continuous therapeutic anticoagulation is desired, DOAC continuation should be preferred over bridging with parenteral anticoagulation.

Risk of Atrial Fibrillation, Ischemic Stroke and Cognitive Impairment: Study of a Population Cohort ≥65 Years of Age

PURPOSE

To evaluate a model for calculating the risk of AF and its relationship with the incidence of ischemic stroke and prevalence of cognitive decline.

MATERIALS AND METHODS

It was a multicenter, observational, retrospective, community-based study of a cohort of general population ≥6ct 35 years, between 01/01/2016 and 31/12/2018. Setting: Primary Care. Participants: 46,706 people ≥65 years with an active medical history in any of the primary care teams of the territory, information accessible through shared history and without previous known AF. Interventions: The model to stratify the risk of AF (PI) has been previously published and included the variables sex, age, mean heart rate, mean weight and CHA2DS2VASc score. Main measurements: For each risk group, the incidence density/1000 person/years of AF and stroke, number of cases required to detect a new AF, the prevalence of cognitive decline, Kendall correlation, and ROC curve were calculated.

RESULTS

The prognostic index was obtained in 37,731 cases (80.8%) from lowest (Q1) to highest risk (Q4). A total of 1244 new AFs and 234 stroke episodes were diagnosed. Q3-4 included 53.8% of all AF and 69.5% of strokes in men; 84.2% of all AF and 85.4% of strokes in women; and 77.4% of cases of cognitive impairment. There was a significant linear correlation between the risk-AF score and the Rankin score (p < 0.001), the Pfeiffer score (p < 0.001), but not NIHSS score (p 0.150). The overall NNS was 1/19.

CONCLUSION

Risk stratification allows identifying high-risk individuals in whom to intervene on modifiable risk factors, prioritizing the diagnosis of AF and investigating cognitive status.