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

Characterizing atrial fibrillation in patients with and without heart failure across the ejection fraction spectrum: Incidence, prevalence, and treatment strategies

AIMS

Heart failure (HF) and atrial fibrillation (AF) often coexist. We explored AF incidence, prevalence, and treatment strategies in patients with versus without HF across the ejection fraction (EF) spectrum.

METHODS AND RESULTS

We analysed patients with HF from the Swedish HF Registry (1 December 2005-31 December 2021), matched 1:1 by sex, age, and county of residence to patients without HF from Statistics Sweden. Two study cohorts were derived (i) to assess AF prevalence and treatments, and (ii) to evaluate AF incidence and related predictors. Overall, 195 106 patients were considered, 50% of them with HF (of whom 54% with HF with reduced [HFrEF], 23% mildly reduced [HFmrEF], and 23% with preserved EF [HFpEF]). From 2006 to 2021, AF prevalence increased in both patients with (57% to 58%) and without HF (8% to 11%). HF patients, particularly if with HFrEF, were more likely receiving AF treatments than those without HF. Over time, antiarrhythmic use decreased, while rate control drugs and oral anticoagulant use, and AF-related procedures increased, regardless of HF and EF. During a median follow-up of 3.7 years, in 86 210 patients without AF, incident AF risk was two-fold higher in HF versus non-HF (hazard ratio [HR] 2.76, 95% confidence interval [CI] 2.45-3.12), highest in HFpEF (HR 3.12, 95% CI 2.65-3.67) versus HFrEF (HR 2.68, 95% CI 2.34-3.06) and HFmrEF (HR 2.53, 95% CI 2.17-2.94).

CONCLUSIONS

Atrial fibrillation prevalence, anticoagulant use, and AF-related procedures increased over time regardless of HF, with HF patients more likely receiving AF treatments. In HF, despite higher AF prevalence and incidence in HFpEF, AF treatment use remained modest, calling for further implementation.

Impact of Diagnosis to Ablation Time on Recurrence of Atrial Fibrillation and Clinical Outcomes After Catheter Ablation: A Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data

BACKGROUND

Current clinical guidelines emphasize the significance of rhythm control with catheter ablation but lack guidance on the timing of atrial fibrillation (AF) ablation relative to the diagnosis time. We aim to investigate the latest evidence on the impact of diagnosis to ablation time (DAT) on clinical outcomes after AF ablation.

METHODS

We searched PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials through August 2024. Pairwise, prognostic, and reconstructed time-to-event data meta-analyses were conducted using R V. 4.3.1. Our primary end point was time to first AF recurrence, with secondary end points of all-cause mortality, tamponade, stroke, and heart failure.

RESULTS

Our cohort included 23 studies with 43 711 patients. Shorter DAT was significantly associated with reduced AF recurrence across both paroxysmal and persistent AF subgroups (P<0.01). There was a significant decrease in benefit for paroxysmal AF over time and a slight decrease in benefit for persistent AF over time. However, the benefit remained significant in both over time. DAT per year was significantly associated with a 10% increased risk of AF recurrence. Reconstructed Kaplan-Meier analysis showed that DAT >1 year was significantly associated with a 70% increased risk of AF recurrence in paroxysmal AF and 30% in persistent AF. DAT ≤1 year was significantly associated with decreased all-cause mortality (P<0.01) and showed a trend toward an association with a lower incidence of stroke (P=0.08). However, there was no significant difference in heart failure between DAT ≤1 year and DAT >1 year.

CONCLUSIONS

Early ablation is more beneficial in paroxysmal AF, with a notable decrease in benefit over time, while in persistent AF, the benefit remains significant but slightly decreases over time. Shorter DAT was significantly associated with decreased all-cause mortality and showed a trend toward an association with a lower incidence of stroke.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/display_record.php?; Unique identifier: CRD42024525542.

Over 10 years of non-vitamin K antagonist oral anticoagulants: highlights, challenges, and future developments

Over the past decade, non-vitamin K antagonist oral anticoagulants have revolutionized anticoagulation therapy, offering substantial benefits over traditional vitamin K antagonists. Non-vitamin K antagonist oral anticoagulants offer reduced bleeding risks, fixed dosing without frequent monitoring, and fewer drug and dietary interactions. Their effectiveness has been demonstrated in preventing stroke in atrial fibrillation, managing venous thromboembolism, and offering new options for patients with coronary artery disease and cancer-associated thrombosis. However, challenges remain, including bleeding risks, high costs, and limited efficacy in certain patient populations. Current research is focused on addressing these limitations, with Factor XI inhibitors emerging as a promising advancement for safer anticoagulation. This review provides an overview of the clinical highlights, challenges, and future directions of anticoagulation therapy.

Evaluation of sex differences in the receipt of concomitant atrial fibrillation procedures during nonmitral cardiac surgery

OBJECTIVE

Women are less likely to receive guideline-recommended cardiovascular care, but evaluation of sex-based disparities in cardiac surgical procedures is limited. Receipt of concomitant atrial fibrillation (AF) procedures during nonmitral cardiac surgery was compared by sex for patients with preoperative AF.

METHODS

Patients with preoperative AF undergoing coronary artery bypass grafting and/or aortic valve replacement at any of the 33 hospitals in Michigan from 2014 to 2022 were included. Patients with prior cardiac surgery, transcatheter AF procedure, or emergency/salvage status were excluded. Hierarchical logistic regression identified predictors of concomitant AF procedures, account for hospital and surgeon as random effects.

RESULTS

Of 5460 patients with preoperative AF undergoing nonmitral cardiac surgery, 24% (n = 1291) were women with a mean age of 71 years. Women were more likely to have paroxysmal (vs persistent) AF than men (80% vs 72%; P < .001) and had a higher mean predicted risk of mortality (5% vs 3%; P < .001). The unadjusted rate of concomitant AF procedure was 59% for women and 67% for men (P < .001). After risk adjustment, women had 26% lower adjusted odds of concomitant AF procedure than men (adjusted odds ratio, 0.74; 95% CI, 0.64-0.86; P < .001). Female sex was the risk factor associated with the lowest odds of concomitant AF procedure.

CONCLUSIONS

Women are less likely to receive guideline recommended concomitant AF procedure during nonmitral surgery. Identification of barriers to concomitant AF procedure in women may improve treatment of AF.

Stroke severity and outcomes in patients with intracerebral hemorrhage on anticoagulants and antiplatelet agents: An analysis from the Japan Stroke Data Bank

BACKGROUND AND AIM

Some patients with intracerebral hemorrhage are on antithrombotic agents at the time of the event and these may worsen outcome, but the relative risk of different oral anticoagulants and antiplatelet agents is uncertain. We determined associations between pre-onset intake of antithrombotic agents and initial stroke severity, and outcomes, in patients with intracerebral hemorrhage.

METHODS

Patients with intracerebral hemorrhage admitted within 24 h after onset between January 2017 and December 2020 and recruited to the Japan Stroke Data Bank, a hospital-based multicenter prospective registry, were included. Enrolled patients were classified into four groups based on the type of antithrombotic agents being used on admission. The outcomes were the National Institutes of Health Stroke Scale (NIHSS) score on admission and modified Rankin Scale (mRS) of 5-6 at discharge.

RESULTS

Of a total 9810 patients with intracerebral hemorrhage (4267 females; mean age = 70 ± 15 years), 77.1% were classified into the no-antithrombotic group, 13.2% into the antiplatelet group, 4.0% into the warfarin group, and 5.8% into the direct oral anticoagulant (DOAC) group. Median (interquartile range) NIHSS score on admission was 12 (5-22), 13 (5-26), 15 (5-30), and 13 (6-24), respectively, in the four groups. In multivariable analysis, the prestroke warfarin use was associated with higher NIHSS score (adjusted incidence rate ratio = 1.09 (95% confidence interval (CI) = 1.06-1.13), with the no-antithrombotic group as the reference), but the antiplatelet group (1.00 (95% CI = 0.98-1.02)) and DOAC group (0.98 (95% CI = 0.95-1.01)) were not. The rate of mRS 5-6 at discharge was 30.8%, 41.9%, 48.6%, and 41.5%, respectively, in the four groups. In multivariable analysis, prestroke warfarin use was associated with mRS 5-6 (adjusted odds ratio = 1.90 (95% CI = 1.28-2.81), with the no-antithrombotic group as the reference), but the antiplatelet group (1.12 (95% CI = 0.91-1.37)) and DOAC group (1.25 (95% CI = 0.88-1.77)) were not.

CONCLUSION

Patients who were taking warfarin prior to intracerebral hemorrhage onset suffered more severe intracerebral hemorrhage as evidenced by higher admission NIHSS and higher discharge mRS. In contrast, no increase in severity was seen with antiplatelet agents.

Impact of Angiographically Detected Residual Trabeculation After Left Atrial Appendage Closure Using the WATCHMAN Device: Insight From the OCEAN-LAAC Registry

BACKGROUND

Research on the impact of angiographically detected residual trabeculation after left atrial appendage closure (LAAC) is limited.

OBJECTIVES

To investigate the incidence, characteristics, and clinical implications of angiographically detected residual trabeculation after LAAC using the WATCHMAN device.

METHODS

We analyzed 1350 consecutive patients with atrial fibrillation undergoing LAAC using the WATCHMAN device from the OCEAN-LAAC registry, which is a prospective ongoing, multicenter Japanese registry. The inclusion criteria comprised patients who successfully underwent LAAC and whose presence or absence of residual trabeculation can be confirmed using a contrast medium. The clinical outcomes were compared between patients with and without angiographically detected residual trabeculation.

RESULTS

Residual trabeculation was angiographically detected in 5.6% (75/1350 patients). At the procedure, the proportion of peri-device leak (PDL) was significantly higher in the residual trabeculation group than in the non-residual trabeculation group (20% vs. 5.1%, p < 0.001). However, the PDL and device-related thrombosis at 45 days and 1 year were comparable between the two groups (37% vs. 23%, p = 0.24; 28% vs. 31%, p = 0.84; 2.1% vs. 1.4%, p = 0.50; 6.9% vs. 6.0%, p = 0.69, respectively). The 3-year cumulative incidence of ischemic stroke, all cardiovascular death, and all-cause death were comparable between the two groups (5.7% vs. 5.5%, log-rank p = 0.96; 7.7% vs. 8.9%, log-rank p = 0.34, 31.4% vs. 22.3%, log-rank p = 0.71, respectively).

CONCLUSION

The angiographically detected residual trabeculation rate was 5.6%, and this population had a significantly higher prevalence of PDL at the procedure. However, the presence of residual trabeculation did not contribute to PDL or device-related thrombosis at follow-up or affect the clinical outcomes.

Malnutrition and risks of atrial fibrillation recurrence after catheter ablation

Background

Recent data showed an association between malnutrition and increased all-cause mortality and thromboembolic risk in patients with atrial fibrillation (AF). However, the impact of malnutrition on the clinical outcomes for patients undergoing catheter ablation for AF is still debated. Our study aimed to examine this relationship using all existing available data.

Methods

We conducted a systematic review of MEDLINE and EMBASE databases from inception to April 2024, analyzing the association between malnutrition, assessed by the Geriatric Nutritional Risk Index (GNRI), and the risk of AF recurrence in patients who underwent catheter ablation for AF, compared to those without malnutrition. Relative Risk (RR) or hazard ratio (HR) and 95% CIs were retrieved from each study and combined using the generic inverse variance method.

Results

We included 3 cohort studies with 1697 participants undergoing AF ablation (10.9%) who had malnutrition indicated by GNRI score below 98. Patients with malnutrition had a higher risk of AF recurrence following catheter ablation for AF compared to those without malnutrition (Pooled RR = 2.74, 95% CI 1.36-5.51, I 2 = 67%, p = .005).

Conclusions

Our pooled analysis indicates that malnourished patients undergoing catheter ablation for AF have an increased risk of AF recurrence compared to non-malnourished patients.

Management strategies to prevent stroke in patients with atrial fibrillation and malignant left atrial appendage

BACKGROUND

Patients with atrial fibrillation and malignant left atrial appendage (LAA) may benefit from LAA closure (LAAC); however, evidence is limited.

OBJECTIVE

The purpose of this study was to determine management strategies and clinical outcomes in patients with atrial fibrillation and malignant LAA.

METHODS

Malignant LAA was defined as a history of ischemic stroke and/or evidence of LAA thrombus despite continuous oral anticoagulation (OAC) therapy (continuous for ≥3 weeks). We studied 80 patients with malignant LAA treated with LAAC. We compared these patients first against 44 patients with malignant LAA treated with OAC alone and second against 114 patients without malignant LAA who were treated with LAAC for conventional indications.

RESULTS

Among patients with malignant LAA (first comparison), those treated with LAAC had a higher 1-year cumulative incidence rate of ischemic stroke than did patients treated with OAC alone (6.3% vs 5.3%; log-rank, P = .09) whereas the difference in stroke risk while receiving OAC was comparable (2.7% vs 5.3%; log-rank, P = .84). Furthermore, all disabling stroke events in patients with malignant LAA treated with LAAC occurred only while not receiving OAC. Among patients treated with LAAC (second comparison), those with malignant LAA had a higher 1-year cumulative incidence rate of ischemic stroke (and ischemic stroke due to device-related thrombosis) than did those without malignant LAA (6.3% vs 2.2%; log-rank, P = .009 and 2.2% vs 0%; log-rank, P = .04, respectively). However, these differences in stroke risk were no longer significant while receiving OAC (2.7% vs 1.0%; log-rank, P = .11).

CONCLUSION

Combination performing LAAC and continuation of OAC may be options to prevent ischemic stroke in patients with high thromboembolic risk and malignant LAA.

Establishing an intravenous sotalol loading program

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia seen clinically with serious sequelae of stroke and heart failure as well as an independent risk factor for increased mortality. The latest guidelines for AF management recommend restoration and maintenance of normal sinus rhythm through the use of antiarrhythmic drugs, cardioversion, or catheter ablation treatment early after AF diagnosis to lower the risk of adverse cardiovascular outcomes. Intravenous (IV) sotalol loading for atrial arrhythmias allows for rapid achievement of the maximum plasma concentration steady state, where patients receive a 60-minute infusion, followed by 2 oral doses of the drug. Practical questions remain about establishing an IV sotalol program. While IV sotalol is not a new medication, the expanded indication for use of a loading dose requires pharmacy and therapeutics committee review of published data, such as indication, dosage, plans for patient and corrected QT monitoring, electrolyte monitoring and replacement, if necessary, order set and protocol development, and a timeline for the infusion process. The purpose of this article is to describe development of an IV sotalol loading program that addresses formulary approval, order set and protocol tips, and preadmission and admission considerations, including monitoring corrected QT intervals, staffing, and locations for the IV sotalol infusion process.

Optimal management of high bleeding risk patients undergoing percutaneous coronary interventions: Where do we stand?

Percutaneous coronary interventions (PCI) are the mainstay of treating obstructive coronary artery disease. However, procedural planning and individualization of the procedure is necessary for different patient phenotypes to optimize outcomes. Specifically, post-PCI pharmacotherapy with antiplatelets complicates the management of patients at high bleeding risk due to comorbidities, such as atrial fibrillation. Aiming to limit post-procedural adverse events and reduce the procedure-related bleeding risk, several novel technologies and hypotheses have been tested in clinical practice. Such frontiers include limiting the duration of dual antiplatelet therapy or even prescribing single regimens, using drug-coated balloons for performing the intervention and the effect of imaging-guided PCI in optimizing stent expansion. Furthermore, specific instruction in different patient phenotypes, such as atrial fibrillation and chronic kidney disease, are emerging, as despite both pathologies being considered at high bleeding risk, one size does not fit all. Thus, our review will provide all the recent updates on the field as well as algorithms and expert opinions on how to manage this, particularly common, phenotype of patient.

Sarcopenia and Insulin Resistance Collective Effect on Atrial Fibrillation Risk: A Non-Diabetic Elderly Cohort Study

BACKGROUND

Appendicular skeletal muscle mass index (ASMI), a crucial indicator of sarcopenia and estimated glucose disposal rate (eGDR), a surrogate marker of insulin resistance (IR), are associated with the risk of cardiovascular diseases. However, it remains unclear whether the collective effects, including the impact of the temporal progression of ASMI and eGDR, affect atrial fibrillation (AF) risk. This study aims to elucidate the association between the collective effects of ASMI and eGDR and AF risk in the non-diabetic older population.

METHODS

A total of 8060 non-diabetic older individuals from a community-based cohort study were used to prospectively analyse the association between the collective effects of baseline ASMI and eGDR and AF risk. Among them, 7651 were eligible and used for dual-trajectory analysis of the association between dual trajectory of ASMI and eGDR and AF risk. The temporal development of ASMI and eGDR over time was determined using a dual-trajectory model. Statistical analyses involved restricted cubic splines and Fine-Gray competing risk models, adjusting for potential confounders.

RESULTS

In the prospective analysis, the hazard ratio (HR) of AF was 1.762 (95% confidence interval [CI]: 1.528-2.032) in the low ASMI group compared to the normal ASMI group in total participants. Restricted cubic splines analysis demonstrated L-shaped associations between AF risk and ASMI and eGDR, with inflection points at 7.23 kg/m2 and 7.85 mg/kg/min, respectively. Low ASMI and moderate and low eGDR exhibited a significant interplay for increasing AF risk (HR: 1.290 and 1.666, 95% CI: 1.136-1.464 and 1.492-1.861, respectively, padj. < 0.001). One-SD increment ASMI and eGDR synergistically reduced AF risk (HR: 0.896, 95% CI: 0.839-0.957, padj. < 0.001). In the dual-trajectory analysis for total participants, five distinct dual trajectories of ASMI and eGDR were identified. Group 4, characterized by moderate-stable ASMI and moderate-stable eGDR, exhibited the lowest incidence of AF (7.03 per 1000 person-years) and was used as a reference for further analyses. Group 1, characterized by high-decrease ASMI and high-decrease eGDR, had the highest AF risk (HR: 2.255, 95% CI: 1.769-2.876, padj. < 0.001), followed by Group 5, with high-decrease ASMI and low-stable eGDR (HR: 1.893, 95% CI: 1.491-2.403, padj. < 0.001) when compared to Group 4 after adjustment for potential confounders including baseline ASMI and eGDR.

CONCLUSIONS

The collective effects of ASMI and eGDR are significantly associated with AF risk in the non-diabetic older population. Collective management of skeletal muscle mass and IR might be a useful and effective management strategy for preventing and controlling AF.

Reducing diltiazem-related hypotension in atrial fibrillation: Role of pretreatment intravenous calcium

PURPOSE

This study evaluated the efficacy of intravenous (IV) calcium pretreatment for preventing diltiazem-induced hypotension and assessed its safety in adult patients with atrial fibrillation (AF)/atrial flutter (AFL) with rapid ventricular response (RVR).

METHODS

This randomized, double-blind, placebo-controlled trial included 217 adults with AF/AFL and a ventricular rate > 120 beats per minute, who were randomized into three groups: those who received an IV NaCl 0.9 % placebo pretreatment prior to IV diltiazem (PD; 73 patients) and those who received 90 mg (C90D; 71 patients) and 180 mg (C180D; 73 patients) IV calcium chloride pretreatment before IV diltiazem. We compared participants' systolic blood pressure (SBP) and heart rate (HR) at baseline and at 5, 10, and 15 min post-treatment, as well as the incidence of adverse events (e.g., hypotension, urticaria, nausea) among the groups.

RESULTS

The PD and C90D pretreatment groups had significantly lower HR measurements at 10 and 15 min compared to the C180D group. In addition, at 5 min, the mean SBP in the PD group was significantly lower compared to the C90D and C180D groups. At 10 min, the mean SBP was significantly higher in the C180D group than in the other groups. Furthermore, at 15 min, the mean SBP was significantly higher in both the C90D and C180D groups than in the PD group. There were no significant differences between the calcium pretreatment and placebo groups in terms of the need for additional diltiazem doses or the incidence of adverse events.

CONCLUSION

IV calcium pretreatment effectively prevents diltiazem-induced hypotension in patients with AF/AFL with RVR without compromising the efficacy of diltiazem in achieving and maintaining ventricular rate control.

TRIAL REGISTRY

National Library of Medicine Clinical Trial Registry; No.: NCT06494007; URL: https://clinicaltrials.gov/study/NCT06494007.

Consumer Wearables-Advancing Atrial Fibrillation Care or Too Much Information?

This Viewpoint describes the diffusion of direct-to-consumer wearable devices capable of early atrial fibrillation detection and the unclear implications for initiation of anticoagulation therapy based on such findings.

Prevalence of cardiac amyloidosis in atrial fibrillation: a CMR study prior to catheter ablation

The frequency of cardiac amyloidosis potentially present in patients with atrial fibrillation (AF) remains unclear. The purpose of this study is to determine the frequency and clinical characteristics of cardiac amyloidosis latent in AF by performing cardiac magnetic resonance imaging (MRI) in patients scheduled for AF ablation. We retrospectively analyzed 193 consecutive patients who underwent CA and cardiac MRI for atrial fibrillation. The primary endpoint of the study was the frequency of histologically confirmed cardiac amyloidosis or suspected cardiac amyloidosis [positive imaging findings on cardiac MRI strongly suspecting cardiac amyloidosis (diffuse subendocardial late gadolinium enhancement or MRI-derived extracellular volume of > 0.40)]. Among the 193 patients, 8 were confirmed or suspected cases of cardiac amyloidosis, representing a frequency of 4% (8/193 patients). Multivariate analysis identified interventricular septal thickness at end-diastole (LVSd) as an independent and significant predictor of cardiac amyloidosis (OR: 1.72, 95% CI 1.12-2.87, p = 0.020).The optimal cut-off value for IVSd was determined to be > 12.9 mm based on the Youden index. At this cut-off, the sensitivity was 75.0% (95% CI 34.9-96.8%) and the specificity was 92.3% (95% CI 87.4-95.7%), allowing for the identification of patients with definite or suspected cardiac amyloidosis. The frequency of confirmed and suspected cases of cardiac amyloidosis among patients with an IVSd > 12.9 mm was 30% (6/20 patients). In addition, prevalence of biopsy-proven cardiac amyloidosis was 10% (2/20). The prevalence of cardiac amyloidosis in atrial fibrillation patients scheduled for ablation with cardiac hypertrophy is not negligible.

The Predictive Value of Circulating Gal-3 for New Stroke Events in Paroxysmal Atrial Fibrillation Patients Despite Oral Anticoagulation Medications

BACKGROUND

CHA2DS2-VASc is used to assess the risk of stroke in patients with atrial fibrillation (AF) and guide anticoagulant treatment decisions, but it has limitations in accurately predicting stroke risk in individual patients. The objective of this study is to conduct a cohort study by assessing preoperative levels of Gal-3 in paroxysmal AF patients, aiming to observe its correlation with the subsequent incidence of stroke events.

METHOD

This study enrolled 197 patients with nonvalvular paroxysmal AF. Blood samples were taken to test Gal-3 levels. All patients were followed up for 4 years after admission.

RESULTS

Compared to the nonstroke cases, serum levels of Gal-3 were markedly elevated in stroke cases (7.08 [IQR, 4.60-10.96] vs. 17.34 [IQR, 8.28-20.31], p < 0.001). Gal-3 yields a superior AUC (0.748, with a 95%CI of 0.681-0.807) compared to other classical stroke indices, such as BNP, CHA2DS2-Vas score, and TNI. Remarkably, the Gal-3 index exhibited a superior predictive capacity, yielding a significant incremental predictive value that surpassed the conventional risk factors (CHA2DS2-VASc score) for stroke events, as evidenced by an IDI of 16.4% (p < 0.001) and an NRI of 34.7% (p = 0.002).

CONCLUSION

The presence of Gal-3 is an independent risk factor for stroke in patients with AF. Elevated levels of Gal-3 have the potential to serve as a valuable biomarker for identifying incident strokes in AF patients. Furthermore, incorporating the assessment of Gal-3 levels into the conventional CHA2DS2-VASc score could significantly enhance its predictive accuracy for stroke in AF patients.

How Would You Manage This Patient With Recent-Onset Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Atrial fibrillation (AF) is the most common arrhythmia. Risk factors for AF include obstructive sleep apnea, physical inactivity, obesity, cigarette use, and alcohol misuse. Atrial fibrillation substantially increases the risk for stroke and is associated with higher rates of mortality than for individuals without AF. Strategies to prevent these risk factors and to optimize those that already exist reduce the risk for subsequent AF. Physicians play an important role in proposing strategies to reduce the risk for AF among patients. Decision making regarding management of AF is often complex and requires consideration of symptoms, burden of AF (the percentage of time in AF), comorbid conditions that increase stroke risk, and the risk for bleeding. In particular, novel risk scoring systems to predict stroke risk, and consideration of factors beyond those in these tools, refine the ability to identify patients with AF who are most likely to benefit from anticoagulation to reduce stroke risk. Early use of catheter ablation of AF in selected patients improves symptoms and reduces the potential for progression from intermittent to persistent AF. A 2023 collaborative guideline from the American College of Cardiology, American Heart Association, American College of Chest Physicians, and the Heart Rhythm Society addressed multiple aspects of care of patients with AF. Here, a general cardiologist and a cardiac electrophysiologist discuss recommendations derived from this guideline and how to apply them to the care of a particular patient.

Identifying left atrium and left atrial appendage prone to thrombus formation in patients with atrial fibrillation using statistical shape modeling

BACKGROUND

The morphology of the left atrium (LA) and left atrial appendage (LAA) is associated with LAA thrombus formation (LAAT) in patients with atrial fibrillation (AF). Statistical shape modeling (SSM) could be a comprehensive and objective method for evaluating LA/LAA shape, thereby improving LAAT risk assessment.

METHODS AND RESULTS

In this individual-matched case-control study, 110 pairs of AF patients with or without LAAT were compared. Using SSM of cardiac computed tomography angiography images, we developed a LA/LAA shape deformation score (LADS). LADS was significantly higher in the LAAT group (4.0 ± 5.0 vs. -4.0 ± 6.5, P < 0.01) and independently associated with LAAT (odds ratio for each point increase in LADS: 1.31, 95 % confidence interval: 1.21-1.42, P < 0.01). LAAT risk assessment was significantly improved by the addition of LADS to clinical characteristics plus traditional structural parameters, evaluated by the area under the receiver-operating characteristic curve (0.879 vs 0.788, P < 0.01), net reclassification improvement (30.9 %, 95 % CI: 23.6-38.1 %, P < 0.05) and integrated discrimination improvement (18.5 %, 95 %CI: 16.8-20.3 %, P < 0.05). The predictive role of LADS in LAAT was confirmed by an unmatched external validation study including 406 patients with AF (19 cases with LAAT). Computational fluid dynamics analysis of 20 patients showed a significant association between LADS and endothelial cell activation potential, time-averaged wall shear stress, relative residence time, and blood velocity in the LAA.

CONCLUSION

SSM-derived LADS was significantly associated with LAAT and improved LAAT risk assessment. The relationship between LAAT and LADS may be attributed to mechanisms involving endothelial dysfunction and blood stasis.

Clinical impact of inappropriate DOAC dosing in atrial fibrillation: Insights from a real-world registry

Background

A significant number of patients with atrial fibrillation (AF) on direct oral anticoagulants (DOACs) receives off-label or inappropriate doses. This study examines the prevalence, dosages, and clinical outcomes in AF-patients on DOAC therapy admitted to an emergency department (ED).

Methods

This retrospective single-center observational study utilized data from the Heidelberg Registry of Atrial Fibrillation (HERA-FIB), consecutively including patients with AF presenting to the ED of the University Hospital of Heidelberg from June 2009 to March 2020. Rates of DOAC dosages at discharge from the ED were correlated with outcomes, focusing on a composite endpoint that included all-cause mortality, stroke, major bleeding, and myocardial infarction (MI).

Resultsand Conclusions

Among 10,222 patients included in the HERA-FIB registry, 4,239 (41.5 %) were prescribed DOACs, and 3,031were eligible for the analysis. Of these, 2,199 (72.6 %) received appropriate dosages, 627 (20.7 %) were under-dosed, and 205 (6.8 %) were over-dosed. Under-dosed AF-patients demonstrated a significantly increased risk of the composite endpoint compared to those receiving appropriate dosages (HR 1.84, 95 %CI:1.55-2.18, p < 0.0001). Over-dosage had no significant effect on the HR for the composite endpoint, all-cause mortality, stroke, MI, or major bleeding compared to correct dosing but was associated with higher risks of the composite endpoint (HR 1.43, 95 %CI:1.04-1.96, p = 0.029) relative to under-dosage. This study underscores the critical importance of accurate DOAC dosing in patients with AF presenting to an ED. Both under-dosing and over-dosing are linked to significant clinical risks, highlighting the urgent need for improved dosing protocols and careful monitoring to enhance patient outcomes.

Renal function and adverse clinical events in anticoagulated patients with atrial fibrillation: insights from the GLORIA-AF Registry Phase III

Renal function, assessed by creatinine clearance (CrCl), affects the efficacy and safety of oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). To investigate the association between CrCl and the risk of clinical adverse events and compare the safety profiles of vitamin K antagonists (VKA) and non-vitamin K antagonist oral anticoagulants (NOAC). Patients with newly diagnosed AF (< 3 months before baseline visit) were collected from the prospective Global Registry on Long-Term Oral Anti-Thrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) registry Phase III. Clinical events assessed included the composite outcome (all-cause death, thromboembolism, and major bleeding), cardiovascular (CV) death, myocardial infarction (MI), and other single outcomes. 10,594 AF patients (mean age 70.35 ± 9.92 years; 55% male; 73% on NOAC) were included. Increasing CrCl was associated with decreased risks of all cause death, composite outcomes and CV-death with in patients with CrCl < 80 mL/min. Multivariate Cox models indicated that compared to VKA, NOAC was associated with lower risks of all cause death (adjusted hazard ratio [aHR] 0.68, 95% CI 0.58-0.78), composite outcomes (aHR 0.77, 95% CI 0.69-0.86), CV-death (aHR 0.70, 95% CI 0.56-0.87), and major bleeding (aHR 0.74, 95% CI 0.61-0.91) in AF patients. For CrCl < 30 mL/min, lower risks of all-cause death, composite outcomes and CV death were related to NOAC therapy. In this large prospective global registry, NOACs were associated with better outcomes compared with VKA for patients with normal or impaired renal function.

High-frequency low-tidal volume ventilation improves procedural and long-term clinical outcomes in persistent atrial fibrillation ablation: Prospective multicenter registry

BACKGROUND

High-frequency, low-tidal volume (HFLTV) ventilation increases the efficacy and efficiency of radiofrequency catheter ablation (RFCA) of paroxysmal atrial fibrillation. Whether those benefits can be extrapolated to RFCA of persistent atrial fibrillation (PeAF) is undetermined.

OBJECTIVE

The purpose of this study was to evaluate whether using HFLTV ventilation during RFCA in patients with PeAF is associated with improved procedural and long-term clinical outcomes compared to standard ventilation (SV).

METHODS

In this prospective multicenter registry (REAL-AF), patients who had undergone pulmonary vein isolation (PVI) + posterior wall isolation (PWI) for PeAF using either HFLTV ventilation or SV were included. The primary efficacy outcome was freedom from all-atrial arrhythmias at 12 months. Secondary outcomes included procedural and long-term clinical outcomes and complications.

RESULTS

A total of 210 patients were included (HFLTV=95 vs. SV=115) in the analysis. There were no differences in baseline characteristics between the groups. Procedural time (80 [66-103.5] minutes vs 110 [85-141] minutes; P <.001), total radiofrequency (RF) time (18.73 [13.93-26.53] minutes vs 26.15 [20.30-35.25] minutes; P <.001), and pulmonary vein RF time (11.35 [8.78-16.69] minutes vs 18 [13.74-24.14] minutes; P <.001) were significantly shorter using HFLTV ventilation compared with SV. Freedom from all-atrial arrhythmias was significantly higher with HFLTV ventilation compared with SV (82.1% vs 68.7%; hazard ratio 0.41; 95% confidence interval [0.21-0.82]; P = .012), indicating a 43% relative risk reduction and a 13.4% absolute risk reduction in all-atrial arrhythmia recurrence. There was no difference in long-term procedure-related complications between the groups (HFLTV 1.1% vs SV 0%, P = .270).

CONCLUSION

In patients undergoing RFCA with PVI + PWI for PeAF, the use of HFLTV ventilation was associated with higher freedom from all-atrial arrhythmias at 12-month follow-up, with significantly shorter procedural and RF times compared to SV, while reporting a similar safety profile.

Diagnostic Accuracy of Apple Watch Electrocardiogram for Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background

Electrocardiography (ECG) is the gold standard for the diagnosis of atrial fibrillation (AF). Recently, smartwatches like the Apple Watch have emerged as a promising, user-friendly device for rapid detection and diagnosis of AF, but the reliability and diagnostic accuracy still remain controversial.

Objectives

The purpose of this study was to perform a systematic review and diagnostic test accuracy meta-analysis evaluating the diagnostic performance of the Apple Watch ECG in detecting AF.

Methods

The literature search was conducted on PubMed, Embase, and Cochrane Library through April 2024 for studies comparing the diagnostic accuracy of Apple Watch to standard 12-lead ECG. Statistical analysis was performed using R Software version 4.4.0 and OpenMeta[Analyst]. Pooled analyses of sensitivity, specificity, and area under the receiver operating characteristic curve were determined along with their 95% CIs. The quality of studies was analyzed using the QUADAS-2 tool.

Results

The meta-analysis included 11 studies comprising 4,241 participants. Their mean age was 62.56 ± 3.92 years, and 28% of the patients were females. The pooled sensitivity and specificity of the Apple Watch for detecting AF were 94.8% (95% CI: 91.7% to 96.8%; I2 = 67%) and 95% (95% CI: 88.6% to 97.8%; I2 = 88%), respectively. The area under the receiver operating characteristic curve was 0.96 (95% CI: 0.92-0.97).

Conclusions

The Apple Watch ECG carries high accuracy in detecting atrial fibrillation, providing a convenient diagnostic option for patients.

Extensive Atrial Fibrosis and Recalcitrant Atrial Fibrillation: A Case Report and Brief Literature Review

Atrial fibrillation is one of the most common supraventricular arrhythmias. It has multiple etiologies, some of which include advanced age, hypertension, valvular heart disease, hyperthyroidism, sleep apnea, ischemic heart disease, cardiomyopathy, and certain medications. Herein, we will discuss a case of extensive atrial fibrosis in a 57-year-old male with recalcitrant atrial fibrillation, the significant role extensive atrial fibrosis plays in the recurrence of atrial fibrillation, a brief pathophysiologic interplay between both pathologies based on current literature and research, and various imaging modalities and treatment options utilized in these cases. Likewise, we will also outline some challenges faced or worth keeping in mind when using the various imaging modalities pertaining to the above subject matter.

Smartphone-Based Applications for Atrial Fibrillation Detection: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

Background: Atrial fibrillation (AF) burden is strongly associated with an increased risk of stroke, which, in most cases, can be prevented through earlier detection of AF and the timely initiation of anticoagulation therapy. Smartphone devices can provide a simple, non-invasive, cost-effective early AF detection solution. Methods: PubMed, Embase, and Scopus databases were searched for studies comparing smartphone-based photoplethysmography (PPG) with standard electrocardiogram for AF detection. A bivariate random-effects model with a 95% confidence interval (CI) was applied to generate the summary receiver operating characteristic (SROC) curve. Results: Fourteen studies were included, comprising 5,090 patients with an AF prevalence of 31.6%. The pooled sensitivity and specificity were 0.96 (95% CI, 0.93-0.97) and 0.97 (95% CI, 0.95-0.98). The area under the SROC curve was 0.98 (95% CI, 0.94-0.99). The diagnostic odds ratio was 960 (95% CI, 439-2,104), with significant heterogeneity (I2 = 51%). The projected positive and negative predictive values were 66.5% and 99.7%, respectively, in the elderly population aged >65 years and 39.2% and 99.9% in the general population. Conclusion: Smartphone-based PPG demonstrated relatively high sensitivity and specificity and appears capable of ruling out AF. Patients aged >65 are more likely to benefit from AF screening.

Exercise-based cardiac rehabilitation for patients with atrial fibrillation receiving catheter ablation: protocol for a feasibility randomised controlled trial (RCT) with embedded process evaluation

INTRODUCTION

Atrial fibrillation (AF) affects approximately 2.5% of the UK population, with a risk of 1 in 3-5 individuals after the age of 45 years. The global prevalence has risen sharply in the past two decades, from 33.3 million to 59 million individuals living with AF, and is associated with stroke, heart failure and mortality. Catheter ablation is commonly used for symptomatic patients to restore normal rhythm. A recent Cochrane review of randomised clinical trials (RCTs) has demonstrated that exercise training may induce positive effects on AF burden, AF severity, exercise capacity, and quality of life. The aim was therefore to investigate the feasibility of delivering exercise-based cardiac rehabilitation for patients with AF receiving catheter ablation within usual care in the UK.

METHODS AND ANALYSIS

A two-armed feasibility RCT with embedded process evaluation will be undertaken as a phased programme of work. Patients on a waiting list for catheter ablation will be offered a referral to cardiac rehabilitation. The intervention consists of supervised exercise sessions run by a clinical exercise physiologist and psychoeducation sessions. The trial (n=60) will involve one National Health Service (NHS) research site enrolling patients to assess intervention and study design processes. Primary outcomes are recruitment rate, adherence to exercise-based cardiac rehabilitation and loss to follow-up. Semistructured interviews and focus groups with patients and clinicians will be used to gather data on the acceptability of the intervention and study procedures. Secondary outcome measures will be taken at baseline (pre-intervention), post-intervention and at 6-month follow-up and will consist of AF burden, AF recurrence, quality of life, exercise capacity measured by peak oxygen consumption and echocardiographic parameters.

ETHICS AND DISSEMINATION

The trial was approved in the UK by the Northwest-Preston Research Ethics Committee (24/NW/0061; IRAS project ID: 330155). Results will be published in peer-reviewed journals and presented at national and international scientific meetings, and summaries will be communicated to participants.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT06401148.

Predictors of Improvement in Left Ventricular Systolic Dysfunction in Patients with Atrial Fibrillation Undergoing Catheter Ablation: Systematic Review

Background

Left ventricular systolic dysfunction (LVSD) can improve after catheter ablation (CA) in many patients with AF. However, prospective prediction of response can be challenging. The aim of this study was, therefore, to perform a systematic literature review of features associated with improvement in left ventricular ejection fraction (LVEF) in patients with AF and LVSD undergoing first CA.

Method

Systematic search of Ovid MEDLINE, Embase and Cochrane Library databases up to 24 January 2024, for studies involving adult patients with LVSD receiving treatment for AF. The focus was on research articles and clinical trials reporting features associated with changes in LVEF following CA. The review followed PRISMA guidelines.

Results

A total of 789 unique articles were reviewed and 20 were included in the systematic review. Sixty-nine per cent (range, 54-79%) of included patients met the criteria for responder status, which were based on LVEF improvement (usually an increase in LVEF >10% or to >50% at follow-up). Baseline surrogates of myocardial fibrosis on MRI (R2=-0.67), electroanatomical mapping (R2=-0.93) and biochemical surrogates have shown the strongest association with LVEF change. Left atrium and LV chamber size, diastolic dysfunction ECGbased parameters and a known heart failure aetiology have shown prognostic value independently and in combination.

Discussion

Imaging, clinical and ECG-based surrogates of LV fibrosis may be pre-CA markers of LVEF improvement in patients with AF and LVSD. However, the confounding effect of procedural outcomes should be considered. A composite risk stratification tool would have clinical utility in risk stratification and patient selection; however, prospective studies are needed.

Factors influencing patient engagement in decision-making for catheter ablation of atrial fibrillation: a cross-sectional survey

AIMS

Patient engagement in decision-making could improve healthcare quality and health outcome, which has been emphasized in atrial fibrillation (AF) management guidelines. However, patients report relatively low level of engagement in decision-making for catheter ablation (CA). Therefore, this study aims to explore the influencing factors of AF patient engagement in decision-making for CA.

METHODS AND RESULTS

A cross-sectional study was conducted. A total of 836 patients were recruited from six tertiary hospitals in Shanghai. Adapted version of the Control Preferences Scale, Chinese version of the All Aspects of Health Literacy Scale, Chinese version of the Facilitation of Patient Involvement Scale, and the Atrial Fibrillation Knowledge Questionnaire were used to measure patient engagement in decision-making, health literacy, perception of physician facilitation, and AF knowledge, respectively. Of the 750 patients who returned valid questionnaires, 20.2% of the patients reported active engagement in decision-making, 39.5% reported collaborative engagement, and 40.3% reported passive engagement. Compared with patients perceiving passive engagement, those with collaborative or active engagement were more likely to be female and have higher income, moderate European Heart Rhythm Association (EHRA) class (II and III), higher perception of physician facilitation, higher health literacy, and higher AF knowledge (P < 0.05 for all). The collaborative engagement group exhibited a shorter AF duration.

CONCLUSION

The degree of patient engagement in CA decision-making varied, with most perceiving passive engagement. Patient engagement in decision-making was influenced by gender, income, duration of AF, EHRA class, perception of physician facilitation, health literacy, and AF knowledge.

Practical guidance for management of atrial fibrillation in sports cardiology

IMPORTANCE

Atrial fibrillation (AF), the most prevalent sustained arrhythmia, portends higher risk of cardiovascular morbidity and mortality, and is associated with quantifiable impairment in quality of life. While physical activity is widely recognized for its cardiovascular benefits, recent evidence challenges its role in the development of AF.

OBSERVATIONS

Emerging data suggest a U-shaped relationship between physical activity and AF risk. Mild to moderate exercise appears protective, whereas prolonged, high-intensity activity is associated with an increased risk, possibly driven by cardiac remodeling, autonomic alterations, and atrial substrate changes typical of the so-called athlete's heart. This relationship is further modulated by other factors, including genetic predisposition, acquired cardiac conditions, and stimulant use. With the growing participation of aging populations in sports, the clinical management of AF in athletes presents unique challenges. Pharmacological strategies for rhythm and rate control may conflict with performance goals, and the use of anticoagulants must be carefully balanced against the risk of traumatic bleeding in contact sports. Recent evidence supports strategies such as short-term anticoagulant withdrawal to mitigate hemorrhagic risk while maintaining thromboembolic protection. A personalized approach, incorporating shared decision-making, is essential, particularly for elite athletes.

CONCLUSIONS AND RELEVANCE

While regular physical activity generally confers cardiovascular benefits, prolonged intense exercise bouts may paradoxically increase the risk of AF. The evaluation and management of AF in athletes require a tailored, multidisciplinary approach that accounts for the distinct needs of this population.

"Artificial Bachmann's Bundle", Employing Carbon Nanotubes Fibers in the Prevention/Management of Atrial Fibrillation

The present communication constitutes a proposal of attempting to restore interatrial electrical conduction in patients with interatrial block and malfunctioning Bachman's bundle, or other interatrial conduction pathways, employing carbon nanotube fibers (i.e., an "artificial Bachman's bundle"), in order to prevent emergence of atrial fibrillation, and by extension even possibly ameliorate or effectively treat paroxysmal/persistent/permanent atrial fibrillation.

Prevalence and relevance of H558R in the efficacy and toxicity of flecainide in patients with atrial fibrillation: a cohort study

BACKGROUND

The SCN5A gene polymorphism histidine-558-to-arginine (H558R) has been associated with atrial fibrillation (AF) and may affect the therapeutic effects of flecainide. This study aimed to assess the prevalence of the H558R polymorphism in a European cohort of patients with AF and examine its association with flecainide's effects on AF recurrence and toxicity.

METHODS

This cohort study included patients diagnosed with AF and prescribed flecainide between 2017 and 2021 in a regional health area. Patients without the polymorphism (H558R-/-) were compared with heterozygous patients (H558R+/-) for a primary outcome of combined 6-month AF recurrence or toxicity. Secondary analyses evaluated the long-term outcomes and compared the prevalence of H558R in the AF cohort to a general population sample (n=3401).

RESULTS

A total of 104 patients were enrolled, with 57% H558R-/-, 37% H558R+/- and 6% H558R+/+. The prevalence of the H558R polymorphism was significantly higher in the AF cohort than in the general population (43.27% vs 24.37%, prevalence ratio 1.78, 95% CI 1.41 to 2.23, p<0.01). H558R+/- patients had a significantly lower risk of 6-month AF recurrence or toxicity (p=0.023, risk ratio 0.423, 95% CI 0.189 to 0.947), corresponding to an absolute risk difference of 21.5%. These findings were similar in the multivariable analysis. In long-term follow-up, H558R+/- patients continued to demonstrate a lower risk of AF recurrence or toxicity (p=0.039, HR 0.53, 95% CI 0.276 to 0.999).

CONCLUSIONS

The H558R polymorphism is more prevalent in patients with AF compared with the general population and its presence is associated with a more favourable response to flecainide treatment.

Atrial Fibrillation: A Review

Importance

In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.

Observations

Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

Conclusions and Relevance

AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

Incidence, Predictors, and Management of Femoral Vascular Complications Following Catheter Ablation for Atrial Fibrillation: A Systematic Duplex Ultrasound Study

Background/Objectives: Catheter ablation is an effective treatment for atrial fibrillation (AF) but is associated with femoral vascular complications. While anticoagulation therapy has been linked to these complications, specific risk factors remain unclear. This study assessed the incidence and predictors of vascular complications after catheter ablation using systematic duplex ultrasound (DUS) as well as their outcomes. Methods: A single-center observational study was conducted with 404 consecutive AF patients who underwent catheter ablation between March 2023 and February 2024. DUS was performed systematically post-procedure in all patients to identify complications; these were primarily treated with DUS-guided manual compression. Results: Vascular complications were observed in 6.4% of patients, higher than reported in previous studies. Hematomas (3.5%) and arteriovenous fistulas (AVFs, 2.0%) were the most common such complications. Multivariate analysis identified repeat ablation (odds ratio [OR] 3.09, 95% confidence interval [CI] 1.10-8.64, p = 0.03) and months of experience <6 months (OR 3.42, 95% CI 1.36-8.63, p = 0.01) as significant predictors of complications. DUS-guided compression managed most complications successfully, with three pseudoaneurysms resolved through compression and one through embolization. However, AVFs were relatively resistant to conservative management, often necessitating prolonged observation or intervention. Conclusions: Systematic DUS following catheter ablation revealed a higher-than-expected incidence of vascular complications. Repeat ablation and months of experience <6 months are potential predictors of femoral vascular complications. DUS-guided compression is effective for most complications, although AVFs present greater treatment challenges.

Adverse events in different administration routes of amiodarone: a pharmacovigilance study based on the FDA adverse event reporting system

Background

Arrhythmias are prevalent cardiac disorders with significant impacts on patient quality of life and mortality. Amiodarone, a class III antiarrhythmic agent, is widely used to manage both atrial and ventricular arrhythmias due to its efficacy in prolonging the cardiac action potential and its multiple antiarrhythmic properties. While clinical trials have highlighted the safety and efficacy of amiodarone, there is limited real-world data on adverse events (AEs) associated with different administration routes. This study aims to address this gap by utilizing the U.S. Food and Drug Administration's Adverse Event Reporting System (FAERS) to investigate the spectrum and timing of AEs related to amiodarone administration through disproportionality analysis and stratification methods.

Methods

Data from the FAERS database were analyzed using disproportionality analysis and reporting odds ratio (ROR) methods for comparative analysis, and the Weibull distribution for time-to-adverse-event analysis. The study examined data from 2004 through the first quarter of 2024 to analyze adverse event signals and the time of occurrence between intravenous and oral amiodarone administration.

Results

A total of 16,749 records of adverse reactions associated with amiodarone were identified. Among these, 2,412 events were related to intravenous amiodarone, and 8,220 events were related to oral amiodarone. The analysis revealed that cardiac and hepatic AEs were more common with intravenous administration, while pulmonary and thyroid-related AEs were more frequent with oral administration. Furthermore, the onset of adverse reactions varied significantly between the routes. The Weibull distribution analysis showed a median onset time of 5 days for intravenous administration compared to 74 days for oral administration. Both routes exhibited early failure-type signals, indicating a decreasing risk of AEs over time.

Conclusion

Amiodarone exhibits varying adverse drug reactions and onset times across different routes of administration. Clinicians should carefully consider these differences when selecting the administration route to balance the risks of adverse reactions with therapeutic benefits.

Clinical, Electrocardiographic and Echocardiographic Predictors of Atrial Fibrillation Recurrence After Pulmonary Vein Isolation

Atrial fibrillation (AF) is a supraventricular arrhythmia and the most common heart rhythm disorder in the adult population worldwide with an estimated prevalence of 2% to 4% of the population. Cases of AF have shown an increasing trend in recent decades, while its frequency is expected to rise even more. Given the significant impact on patients' quality of life, as well as its major complications, including thromboembolic events, effective rhythm control strategies other than antiarrhythmic medication have emerged, with catheter ablation (CA) being the cornerstone of these. In recent years, CA has been upgraded to a first-line treatment for selected patients. However, complications do exist and arrhythmia-free survival is not always guaranteed. The need to better identify patients more suitable for this specific therapeutic measure is crucial in improving outcomes and preventing arrhythmia recurrences. This review aims to present currently identified predictors of AF recurrence after catheter ablation based on clinical characteristics and electrocardiographic and echocardiographic parameters, in an era of increasing interventional rhythm control approaches for the management of atrial fibrillation.

Cryoballoon Pulmonary Vein Isolation in Obese Patients with Atrial Fibrillation Compared to Non-Obese Counterparts: A Meta-Analysis

Introduction: Obesity is an important risk factor for atrial fibrillation (AF) development. Data on cryoballoon ablation (CBA) outcomes in obese patients have so far been scarce. We reviewed the existing literature to compare the efficacy and safety of CBA in obese versus non-obese AF patients. Methods: A systematic literature search was conducted for studies comparing clinical outcomes (arrhythmia recurrence and/or procedural data and/or safety outcomes) between obese and non-obese patients undergoing CBA for AF. Statistical pooling was performed according to a random-effects model with generic inverse-variance weighting of relative risks (RRs) and standardised mean differences (SMDs) computing risk estimates with 95% confidence intervals (CIs). Results: Obese and non-obese patients had comparable arrhythmia recurrence rates (normal versus overweight, RR = 0.95, 95% CI: 0.82-1.11, p = 0.55, I2% = 91%; normal versus class I obesity, RR = 0.97, 95% CI: 0.82-1.13, p = 0.68, I2% = 87%; normal versus class II obesity, RR = 0.98, 95% CI: 0.91-1.07, p = 0.29, I2% = 65%). Procedure time was marginally increased in obese patients compared to non-obese counterparts (normal versus overweight, SMD = 0.05, 95% CI: -0.15-0.26, p = 0.62, I2% = 74%; normal versus class I obesity, SMD = 0.10, 95% CI: -0.00-0.19, p = 0.06, I2% = 2%; overweight versus class I obesity, SMD = 0.11, 95% CI: 0.01-0.21, p = 0.048, I2% = 25%). Regarding radiation exposure, fluoroscopy time was increased in patients with class I obesity compared to normal-weight or overweight patients and dose area product was also increased in obese patients compared to non-obese patients. Lastly, the risk of complications did not differ between obese and non-obese patients. Statistical heterogeneity and the small number of patients included are the main limitations of this study. Conclusion: CBA seems to be effective for obese patients suffering from AF, featuring also similar safety outcomes with non-obese individuals. Radiation exposure was increased in obese patients.

Association between triglyceride glucose index and adverse cardiovascular prognosis in patients with atrial fibrillation without diabetes: a retrospective cohort study

BACKGROUND

Atrial fibrillation (AF) is the most prevalent arrhythmia encountered in clinical practice. Triglyceride glucose index (Tyg), a convenient evaluation variable for insulin resistance, has shown associations with adverse cardiovascular outcomes. However, studies on the Tyg index's predictive value for adverse prognosis in patients with AF without diabetes are lacking.

METHODS

This retrospective study utilized electronic medical records to collect data on patients with AF hospitalized at West China Hospital from January to June 2020. Participants were categorized into three groups based on their Tyg index levels. The primary outcome, major adverse cardiovascular events, included cardiac death, stroke, and myocardial infarction. Kaplan-Meier curve, Cox proportional hazards regression model, and restricted cubic spline were employed to explore the relationship between the Tyg index and outcomes. The predictive performance of the CHA2DS2-VASc model was evaluated after incorporating the Tyg index.

RESULTS

The study comprised 864 participants (mean age 67.69 years, 55.32% male, 57.52% paroxysmal AF). Patients with high Tyg index had a significantly higher risk of developing major adverse cardiovascular events (MACE) (P < 0.001, hazard ratio: 2.05, 95% confidence interval:1.65-2.56). The MACE risk in the middle Tyg group was similar to that in the low Tyg group (P = 0.1) during the 48-month follow-up period. However, focusing on the last 24 months revealed a higher MACE risk (P = 0.015) in the middle Tyg group. The restricted cubic spline analysis revealed an S-shaped correlation between Tyg and MACE. The CHA2DS2-VASc model combined with the Tyg index showed improved predictive performance and net benefit.

CONCLUSIONS

A high Tyg index is associated with poorer prognosis in patients with AF without diabetes. Integrating the Tyg index into the CHA2DS2-VASc model may enhance its predictive performance, offering clinical utility.

Consumer-grade wearable devices in arrhythmia diagnostics for clinicians: where we are and where we are going

Atrial arrhythmias, including atrial fibrillation (AF), are a major contributor to cardiovascular morbidity and mortality. Early detection and effective management are critical to mitigating adverse outcomes such as stroke, heart failure, and overall mortality. Wearable devices have emerged as promising tools for monitoring, detecting, and managing atrial arrhythmias near-continuously. This comprehensive analysis explores these wearable technologies' current role and capabilities for clinicians' daily practice. Despite challenges related to data accuracy, privacy, patient compliance, and integration with healthcare systems, ongoing advancements hold significant promise for the future. Continued research and development are essential to fully realize the potential of wearables in improving clinical outcomes for patients with atrial arrhythmias.

Safety and effectiveness of pulsed field ablation for pulmonary vein isolation in atrial fibrillation patients: One-year single center experience

INTRODUCTION AND OBJECTIVES

Pulmonary vein (PV) isolation is one of the cornerstones of rhythm-control therapy for symptomatic atrial fibrillation (AF) patients. Pulsed field ablation (PFA) is a novel ablation modality that involves the application of electrical pulses causing cellular death, and it has preferential tissue specificity. In this study, we aimed to share a one-year single center experience of AF ablation with PFA.

METHODS

Single center, retrospective study of consecutive patients undergoing PVI using the pentaspline PFA catheter between June 2022 and July 2023. Data on demographic, procedural, and electrocardiographic recurrence (assessed after a three-month blanking period) were analyzed.

RESULTS

One hundred twenty-three consecutive patients were included (62±11 years, 59% male), with a mean CHA2DS2-VASc score of 2±1 points, median left ventricular ejection fraction of 61% [IQR 60-65%] and a median left atrial volume index (by CT scan) of 55 mL/m2 [IQR 41-67 mL/m2]. Fifty-two percent of patients presented paroxysmal AF and 21 patients (17%) underwent a redo ablation. Median procedure time was 83 min [IQR 59-117 min] and median fluoroscopy time was 11.6 min [IQR 8.2-15.6 min]; posterior wall isolation was performed in 43 (35%). Two patients (1.6%) experienced acute cardiac tamponade, immediately treated with pericardiocentesis. Other complications were primarily vascular, in 4% of cases (three femoral hematomas, one femoral pseudoaneurysms, one arteriovenous fistula). Over 290 (IQR 169-387) days of follow-up, considering electrocardiographic recurrence beyond the blanking period, 9% of patients had AF recurrence (two with paroxysmal AF and nine with persistent AF).

CONCLUSIONS

Pulsed field ablation for PVI and posterior wall ablation was an efficient and safe procedure with low rate of complications and high percentage of patients were free from AF in short-term follow-up. We need more studies to evaluate long-term success.

Proteomics and Recurrence of Atrial Fibrillation: A Pilot Study Nested in the PREDIMAR Trial

INTRODUCTION

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide. Although catheter ablation is the most efficacious therapy, relapses occur frequently (30%) in the first year after ablation. Novel biomarkers of recurrence are needed for a better prediction of recurrence and management of AF. In this pilot study, we aimed to analyze the baseline proteome of subjects included in a case-control study to find differential proteins associated with AF recurrence.

METHODS

Baseline serum proteomics (354 proteins) data from 16 cases (recurrent AF) and 17 controls (non-recurrent) were obtained using MS/MS analysis. A false discovery rate was performed using a nonlinear fitting method for the selection of proteins. Logistic regression models were used to further analyze the association between differentially expressed proteins and AF recurrence.

RESULTS

Ten proteins were differentially represented in cases vs. controls. Two were upregulated in the cases compared to the controls: keratin type I cytoskeletal 17 (Fold-change [FC] = 2.14; p = 0.017) and endoplasmic bifunctional protein (FC = 1.65; p = 0.032). Eight were downregulated in the cases compared to the controls: C4bpA (FC = 0.64; p = 0.006), coagulation factor XI (FC = 0.83; p = 0.011), CLIC1 (FC = 0.62; p = 0.017), haptoglobin (FC = 0.37; p = 0.021), Ig alpha-2 chain C region (FC = 0.49; p = 0.022), C4bpB (FC = 0.73; p = 0.028), N-acetylglucosamine-1-phosphotransferase subunit gamma (FC = 0.61; p = 0.033), and platelet glycoprotein Ib alpha chain (FC = 0.84; p = 0.038).

CONCLUSION

This pilot study identifies ten differentially expressed serum proteins associated with AF recurrence, offering potential biomarkers for improved prediction and management.

Atrial fibrillation versus atrial myopathy in thrombogenesis: Two sides of the same coin?

Atrial fibrillation (AF) and atrial myopathy are recognized contributors to cardiovascular morbidity, particularly ischemic stroke. AF poses an elevated risk of thrombogenesis due to irregular heart rhythm leading to blood stasis and clot formation. Atrial myopathy, marked by structural and functional alterations in the atria, is emerging as a crucial factor influencing thromboembolic events, independently of AF. This narrative review article provides an overview of the interwoven relationship between AF and atrial myopathy in thrombogenesis, focusing on the epidemiology, risk factors, and clinical implications of these two entities. The discussion encompasses the association between AF burden and stroke risk, evaluating current evidence and guidelines for anticoagulant therapy. Additionally, it explores the role of atrial myopathy in the pathogenesis of thromboembolic events, emphasizing the patient's clinical profile assessed by the CHA2DS2-VASc score. The manuscript provides insights into ongoing trials and future perspectives, discussing potential advancements in antithrombotic therapy, fibrin clot dynamics, and anti-inflammatory strategies. This comprehensive review challenges the conventional perception of AF as a sole cause of stroke, urging a holistic approach to risk assessment of thrombogenesis and management in the high-risk population that AF patients constitute.

Heart failure with preserved ejection fraction and atrial fibrillation: epidemiology, pathophysiology, and diagnosis interplay

Heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are increasingly prevalent cardiovascular conditions, particularly among the elderly population. These two conditions share common risk factors and often coexist, leading to a complex interplay that alters the clinical course of each other. The pathophysiology of HFpEF is multifaceted and intricately linked, with atrial disease serving as a common pathophysiological pathway. Diagnosis of HFpEF in the setting of AF, and vice versa, can be challenging; thus, effective screening and diagnostic strategies are needed. Understanding the complex relationship between HFpEF and AF is crucial for optimal patient management by timely disease recognition and identification of therapeutic interventions or treatment strategies.

Mendelian Randomization Study Reveals Causal Pathways for Hypertrophic Cardiomyopathy, Cardiovascular Proteins, and Atrial Fibrillation

Aims/Background Research evidence has demonstrated a significant association between hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF), but the causality and pattern of this link remain unexplored. Therefore, this study investigated the causal relationship between HCM and AF using a two-sample and bidirectional Mendelian randomization (MR) approach. Additionally, this assessed the role of cardiovascular proteins (CPs) associated with cardiovascular diseases between HCM and AF by applying a two-step MR analysis. Methods Data for HCM, AF, and 90 CPs were obtained from the Finn Gen and IEU Open GWAS Project databases. MR-Egger, inverse variance weighting (IVW), weighted median estimator (WME), weighted mode, and simple mode were used to estimate causal inferences. Furthermore, Cochran's Q test, MR-Egger's intercept terms, and Leave-one-out methods determined the heterogeneity, horizontal pleiotropy, and sensitivity. Additionally, mediation effects were used to assess the role of CPs in the relationship between HCM and AF. Results Two-sample and bidirectional MR analysis revealed HCM as a risk factor for AF (odds ratio (OR) = 1.008, 95% confidence interval (CI): 1.001-1.016, p = 0.029) and AF was found to increase the risk of developing HCM (OR = 1.145, 95% CI: 0.963-1.361, p = 0.126). Moreover, Two-step MR analyses indicated that 5 CPs were causally associated with HCM; 12 CPs with AF and 1 CP (Melusin) with both HCM and AF. Additionally, Melusin was observed as a protective factor for both HCM and AF and may serve as a mediator variable for these two conditions (mediation effect 0.0004, mediation ratio 5.5178%, 95% CI: 5.4624-5.5731). Conclusion HCM may increase the risk of developing AF, with Melusin serving as a mediator for this risk.

Clinical utility of systolic left ventricular ejection fraction in atrial fibrillation: Role of prospective ECG-triggered cardiac CT

BACKGROUND

The assessment of left ventricular (LV) systolic function and quantification of LV ejection fraction (LVEF) in patients with atrial fibrillation (AF) can be difficult. We previously demonstrated that LV volume changes over the 100 ms of systole (LVEF100ms) can be used as a measure of LV systolic function.

OBJECTIVE

We sought to evaluate the applicability of LVEF100ms in patients with AF.

METHODS

We screened patients with AF who underwent prospective systolic electrocardiogram-triggered cardiac computed tomography from January 2015 to June 2023. The correlation between LVEF100ms and echocardiography-derived LVEF was assessed. Patients were categorized into 3 groups on the basis of echocardiographic LVEF (≤40%, 40%-55%, and ≥55%), and LVEF100ms was compared among these groups. Receiver operating characteristic curve analysis and Cox proportional hazards models were used to determine the optimal LVEF100ms cutoff for predicting LVEF ≤ 40% and major adverse cardiovascular events (MACE), defined as a composite of cardiac death, myocardial infarction, heart failure hospitalization, and stroke.

RESULTS

Of the total 123 patients, 62 (50.4%) had an LVEF of ≥55%, 40 (32.5%) had an LVEF of 40%-50%, and 21 (17.1%) had an LVEF of ≤40%. LVEF100ms correlated with echocardiography-derived LVEF (P < .001) and differed significantly among groups (P < .001). LVEF100ms ≤ 3.3% predicted LVEF ≤ 40% (area under the curve 0.809; sensitivity 87%; specificity 67%). Patients with an LVEF100ms of ≤3.3% had a higher rate of MACE than did those without (P = .030), and LVEF100ms ≤ 3.3% was an independent predictor of MACE.

CONCLUSION

LVEF100ms can provide a useful indicator of LV dysfunction in patients with AF undergoing prospective electrocardiogram-triggered cardiac computed tomography.

Abelacimab versus Rivaroxaban in Patients with Atrial Fibrillation

BACKGROUND

Abelacimab is a fully human monoclonal antibody that binds to the inactive form of factor XI and blocks its activation. The safety of abelacimab as compared with a direct oral anticoagulant in patients with atrial fibrillation is unknown.

METHODS

Patients with atrial fibrillation and a moderate-to-high risk of stroke were randomly assigned, in a 1:1:1 ratio, to receive subcutaneous injection of abelacimab (150 mg or 90 mg once monthly) administered in a blinded fashion or oral rivaroxaban (20 mg once daily) administered in an open-label fashion. The primary end point was major or clinically relevant nonmajor bleeding.

RESULTS

A total of 1287 patients underwent randomization; the median age was 74 years, and 44% were women. At 3 months, the median reduction in free factor XI levels with abelacimab at a dose of 150 mg was 99% (interquartile range, 98 to 99) and with abelacimab at a dose of 90 mg was 97% (interquartile range, 51 to 99). The trial was stopped early on the recommendation of the independent data monitoring committee because of a greater-than-anticipated reduction in bleeding events with abelacimab. The incidence rate of major or clinically relevant nonmajor bleeding was 3.2 events per 100 person-years with 150-mg abelacimab and 2.6 events per 100 person-years with 90-mg abelacimab, as compared with 8.4 events per 100 person-years with rivaroxaban (hazard ratio for 150-mg abelacimab vs. rivaroxaban, 0.38 [95% confidence interval {CI}, 0.24 to 0.60]; hazard ratio for 90-mg abelacimab vs. rivaroxaban, 0.31 [95% CI, 0.19 to 0.51]; P<0.001 for both comparisons). The incidence and severity of adverse events appeared to be similar in the three groups.

CONCLUSIONS

Among patients with atrial fibrillation who were at moderate-to-high risk for stroke, treatment with abelacimab resulted in markedly lower levels of free factor XI and fewer bleeding events than treatment with rivaroxaban. (Funded by Anthos Therapeutics; AZALEA-TIMI 71 ClinicalTrials.gov number, NCT04755283.).

Assessing the applicability of the DOAC, HAS-BLED and ORBIT risk scores in Chinese patients on non-vitamin K antagonist oral anticoagulants

AIMS

The suitability of the DOAC score for assessing bleeding risk in Chinese patients with atrial fibrillation (AF) who are receiving non-vitamin K antagonist oral anticoagulants (NOACs) remains unclear. We compared the DOAC score to the HAS-BLED and ORBIT scores in Chinese patients in a real-world retrospective study.

METHODS

The efficacy of these scores was assessed by a comparison study that measured their discrimination, calibration, net reclassification index (NRI), and decision curve analysis (DCA) over a 1-year follow-up period.

RESULTS

Among 2532 patients with non-valvular AF (mean age, 71.7 ± 11.3 years, 58.5% men), major bleeding (MB) occurred in 91 patients (3.59%/year): 44 intracranial haemorrhage (ICH) events (1.74%/year) and 49 gastrointestinal bleeding (GB) events (1.94%/year). The best predictor for MB was the HAS-BLED score (area under the receiver operating characteristic curve [AUC], 0.674). HAS-BLED score ≥3 provided the best prediction for MB (AUC, 0.642), followed by DOAC score ≥8 and ORBIT score ≥4 (AUCs of 0.615 and 0.583, respectively). The DOAC and HAS-BLED scores did not differ significantly in discriminating MB events and risk reclassification. The calibration performance of the HAS-BLED score was superior to that of the other two scores. Decision curve analysis showed that using the HAS-BLED score to predict MB and ICH is clinically beneficial. However, there were no significant distinctions among the three models in forecasting GB.

CONCLUSIONS

In a non-valvular AF Chinese patients receiving NOACs, the HAS-BLED score showed an ability to predict MB comparable to that of the DOAC score and superior to that of the ORBIT score. The DOAC score does not seem to be more suitable for Chinese patients than the HAS-BLED score.

Representation of Women in Atrial Fibrillation Ablation Randomized Controlled Trials: Systematic Review

BACKGROUND

Sex inequality in randomized controlled trials (RCTs) related to cardiovascular disease has been observed. This study examined the proportion of women enrolled in atrial fibrillation (AF) ablation RCTs and the potential risks of underrepresentation of women.

METHODS AND RESULTS

We systematically searched PubMed and Embase for AF ablation RCTs published from 2015 to 2022. Participant characteristics were compared among trials with higher and lower proportions of women. Of 147 AF ablation RCTs (30,055 participants), only 10 trials had enrolled women ≥50% of the total participants. Additionally, 42 trials (28.57%) excluded pregnant/breastfeeding women; 6 (4.1%) excluded reproductive-age women without reliable birth control. The proportion of women in AF RCTs ranged from 9% to 71% (median 31.5%), whereas the median proportion of men was 67.7%. The rate of women included in the trials was stable from 2015 to 2022 (P=0.49). Study characteristics, including funding source, showed no correlation with the rate of inclusion of women. RCTs with a higher proportion of female participants enrolled older patients with AF, had a higher prevalence of hypertension but less persistent AF, and smaller left atrium size (P<0.05 for all). Biological sex was evaluated as a risk factor or in a subgroup analysis in 28 RCTs; 10.7% of these trials observed the implication of sex on their results.

CONCLUSION

Women were underrepresented in contemporary AF ablation RCTs. Additionally, women enrolled in AF RCTs were likely to have more comorbidities but less advanced AF, limiting the applicability of the results to women with AF.

Health Care Resource Use and Costs of Rivaroxaban Versus Warfarin Among Nonvalvular Atrial Fibrillation Polypharmacy Patients With Obesity

BACKGROUND

The economic burden of nonvalvular atrial fibrillation (NVAF) is substantial. Many patients with NVAF are obese and manage other health conditions requiring multiple medications. This real-world study compared health care resource use (HRU) and costs for rivaroxaban and warfarin in patients with NVAF who had polypharmacy and obesity.

METHODS AND RESULTS

We used health care claims databases (Merative MarketScan commercial and Medicare supplemental claims) to identify patients initiating the direct oral anticoagulant rivaroxaban or warfarin with ≥1 diagnostic claim for atrial fibrillation, presence of polypharmacy (based on 3 categories for the number of concurrent medications: 1-4, 5-9, ≥10), and obesity. Cohorts were balanced for demographic and baseline characteristics using propensity score matching. All-cause and NVAF-related HRU rates and costs were compared between treatments using rate ratios and adjusted mean differences per patient per year. Eligible patients totaled 95 875, with 19 990 patients in each treatment cohort following propensity score matching. All-cause HRU rates were significantly lower with rivaroxaban versus warfarin, and hospital stays were reduced by 3.1 days with rivaroxaban. Mean (95% CI) all-cause total medical and total health care costs per patient per year were significantly reduced with rivaroxaban versus warfarin (-$4499 [-$5660 to -$3305] and -$1627 [-$2790 to -$438], respectively). NVAF-related HRU was reduced with rivaroxaban versus warfarin, but total NVAF-related medical costs were not significantly different between treatment groups ($144 [-$756 to $1079] per patient per year). Subgroup and sensitivity analysis results were generally consistent with the main analysis.

CONCLUSIONS

Among patients with NVAF, polypharmacy, and obesity, rivaroxaban was associated with a reduction in HRU and all-cause costs compared with warfarin.

Contemporary Administrative Codes to Identify Pulmonary Vein Isolation Procedures for Atrial Fibrillation

BACKGROUND

Use of pulmonary vein isolation (PVI) to treat atrial fibrillation continues to increase. Despite great interest in leveraging administrative data for real-world analyses, contemporary procedural codes for identifying PVI have not been evaluated.

METHODS AND RESULTS

In this observational retrospective cohort study, inpatient PVIs were identified among US Medicare fee-for-service beneficiaries using Current Procedural Terminology (CPT) code 93656 in Carrier Line Files. Each patient was matched with their claims from Medicare Provider Analysis and Review to compare CPT with International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) claims submitted by health care facilities to bill for PVIs. We performed the reverse for commonly matched ICD-10-PCS codes, to identify corresponding CPT-billed procedures. Finally, we reviewed institutional cases for additional comparison of CPT and ICD-10-PCS assignation for PVI. We identified 25 617 inpatient PVIs from January 2017 to December 2021, of which 18 165 (71%) were linked to Medicare Provider Analysis and Review. Of these, 16 672 (92%) were billed as ICD-10-PCS 02583ZZ: "Destruction of Conduction Mechanism, Percutaneous Approach." The reverse process yielded heterogeneous results: among 75 003 procedures billed as ICD-10-PCS 02583ZZ, only 15 691 (21%) matched with CPT 93656 (PVI), as several other unrelated procedures were billed under this ICD-10-PCS code. Institutional case review confirmed the greater specificity of CPT codes.

CONCLUSIONS

The ICD-10-PCS code associated with CPT-billed PVI procedures actually referred to ablation of the atrioventricular junction. Yet this ICD-10-PCS code also matched with a wide range of other procedures distinct from PVI. We conclude that ICD-10-PCS codes alone are not sensitive nor specific for identifying PVI in claims and cannot be reliably used in isolation for health services research on this important procedure.

CMR assessment of epicardial edipose tissue in relation to myocardial inflammation and fibrosis in patients with new-onset atrial arrhythmias after STEMI

BACKGROUND

Previous studies have shown that epicardial edipose tissue(EAT) appears to be associated with myocardial inflammation and fibrosis, but this is not clear in patients with new-onset atrial arrhythmias after STEMI. The present study focused on using CMR to assess the association of epicardial fat with myocardial inflammation and fibrosis and its predictive value in patients with new-onset atrial arrhythmias after STEMI.

METHODS

This was a single-centre, retrospective study. We consecutively selected patients who completed CMR during their hospitalisation for PCI after STEMI from May 2019-January 2023, and then underwent regular follow-up, grouped by the presence or absence of new atrial arrhythmias, and enrolled patients were divided into atrial arrhythmia and non-atrial arrhythmia groups.

RESULTS

In the atrial arrhythmia group, age, heart rate, Peak hs-TnT, PeakNT-proBNP, EATV, LAES, LAED, T1 native, T1*, ECV, and T2 were higher than those in the non-atrial arrhythmia group, and LVEF was lower than those in the non-atrial arrhythmia group. EATV showed a positive and significant correlation with T1native, T1*, ECV, and T2. (T1 native: r = 0.476,p < 0.001; ECV: r = 0.529,p < 0.001; T1*: r = 0.467,p < 0.001; T2: r = 0.538,p < 0.001). Multifactorial logistic regression analysis showed age, LVEF, EATV, T1*,ECV, T2 as independent risk factors for atrial arrhythmia. (p < 0.05) ROC analysis showed that the AUC for age was 0.568; AUC for LVEF was 0.656; AUC for EATV was 0.768; AUC for ECV was 0.705; AUC for T1* was 0.612; and AUC for T2 was 0.772.

CONCLUSION

In patients with STEMI, EAT is associated with myocardial inflammation, fibrosis. Age, LVEF, EATV, T1*,ECV, T2 are independent risk factors for new onset atrial arrhythmias and have good predictive value.

Enhanced Endothelialization Using Resveratrol-Loaded Polylactic Acid-Coated Left Atrial Appendage Occluders in a Canine Model

Left atrial appendage occlusion (LAAO) is a well-established alternative to anticoagulation therapy for patients with atrial fibrillation who have a high bleeding risk. After occluder implantation, anticoagulation therapy is still required for at least 45 days until complete LAAO is achieved by neoendocardial coverage of the device. We applied a polylactic acid-resveratrol coating to the LAAO membrane to enhance endothelialization with the goal of shortening the anticoagulation therapy duration. Eighteen dogs were randomly divided into the experimental group (coated occluders) or the control group (noncoated occluders). The dogs were sacrificed in cohorts at days 14, 28, and 90 for anatomical and pathological examination to evaluate endothelialization and thrombus formation. Transesophageal echocardiography (TEE) was performed before sacrifice to evaluate device-related adverse events. According to the anatomical and pathological examinations, all except one LAAO cover exhibited larger or thicker tissue or neoendocardial coverage in the experimental group compared with the control group at the same sacrifice time points. All connection hubs were densely covered by endothelial cells at 90 days and completely covered at 28 days in the experimental group, while all connection hubs were thinly covered at 90 days and two connection hubs were exposed at 28 days in the control group. Pathological examination revealed no thrombus formation in the experimental group, while a small amount of thrombus was observed in one dog at 90 days and in two dogs at 28 days in the control group. Finally, TEE showed no peri-device leakage (PDL) in the experimental group, whereas a small amount of PDL was detected in one dog (3.2 mm) at 28 days and in one dog (3.7 mm) at 14 days in the control group. The resveratrol-loaded polylactic acid-covered LAAO device enhanced endothelialization and reduced thrombus formation and PDL. This effect could possibly reduce the anticoagulation therapy duration.