New-onset postoperative atrial fibrillation after heart surgery

BACKGROUND

New-onset postoperative atrial fibrillation (poAF) complicates approximately 20-60% of all cardiac surgical procedures and is associated with an increased periprocedural mortality and morbitity, prolonged hospital stay, increased costs, and worse long-term survival. Unfortunately multiple advances in surgery and perioperative care over the last two decades have not led to a reduction in the incidence of poAF or associated complications in the daily clinical practice.

METHODS

A narrative review of the available literature was performed.

RESULTS

An extensive review of the pathophysiology of poAF following cardiac surgery, clinical, and procedural risk-factors is provided, as well as prophylactic measures and treatment.

CONCLUSION

Multiple strategies to prevent and manage poAF following heart surgery already exist. Our hope is that this review will facilitate more rigorous testing of prevention strategies, implementation of prophylaxis regimens as well as optimal treatment of this common and serious complication.

Noninvasive stereotactic radioablation for the treatment of atrial fibrillation: First-in-man experience

PURPOSE

Catheter ablation is an effective therapy for atrial fibrillation (AF). However, risks remain, and improved efficacy is desired. Stereotactic body radiotherapy (SBRT) is a well-established therapy used to noninvasively treat malignancies and functional disorders with precision. We evaluated the feasibility of stereotactic radioablation for treating paroxysmal AF.

METHODS

Two patients with drug-refractory paroxysmal AF underwent pulmonary vein isolation with SBRT. After placement of a percutaneous active fixation temporary pacing lead tracking fiducial, computed tomography (CT) angiography was performed to define left atrial anatomy. A tailored planning treatment volume was created to deliver contiguous linear ablations to isolate the pulmonary veins and posterior wall. Patients were treated on an outpatient basis in the radioablation suite. Clinical follow-up was performed through at least 24 months after therapy.

RESULTS

Both patients successfully underwent SBRT planning and treatment without significant early or long-term side effects up to 48 months of follow-up. One patient had AF recurrence after 6 months free of arrhythmia, while the second patient remains free of AF after 24 months with fibrosis detected on MRI scan consistent with the ablation lesion set. An incidentally noted small pericardial effusion occurred in one patient.

CONCLUSION

Stereotactic radioablation may be feasible for the treatment of drug-refractory AF. Further evaluation is warranted.

Digoxin is associated with worse outcomes in patients with heart failure with reduced ejection fraction

AIMS

The aim of this study was to investigate the impact of digoxin use on the outcomes of patients with heart failure with reduced ejection fraction (HFrEF) and its possible interaction with atrial fibrillation or use of currently guideline-recommended treatments in the real world in China.

METHODS AND RESULTS

Patients hospitalized with HFrEF from 45 hospitals participating in the China National Heart Failure Registration Study (CN-HF) were enrolled to assess the all-cause mortality, HF mortality, all-cause re-hospitalization, and HF re-hospitalization associated with digoxin use. Eight hundred eighty-two eligible HFrEF patients in the CN-HF registry were included: 372 patients with digoxin and 510 patients without digoxin. Among them, 794 (90.0%) patients were followed up for the endpoint events, with a median follow-up of 28.6 months. Kaplan-Meier survival analysis showed that the all-cause mortality (P < 0.001) and all-cause re-hospitalization (P = 0.020) were significantly higher in digoxin group than non-digoxin group, while HF mortality (P = 0.232) and HF re-hospitalization (P = 0.098) were similar between the two groups. The adjusted Cox proportional-hazards regression analysis demonstrated that digoxin use remained as an independent risk factor for increased all-cause mortality [hazard ratio (HR) 1.76; 95% confidence interval (CI) 1.27-2.44; P = 0.001] and all-cause re-hospitalization (HR 1.27; 95% CI 1.03-1.57; P = 0.029) in HFrEF patients and the predictive value of digoxin for all-cause mortality irrespective of rhythm or in combination with other guideline-recommended therapies.

CONCLUSIONS

Digoxin use is independently associated with increased risk of all-cause mortality and all-cause re-hospitalization in HFrEF patients.

Left atrial mechanical remodelling assessed as the velocity of left atrium appendage wall motion during atrial fibrillation is associated with maintenance of sinus rhythm after electrical cardioversion in patients with persistent atrial fibrillation

The velocity of left atrium appendage (LAA) wall motion during atrial fibrillation (AF) is a potential marker of mechanical remodelling. In this study, we investigated whether the velocity of LAA wall motion during AF predicted the success of electrical cardioversion and long-term sinus rhythm maintenance. Standard echocardiographic data were obtained by transthoracic echocardiography, and LAA wall motion velocities were measured by transoesophageal echocardiography. With logistic regression and receiver operating characteristic curve analyses, we related echocardiographic and clinical data to cardioversion outcomes and sinus rhythm maintenance at 12 months. Of 121 patients prospectively included in the study, electrical cardioversion restored sinus rhythm in 97 (81.2%), and 51 (42%) patients maintained sinus rhythm at 12 months. Patients in whom cardioversion restored sinus rhythm had higher LAA wall motion velocities than did the patients with failed cardioversions (p <0.001). Compared to patients with AF at 12 months, patients who maintained sinus rhythm had lower maximum and end-diastolic left atrial volumes (p ≤ 0.01), lower E/e’ ratios (p = 0.005), higher s’ values (p = 0.013), and higher LAA motion velocities (p < 0.001). On multivariate logistic regression, only LAA wall motion velocity and E/e’ ratios remained significant predictors of sinus rhythm maintenance at 12 months (p ≤ 0.04). LAA wall motion velocity was also a significant predictor of sinus rhythm maintenance when corrected for clinical variables (p = 0.039). Conclusion: LAA wall motion velocity, as a marker of mechanical remodelling, can predict short-term and long-term sinus rhythm maintenance after electrical cardioversion in AF.

Computational Simulation of Cardiac Function and Blood Flow in the Circulatory System under Continuous Flow Left Ventricular Assist Device Support during Atrial Fibrillation

Prevalence of atrial fibrillation (AF) is high in heart failure patients supported by a continuous flow left ventricular assist device (CF-LVAD); however, the long term effects remain unclear. In this study, a computational model simulating effects of AF on cardiac function and blood flow for heart failure and CF-LVAD support is presented. The computational model describes left and right heart, systemic and pulmonary circulations and cerebral circulation, and utilises patient-derived RR interval series for normal sinus rhythm (SR). Moreover, AF was simulated using patient-derived unimodal and bimodal distributed RR interval series and patient specific left ventricular systolic functions. The cardiovascular system model simulated clinically-observed haemodynamic outcomes under CF-LVAD support during AF, such as reduced right ventricular ejection fraction and elevated systolic pulmonary arterial pressure. Moreover, relatively high aortic peak pressures and middle arterial peak flow rates during AF with bimodal RR interval distribution, reduced to similar levels as during normal SR and AF with unimodal RR interval distribution under CF-LVAD support. The simulation results suggest that factors such as distribution of RR intervals and systolic left ventricular function may influence haemodynamic outcome of CF-LVAD support during AF.

Real-world cost-effectiveness of rivaroxaban compared with vitamin K antagonists in the context of stroke prevention in atrial fibrillation in France

Objective

The objective was to assess the real-world cost-effectiveness of rivaroxaban, versus vitamin K antagonists (VKAs), for stroke prevention in patients with atrial fibrillation (AF) from a French national health insurance perspective.

Methods

A Markov model was developed with a lifetime horizon and cycle length of 3 months. All inputs were drawn from real-world evidence (RWE) studies: data on baseline patient characteristics at model entry were obtained from a French RWE study, clinical event rates as well as persistence rates for the VKA treatment arm were estimated from a variety of RWE studies, and a meta-analysis provided comparative effectiveness for rivaroxaban compared to VKA. Model outcomes included costs (drug costs, clinical event costs, and VKA monitoring costs), quality-adjusted life-years (QALY) and life-years (LY) gained, incremental cost per QALY, and incremental cost per LY. Sensitivity analyses were performed to test the robustness of the model and to better understand the results drivers.

Results

In the base-case analysis, the incremental total cost was €714 and the total incremental QALYs and LYs were 0.12 and 0.16, respectively. The resulting incremental cost/QALY and incremental cost/LY were €6,006 and €4,586, respectively. The results were more sensitive to the inclusion of treatment-specific utility decrements and clinical event rates.

Conclusions

Although there is no official willingness-to-pay threshold in France, these results suggest that rivaroxaban is likely to be cost-effective compared to VKA in French patients with AF from a national insurance perspective.

Stroke Prophylaxis in Patients with Atrial Fibrillation and End-Stage Renal Disease

Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention.

Comorbidities in chronic heart failure: An update from Italian Society of Cardiology (SIC) Working Group on Heart Failure

The increasing number of patients with heart failure HF and comorbidities is due to aging population and increase of life expectancy of patients with cardiovascular disease. Encouraging results derived by recent trials may suggest some comorbidities as new targets for new drugs, highlighting the need for a better understanding of the comorbidities' effects in HF patients and the need of a multidisciplinary approach for the management of chronic HF with comorbidities. We report a brief review about main cardiovascular and non-cardiovascular comorbidities in HF patients in order to update physicians and researchers engaged in the HF research or in "fight against heart failure."

Thawing Rate Predicts Acute Pulmonary Vein Isolation after Second-Generation Cryoballoon Ablation

OBJECTIVE

To evaluate whether thawing rate could be a novel predictor of acute pulmonary vein isolation (PVI) and explore the predictive value of thawing rate as a factor ensuring long-term PVI (vagus reflex).

METHODS

A total of 151 patients who underwent cryoballoon ablation for atrial fibrillation (AF) were enrolled in this retrospective study between January 2017 and June 2018. The thawing rate was calculated using the thawing phase of the cryoablation curve. Receiver operating characteristic (ROC) curve was used to analyze the predictive value of the thawing rate for acute PVI and vagus reflex.

RESULTS

ROC curve analyses revealed that the interval thawing rate at 15°C (ITR15) was the most valuable predictor of PVI, with the highest area under curve (AUC) value of the ROC curve. The best cut-off value of ITR15 for PVI was ≤2.14°C/S and its sensitivity and specificity were 88.62% and 67.18%, respectively. In addition, the ITR15 of the successful PVI group after cryoballoon ablation was significantly slower than the failed PVI group. ITR15 was a predictor of vagus reflex and the occurrence of vagus reflex group had a slower ITR15 compared to the non-occurrence group.

CONCLUSIONS

Thawing rate was a novel predictor of acute PVI and the ITR15 was the most valuable predictor of acute PVI. In addition, ITR15 was a predictive factor ensuring long-term PVI (vagus reflex). Our study showed that thawing rate may serve in the early identification of useless cryoballoon ablation.

Comparative effectiveness of catheter ablation devices in the treatment of atrial fibrillation: a network meta-analysis

Atrial fibrillation (AF) ablation is most commonly performed using radiofrequency (RF) and cryoballoon (CB) catheters. Ablation Index is a novel lesion-quality marker associated with improved outcomes in RF ablation. Due to lack of direct comparative evidence between the latest generations of technologies, there is uncertainty regarding the best treatment option. Aim: To conduct a network meta-analysis to evaluate the comparative effectiveness of RF with Ablation Index to other catheter ablation devices in the treatment of AF. Methods: Searches for randomized and nonrandomized prospective comparative studies of ablation catheters were conducted in multiple databases. The outcome of interest was 12-month freedom from atrial arrhythmias after a single ablation procedure. Studies were grouped as high-, low- and unclear-quality based on study design and balanced baseline patient characteristics. Bayesian hierarchical network meta-analysis was conducted and results presented as relative risk ratios with 95% credible intervals (CrIs). Results: 12 studies evaluating five different catheter ablation devices were included. Radiofrequency ablation with Ablation Index was associated with statistically significantly greater probability of 12-month freedom from atrial arrhythmias than Arctic Front (relative risk: 1.77; 95% CrI: 1.21-2.87), Arctic Front Advance™ (1.41; 1.06-2.47), THERMOCOOL™ (1.34; 1.17-1.48) and THERMOCOOL SMARTTOUCH™ (1.09; 1-1.3). Results were robust in multiple sensitivity analyses. Conclusion: Radiofrequency catheter with Ablation Index is superior to currently available options for 12-month freedom from atrial arrhythmias after AF ablation. This study provides decision-makers with robust, pooled, comparative evidence of the latest ablation technologies.

Assessing adherence and persistence to non-vitamin K antagonist oral anticoagulants (NOACs) among patients with atrial fibrillation in tertiary-care referral centers in Malaysia

Introduction:

Non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran and rivaroxaban, are now available for stroke prevention in patients with atrial fibrillation (AF) and are often clinically preferred over vitamin K antagonists (VKAs), such as warfarin. Data describing adherence and persistence to NOACs in real-life clinical practice in Malaysia are scarce. This study aimed to assess adherence and persistence to NOACs in patients with AF in two tertiary-care referral centers: Hospital Kuala Lumpur (HKL) and Hospital Serdang (HSDG).

Materials and Methods:

This was a retrospective cohort study that included all patients with AF who were treated with NOACs (dabigatran or rivaroxaban) in HKL and HSDG. Data were obtained from medical records and pharmacy databases. Adherence was assessed using proportion of days covered (PDC) over a 1-year duration. High adherence was defined as PDC ≥80%. A gap of >60 days between two consecutive refills was used to define non-persistence.

Result:

There were 281 patients who met the inclusion criteria, with 54.1% (n = 152) male. There were 75.1% (n = 211) patients on dabigatran and others on rivaroxaban. Only 66.9% (n = 188) of patients achieved high adherence with PDC ≥80% and 69.8% (n = 196) were persistence with >60-day gap over 12 months. Adherence and persistence were both influenced by treatment center, whereas polypharmacy only influenced adherence.

Conclusion:

Overall adherence and persistence to NOACs were suboptimal and varied between treatment centers, potentially due to institution-specific administrative and clinical practice differences. Clinical care and outcomes can potentially be optimized by identifying factors affecting adherence and persistence and by implementing interventions to improving them.

Safety of switching from vitamin K antagonist to non-vitamin K antagonist oral anticoagulant in frail elderly with atrial fibrillation: rationale and design of the FRAIL-AF randomised controlled trial

INTRODUCTION

Clinical guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF). Frail elderly were under-represented in the landmark NOAC-trials, leaving a knowledge gap on the optimal anticoagulant management (VKA or NOAC) in this increasing population. The aim of the Frail-AF (FRAIL-AF) study is to assess whether switching from international normalised ratio (INR)-guided VKA-management to a NOAC-based treatment strategy compared with continuing VKA-management is safe in frail elderly patients with AF.

METHODS AND ANALYSIS

The FRAIL-AF study is a pragmatic, multicentre, open-label, randomised controlled clinical trial. Frail elderly (age ≥75 years plus a Groningen Frailty Indicator score ≥3) who receive VKA-treatment for AF in the absence of a mechanical heart valve or severe mitral valve stenosis will be randomised to switch to a NOAC-based treatment strategy or to continue INR-guided VKA-management. Patients with severe renal impairment (estimated glomerular filtration rate <30 mL/min/1.73 m2) will be excluded from randomisation. Based on existing trial evidence in non-frail patients, we will aim to explore whether NOAC-treatment is superior to VKA-therapy in reducing major or clinically relevant non-major bleeding events. Secondary outcomes include minor bleeding, the composite of ischaemic and haemorrhagic stroke, health-related quality of life and cost-effectiveness. The follow-up period for all subjects is 12 months.

ETHICS AND DISSEMINATION

The protocol was approved by the Medical Research Ethics Committee of the University Medical Center Utrecht, the Netherlands and by the Central Committee on Research Involving Human Subjects, the Netherlands. All patients are asked written informed consent. Results are expected in 2022 and will be disseminated through peer-reviewed journals as well as presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

EudraCT: 2017-000393-11; The Netherlands Trial Registry: 6721 (FRAIL-AF study).

Thromboembolism in Atrial Fibrillation: Role of the Left Atrial Appendage

Atrial fibrillation (AF) is the most common arrhythmia. Patients with AF have a higher risk for thromboembolism than individuals without AF. The left atrial appendage (LAA) is the main source of thromboembolism because of its anatomic, mechanical, and electrophysiologic properties, and accounts for more than 90% of thrombus formation in patients with AF. Advancement in imaging expands knowledge about anatomic and physiologic characteristics of LAA. The risk of thromboembolism events in patients with AF depends on clinical comorbidities and structural and physiologic parameters of atria, especially LAA. This article discusses AF-related thromboembolic events and the role of the LAA.

Non-vitamin K antagonist oral anticoagulants (NOACs) post-percutaneous coronary intervention: a network meta-analysis

BACKGROUND

Clinicians must balance the risks of bleeding and thrombosis after percutaneous coronary intervention (PCI) in people with an indication for anticoagulation. The potential of non-vitamin K antagonists (NOACs) to prevent bleeding complications is promising, but evidence remains limited.

OBJECTIVES

To review the evidence from randomised controlled trials assessing the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) compared to vitamin K antagonists post-percutaneous coronary intervention (PCI) in people with an indication for anticoagulation.

SEARCH METHODS

We identified studies by searching CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science and two clinical trials registers in February 2019. We checked bibliographies of identified studies and applied no language restrictions.

SELECTION CRITERIA

We searched for randomised controlled trials (RCT) that compared NOACs and vitamin K antagonists for people with an indication for anticoagulation who underwent PCI.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects, pairwise analyses using Review Manager 5 and network meta-analyses (NMA) using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons, and allow ranking of treatments on a continuous 0 to 1 scale.

MAIN RESULTS

We identified nine RCTs that met the inclusion criteria, but four were ongoing trials, and were not included in this analysis. We included five RCTs, with 8373 participants, in the NMA (two RCTs compared apixaban to a vitamin K antagonist, two RCTs compared rivaroxaban to a vitamin K antagonist, and one RCT compared dabigatran to a vitamin K antagonist). Very low- to moderate-certainty evidence suggests little or no difference between NOACs and vitamin K antagonists in death from cardiovascular causes (not reported in the dabigatran trial), myocardial infarction, stroke, death from any cause, and stent thrombosis. Apixaban (RR 0.85, 95% CI 0.77 to 0.95), high dose rivaroxaban (RR 0.86, 95% CI 0.74 to 1.00), and low dose rivaroxaban (RR 0.80, 95% CI 0.68 to 0.92) probably reduce the risk of recurrent hospitalisation compared with vitamin K antagonists. No studies looked at health-related quality of life. Very low- to moderate-certainty evidence suggests that NOACs may be safer than vitamin K antagonists in terms of bleeding. Both high dose dabigatran (RR 0.53, 95% CI 0.29 to 0.97), and low dose dabigatran (RR 0.38, 95% CI 0.21 to 0.70) may reduce major bleeding more than vitamin K antagonists. High dose dabigatran (RR 0.83, 95% CI 0.72 to 0.96), low dose dabigatran (RR 0.66, 95% CI 0.58 to 0.75), apixaban (RR 0,67 , 95% Cl 0.51 to 0.88), high dose rivaroxaban (RR 0.66, 95% CI 0.52 to 0.83), and low dose rivaroxaban (RR 0.71, 95% CI 0.57 to 0.88) probably reduce non-major bleeding more than vitamin K antagonists. The results from the NMA were inconclusive between the different NOACs for all primary and secondary outcomes.

AUTHORS' CONCLUSIONS

Very low- to moderate-certainty evidence suggests no meaningful difference in efficacy outcomes between non-vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists following percutaneous coronary interventions (PCI) in people with non-valvular atrial fibrillation. NOACs probably reduce the risk of recurrent hospitalisation for adverse events compared with vitamin K antagonists. Low- to moderate-certainty evidence suggests that dabigatran may reduce the rates of major and non-major bleeding, and apixaban and rivaroxaban probably reduce the rates of non-major bleeding compared with vitamin K antagonists. Our network meta-analysis did not show superiority of one NOAC over another for any of the outcomes. Head to head trials, directly comparing NOACs against each other, are required to provide more certain evidence.

Patient Preferences for Nonvitamin K Antagonist Oral Anticoagulants in Stroke Prevention: A Multicountry Discrete Choice Experiment

Purpose

The patient's perspective is becoming increasingly important in clinical and policy decisions. This study examined atrial fibrillation (AF) patient preferences for different characteristics of nonvitamin K antagonist oral anticoagulants (NOACs).

Methods

A discrete choice experiment (DCE) addressing AF patients treated with NOACs in France, Germany, and the United Kingdom was conducted. The DCE included the following attributes: frequency of administration (once/twice daily), size of tablet/capsule (6-9 mm/20 mm), meal-related intake (intake with food required/independent), and distance to treating physician (1 km/10 km). Preferences were analyzed based on a conditional logit regression model.

Results

In total, 758 patients (males: 57.3%; mean age: 71.4 years) with an average disease duration of 5.5 years were included (apixaban/dabigatran/edoxaban/rivaroxaban: 34.0%/14.5%/6.6%/44.9%, respectively). Patients preferred NOAC treatment options characterized by once-daily dosing regimens (42.8%; p < 0.001), shorter distance to treating physicians (25.0%; p < 0.001), a small-sized tablet (21.5%; p < 0.001), and intake independent of food (10.6%; p < 0.001).

Conclusions

Patients primarily prefer a once-daily NOAC regimen. Individual preferences should be considered for the treatment of AF patients as this may result in improved treatment adherence and consequently better effectiveness and safety in routine clinical practice.

Time-trends and treatment gaps in the antithrombotic management of patients with atrial fibrillation after percutaneous coronary intervention: Insights from the CHUM AF-STENT Registry

Background

The management of atrial fibrillation and flutter (AF) patients undergoing percutaneous coronary intervention (PCI) has undergone a rapid recent evolution. In 2016, the Canadian Cardiovascular Society (CCS) published expert recommendations to help guide clinicians in balancing bleeding and thrombotic risks in these patients.

Hypothesis

Antithrombotic regimen prescriptions for AF patients undergoing PCI evolved after the publication of the 2016 CCS AF guidelines.

Methods

A prospective cohort of AF patients undergoing PCI with placement of a coronary stent from a single tertiary academic center was analyzed for the recommended antithrombotic regimen at discharge. Prescribing behavior was compared between three time periods (Cohort A [2010‐2011]; Cohort B [2014‐2015]; Cohort C [2017]) using the χ² test. In addition, antithrombotic management in Cohorts B and C were compared to guideline‐recommended therapy.

Results

A total of 459 patients with AF undergoing PCI were identified. Clinical and procedural characteristics were similar between cohorts, with the exception of an increase in drug‐eluting stent (DES) use over time (P < .01). Overall, the rate of oral anticoagulation (OAC) increased over time (P < .01), associated with an increase in nonvitamin K OAC prescription (P < .01) and a concomitant decrease in vitamin K antagonist prescription (P < .01). Despite this, the overall rate of anticoagulation remains below what would be predicted with perfect guideline compliance (75% vs 94%, P < .01).

Conclusion

There has been a dramatic shift in clinical practice for AF patients requiring PCI, with increases in prescription of OAC even in the context of an increase in the use of DES. However, room for further practice optimization still exists.

Predictors of Recurrence of AF in Patients After Radiofrequency Ablation

Catheter ablation is a well-known treatment for patients with AF. Despite the growing knowledge in the field, the identification of predictors of recurrence of AF after catheter ablation is one of the primary goals and is of major importance to improve long-term results of the procedure. The aim of this article is to provide an overview of what has been published in recent years and to summarise the major predictors, helping cardiac electrophysiologists in the selection of the right candidates for catheter ablation.

Cabins, castles, and constant hearts: rhythm control therapy in patients with atrial fibrillation

Recent innovations have the potential to improve rhythm control therapy in patients with atrial fibrillation (AF). Controlled trials provide new evidence on the effectiveness and safety of rhythm control therapy, particularly in patients with AF and heart failure. This review summarizes evidence supporting the use of rhythm control therapy in patients with AF for different outcomes, discusses implications for indications, and highlights remaining clinical gaps in evidence. Rhythm control therapy improves symptoms and quality of life in patients with symptomatic AF and can be safely delivered in elderly patients with comorbidities (mean age 70 years, 3-7% complications at 1 year). Atrial fibrillation ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, but recurrent AF remains common, highlighting the need for better patient selection (precision medicine). Antiarrhythmic drugs remain effective after AF ablation, underpinning the synergistic mechanisms of action of AF ablation and antiarrhythmic drugs. Atrial fibrillation ablation appears to improve left ventricular function in a subset of patients with AF and heart failure. Data on the prognostic effect of rhythm control therapy are heterogeneous without a clear signal for either benefit or harm. Rhythm control therapy has acceptable safety and improves quality of life in patients with symptomatic AF, including in elderly populations with stroke risk factors. There is a clinical need to better stratify patients for rhythm control therapy. Further studies are needed to determine whether rhythm control therapy, and particularly AF ablation, improves left ventricular function and reduces AF-related complications.

Net Clinical Benefit of Left Atrial Appendage Closure Versus Warfarin in Patients With Atrial Fibrillation: A Pooled Analysis of the Randomized PROTECT-AF and PREVAIL Studies

Background The PROTECT-AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy) trials demonstrated noninferiority of left atrial appendage closure (LAAC) to warfarin for the composite end point of stroke, systemic embolism, or cardiovascular death. This study aims to quantify the net clinical benefit (NCB) of LAAC versus warfarin, accounting for differences in clinical impact of different event types. Methods and Results We performed a post hoc analysis of the PROTECT-AF and PREVAIL trials, which randomized atrial fibrillation patients to LAAC or warfarin in a 2:1 fashion. The trials enrolled patients in the United States and Europe between 2005 and 2012 with paroxysmal, persistent, or permanent atrial fibrillation and CHADS2 risk scores ≥1. Relative to an index weight for death (1.0), events were assigned weights based on their disabling effect: (1) stroke event weights were based on modified Rankin scores in the base case analyses, and (2) major bleed (0.05) and pericardial effusion (0.05). NCB was calculated as the sum of weight-adjusted events per 100 patient-years. Among 1114 randomized subjects, the NCB of LAAC was 1.42% per year (95% CI 0.01-2.82, P=0.04) and a relative risk of 0.74 (95% CI 0.56-1.00). NCB point estimates favored warfarin early in follow-up, but trended in favor of LAAC after 1 to 2 years. The benefit of LAAC was preserved across subgroups, with particular benefit observed in the subgroup of prior stroke and without diabetes mellitus. Conclusions This analysis demonstrates long-term NCB of LAAC with Watchman over warfarin therapy, as the upfront risk of periprocedural events is counterbalanced over time by reduced bleeding events and mortality. Clinical Trial Registration UR: http://www.clinicaltrials.gov. Unique identifiers: NCT01182441 and NCT00129545.

Real-time photoacoustic assessment of radiofrequency ablation lesion formation in the left atrium

In interventional electrophysiology, catheter-based radiofrequency (RF) ablation procedures restore cardiac heart rhythm by interrupting aberrant conduction paths. Real-time feedback on lesion formation and post-treatment lesion assessment could overcome procedural challenges related to ablation of underlying structures and lesion gaps. This study aims to evaluate real-time visualization of lesion progression and continuity during intra-atrial ablation with photoacoustic (PA) imaging, using clinically deployable technology. A PA-enabled RF ablation catheter was used to ablate and illuminate porcine left atrium, both excised and intact in a passive beating heart ex-vivo, for photoacoustic signal generation. PA signals were received with an intracardiac echography catheter. Using the ratio of PA images acquired with excitation wavelengths of 790 nm and 930 nm, ablation lesions were successfully imaged through circulating saline and/or blood, and lesion gaps were identified in real-time. PA-based assessment of RF-ablation lesions was successful in a realistic preclinical model of atrial intervention.

Applying sinus node function testing to evaluate perioperative management for patients suffering from tachycardia-bradycardia syndrome before atrial fibrillation ablation

Sinus node (SN) function is an important prognostic factor of atrial fibrillation (AF). However, AF ablation guideline has not recommended SN function test before ablation. SN function testing before AF ablation in patients with tachycardia-bradycardia syndrome should be beneficial to determine further therapy strategies and prognosis.

Carotid Atherosclerosis in Patients with Atrial Fibrillation

PURPOSE OF REVIEW

This review aims to explore the relationship between AF and carotid atherosclerosis, and the impact on the outcomes of cardiovascular and cerebrovascular events. Also, our aim is to critically review current knowledge and delineate future directions for effective treatment or prevention as well as strategies for improvement of the quality of life and survival.

RECENT FINDINGS

Atrial fibrillation (AF) is the most common arrhythmia, increasing the risk of stroke and cardiovascular morbidity and mortality representing a significant worldwide public health problem. On the other hand, carotid artery atherosclerosis can also significantly increase the risk of stroke, transient ischemic attack (TIA), and death. Firstly, we report epidemiological data on AF patients in different countries and regions having carotid artery abnormalities such as carotid artery plaque formation, atherosclerotic, and even stenosis. Despite geographical variations, these abnormalities were more frequent in AF patients and correlated with the duration of AF and the value of CHA₂DS₂-VASc score. Moreover, it is evident that AF patients with carotid artery abnormalities have significantly increased risk of adverse outcomes from the heart and brain. According to the CHA₍₂₎DS₂ (-VASc) score, AF patients are managed with anticoagulation therapy. Reviewing existing data on the treatment for stroke prevention in patients with AF, carotid artery disease, or both, we found that antiplatelet therapy could be combined with anticoagulant therapy appropriately in certain circumstances. In addition, some emerging technologies, such as the percutaneous permanent carotid filter, may be used safely and effectively to prevent the occurrence of stroke in patients both with AF and carotid artery atherosclerosis.

Safety and efficacy of the ThermoCool SmartTouch SurroundFlow catheter for atrial fibrillation ablation: A meta-analysis

Background

The ThermoCool Smarttouch Surroundflow catheter (STSFc) is an advanced catheter, which integrating contact force sensing and surroundflow technology. However, comparative data between STSFc and contact force sensing catheter (Thermocool SmartTouch catheter [STc]) are limited.

Hypothesis

We thought that STSFc might bring more clinical benefits. The aim of this meta‐analysis was to compare the safety and efficiency between the STSFc and the STc for treatment of atrial fibrillation (AF).

Methods

The Medline, PubMed, Embase, and Cochrane Library databases were searched for studies comparing STSFc and STc.

Results

Four trials involving 727 patients were included in the study. Pool‐analyses demonstrated that, as compared STc ablation, STSFc ablation was more beneficial in terms of procedural times (standard mean difference [SMD]: −0.22; 95% confidence interval [CI], −0.37 to −0.07, P = .005) and irrigation fluid volume (SMD: −1.94; 95% CI, −2.65 to −1.22, P < .0001). There was no significant difference between STSFc and STc (risk ratio [RR]: 1.02; 95% CI: 0.86 to 1.21, P = .79) for free from AF. Evidence of complications were low and similar for both groups (RR: 0.83; 95% CI: 0.19‐3.55, P = .80). Additionally, patients administered STSFc ablation tended to have shorter fluoroscopic times (SMD: −0.20; 95% CI, −0.63‐0.23, P = .21).

Conclusions

STSFc ablation was associated with reducing procedural times and irrigation fluid volume. Further, STSFc ablation tended to shorten fluoroscopic times. Therefore, STSFc ablation would be a better choice for AF patients especially in patients with heart failure.

Smartwatch for the Detection of Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia and poses a substantial economic burden due to associated thromboembolic complications. Screening for AF may theoretically be effective, but there is no consensus regarding the optimal screening method because the available tools are either invasive or not cost-effective. Recently, smartwatch industry has received a surge of interest for this purpose by introducing technologies such as photoplethysmography, artificial intelligence, and actual electrodes taking an electrocardiogram to measure and analyze heart rate and rhythm with relatively acceptable accuracy. Combined with other features such as ease of use and connectivity, smartwatches can potentially be used for large-scale AF screening and might eventually replace the current gold standards. In this review, we discuss the feasibility of this approach and summarize the current evidence on AF detection with smartwatches.

Small vessel disease is associated with an unfavourable outcome in stroke patients on oral anticoagulation

Introduction

Cerebral small vessel disease is an important cause for both ischaemic stroke and intracranial haemorrhage. To date, knowledge on the impact of small vessel disease on the clinical course in stroke patients treated with oral anticoagulation for atrial fibrillation is limited.

Patients and Methods

Registry-based prospective observational study of 320 patients (aged 78.2 ± 9.2 years) treated with anticoagulation following atrial fibrillation stroke. Patients underwent standardised magnetic-resonance-imaging assessing measures of small vessel disease, including cerebral microbleeds and white matter hyperintensities. Median follow-up was 754 (interquartile range = [708-828]) days. Using adjusted logistic and Cox regression, we assessed the association of imaging measures with clinical outcome including recurrent ischaemic stroke, intracranial haemorrhage and death and assessed disability (modified Rankin Scale).

Results

Overall, recurrent ischaemic stroke was more common than intracranial haemorrhage (22 versus 8, respectively). Cerebral microbleeds were related to an increased risk of the composite endpoint (ischaemic stroke, intracranial haemorrhage, death: odds ratio (OR) 2.05, 95% confidence interval (CI) 1.27-3.31; P = 0.003), as were white matter hyperintensities (OR 2.00, 95%CI 1.23-3.27, P = 0.005). This was also true in time-to-event analysis (cerebral microbleeds: HR 2.31, 95%CI 1.39-3.52; P < 0.001; white matter hyperintensities: HR 1.99, 95%CI 1.20-3.17; P = 0.007). Both measures were associated with an increased risk for recurrent ischaemic stroke (cerebral microbleeds: HR 4.42, 95%CI 1.07-18.20; P = 0.04; white matter hyperintensities: HR 5.27, 95%CI 1.08-25.79, P = 0.04) and intracranial haemorrhage (cerebral microbleeds: HR 2.43, 95%CI 1.04-5.69; P = 0.04; white matter hyperintensities: HR 2.57, 95%CI 1.11-5.98, P = 0.03). Furthermore, confluent white matter hyperintensities were associated with increased disability (OR 4.03; 95%CI 2.16-7.52; P < 0.001) and mortality (HR 1.81, 95%CI 1.04-3.14, P = 0.04).

Discussion and conclusion

In atrial fibrillation stroke patients treated with oral anticoagulation, small vessel disease is associated with an unfavourable outcome. The presence of microbleeds indicated a risk higher for recurrent ischaemic stroke than for intracranial haemorrhage.

Long-term impact of catheter ablation on arrhythmia burden in low-risk patients with paroxysmal atrial fibrillation: The CLOSE to CURE study

BACKGROUND

Few studies evaluated the impact of catheter ablation (CA) on atrial tachyarrhythmia (ATA) burden in paroxysmal atrial fibrillation (AF).

OBJECTIVE

In the prospective, patient-controlled CLOSE to CURE study, we determined the longer-term impact of optimized CA on ATA burden by using an insertable cardiac monitor (ICM).

METHODS

A total of 105 patients with paroxysmal AF were implanted with an ICM 65 (interquartile range [IQR] 61-78) days before CA. CA consisted of contact force-guided pulmonary vein isolation targeting an intertag distance of ≤6 mm and a region-specific ablation index. The primary end point was reduction in ICM-detected ATA burden; secondary end points were single-procedure freedom from ATA, quality of life, and adverse events.

RESULTS

The mean age was 62 ± 8 years; the median CHA₂DS₂-VASc score was 1 (IQR 1-2); and the median left atrial diameter was 43 (IQR 39-43) mm. After pulmonary vein isolation (1.13 ± 0.39 procedures per patient), median ATA burden decreased from 2.68% (IQR 0.09%-15.02%) at baseline to 0% (IQR 0%-0%) during the first year and to 0% (IQR 0%-0%) during the second year (reduction in ATA burden 100% [IQR 100%-100%]; P < .001). Single-procedure freedom from any ATA was 87% at 1 year and 78% at 2 years. Quality of life improved significantly across all scores. Adverse events occurred in 5 patients (4.8%).

CONCLUSION

CA has become an effective procedure in paroxysmal AF, with a major impact on ICM-detected ATA burden. Whereas conventional survival analysis suggests a progressive decline in efficacy, we observed that burden reduction is maintained at longer follow-up. These data imply that ATA burden is a more optimal end point for assessing ablation efficacy.

Monitoring of low dabigatran concentrations: diagnostic performance at clinically relevant decision thresholds

The direct oral anticoagulant dabigatran does not require therapeutic drug monitoring, however emergency measurements are gaining importance. Current assays feature good performance at intermediate and high dabigatran concentrations but show limited accuracy at low concentrations. This area requires more attention as clinical decision threshold values currently lie at 30 and 50 ng/ml. The objective of the study was to evaluate and compare diagnostic performance of dabigatran assays at these thresholds. Dabigatran concentrations of 293 plasma samples taken from 50 patients were measured with the INNOVANCE direct thrombin inhibitor assay (DTI) from Siemens, the Biophen direct thrombin inhibitor assay (BDTI), the BDTI using a low range calibrator (BDTI-low), the Hemoclot direct thrombin inhibitor assay (HTI) and an ecarin clotting time assay (ECT). Assay results were compared to ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS), and test characteristics were calculated for thresholds of 30 and 50 ng/ml. DTI, BDTI-low and ECT showed very strong correlation and high agreement with UPLC-MS/MS and an improved determination of low dabigatran concentrations. ROC curve analyses revealed very high accuracy at the 30/50 ng/ml thresholds for DTI (AUC = 0.989/0.995), BDTI-low (AUC = 0.980/0.991) and ECT (AUC = 0.990/0.996) measurements. Sensitivity and specificity in detecting were calculated for DTI (98/92%), BDTI-low (87/95%), ECT (97/96%), BDTI (99/82%) and HTI (86/89%) measurements. Compared to the previously available HTI and BDTI, both novel assays, DTI and BDTI-low, reliably determine low dabigatran plasma concentrations around the clinical decision thresholds with very high sensitivity and specificity.

Impact of methodological choices on a meta-analysis of real-world evidence comparing non-vitamin-K antagonist oral anticoagulants with vitamin K antagonists for the treatment of patients with non-valvular atrial fibrillation

Objective: The aim of this study was to investigate the impact of methodological choices in a meta-analysis of real-world evidence (RWE) comparing three non-vitamin-K antagonist oral anticoagulants with vitamin K antagonists (VKAs) for the treatment of patients with non-valvular atrial fibrillation (NVAF). Methods: The meta-analysis was based on a systematic review of RWE studies enrolling incident and prevalent patients aged ≥18 years with NVAF and receiving either rivaroxaban, dabigatran, apixaban or a VKA. Five different scenarios were considered to explore the impact of the initial meta-analysis assumptions: (1) using studies that involved only incident patients; (2) excluding studies that only reported crude values and did not consider any adjustment; (3) including all studies independently of possible database overlap; (4) using studies with data on different dosages for rivaroxaban and dabigatran; and (5) assigning quality weights to studies to assess quality of reporting. These scenarios were run on three outcomes: ischemic stroke (IS), myocardial infarction (MI) and intracranial hemorrhage (ICH). Results: Across all scenarios, rivaroxaban was associated with significantly lower risks of IS and ICH than VKAs. In most scenarios, dabigatran was associated with significantly lower risks of IS and ICH. In all scenarios, apixaban was associated with a significantly lower risk of ICH. Conclusions: Sensitivity analyses showed the impact of similar assumptions was different depending on the outcome and the drug considered. The development of recommendations and guidelines for the inclusion of RWE in meta-analyses could prove useful in evaluating the effectiveness of health care interventions.

Efficacy and safety of catheter ablation for atrial fibrillation in congenital heart disease - A systematic review and meta-analysis

BACKGROUND

Prevalence of atrial fibrillation (AF) in patients with congenital heart disease (CHD) is on the rise. Anti-arrhythmic drugs are usually the first line of treatment in CHD, however, it is often ineffective and poorly tolerated. We aimed to perform a systematic review to assess the efficacy and safety of catheter ablation for AF in CHD.

METHODS

We performed a comprehensive search on catheter ablation for atrial fibrillation in congenital heart disease up until July 2019 through several electronic databases.

RESULTS

Ablation of AF in patients with CHD had a modest 12 months AF freedom ranging from 32.8% to 63%, which can be increased by subsequent/repeat ablation. The complexity of CHD appears to have a significant effect on a study but not in others. Catheter ablation in ASD and persistent left superior vena cava had a high success rate. Overall, catheter ablation is safe whichever the type of CHD is.

CONCLUSION

Catheter ablation for AF in CHD had modest efficacy that can be increased by subsequent/repeat ablation and it also has an excellent safety profile. Ablation in complex CHD could also have similar efficacy, however, it is preferably done by experts in a high volume tertiary center.

Incidence and Predictors of Atrial Fibrillation Progression

Background The incidence and predictors of atrial fibrillation (AF) progression are currently not well defined, and clinical AF progression partly overlaps with rhythm control interventions (RCIs). Methods and Results We assessed AF type and intercurrent RCIs during yearly follow-ups in 2869 prospectively followed patients with paroxysmal or persistent AF. Clinical AF progression was defined as progression from paroxysmal to nonparoxysmal or from persistent to permanent AF. An RCI was defined as pulmonary vein isolation, electrical cardioversion, or new treatment with amiodarone. During a median follow-up of 3 years, the incidence of clinical AF progression was 5.2 per 100 patient-years, and 10.9 per 100 patient-years for any RCI. Significant predictors for AF progression were body mass index (hazard ratio [HR], 1.03; 95% CI, 1.01-1.05), heart rate (HR per 5 beats/min increase, 1.05; 95% CI, 1.02-1.08), age (HR per 5-year increase 1.19; 95% CI, 1.13-1.27), systolic blood pressure (HR per 5 mm Hg increase, 1.03; 95% CI, 1.00-1.05), history of hyperthyroidism (HR, 1.71; 95% CI, 1.16-2.52), stroke (HR, 1.50; 95% CI, 1.19-1.88), and heart failure (HR, 1.69; 95% CI, 1.34-2.13). Regular physical activity (HR, 0.80; 95% CI, 0.66-0.98) and previous pulmonary vein isolation (HR, 0.69; 95% CI, 0.53-0.90) showed an inverse association. Significant predictive factors for RCIs were physical activity (HR, 1.42; 95% CI, 1.20-1.68), AF-related symptoms (HR, 1.84; 95% CI, 1.47-2.30), age (HR per 5-year increase, 0.88; 95% CI, 0.85-0.92), and paroxysmal AF (HR, 0.61; 95% CI, 0.51-0.73). Conclusions Cardiovascular risk factors and comorbidities were key predictors of clinical AF progression. A healthy lifestyle may therefore reduce the risk of AF progression.

Meta-Analysis Evaluating Outcomes of Surgical Left Atrial Appendage Occlusion During Cardiac Surgery

Surgical left atrial appendage occlusion (S-LAAO) has become a common procedure performed in patients undergoing cardiac surgery; however, evidence to support this procedure remains inconclusive. This meta-analysis aims to assess the efficacy of S-LAAO in terms of ischemic stroke, postoperative atrial fibrillation, and all-cause mortality. A thorough literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We identified 10 relevant studies for our meta-analysis. It included 6,779 patients who underwent S-LAAO and 6,573 who did not undergo LAAO. In terms of ischemic stroke, the S-LAAO cohort had a lower events (pooled odds ratio [OR] 0.655 (0.518 to 0.829), p = 0.0004) compared with the non-LAAO cohort. S-LAAO cohort also had lower events of all-cause mortality (pooled OR 0.74 (95% confidence interval 0.55 to 0.99), p = 0.0408) when compared with the non-LAAO cohort. In regards to postoperative atrial fibrillation, there was no difference between the 2 groups (pooled OR 1.29 (95% confidence interval 0.81 to 2.06), p = 0.2752). In conclusion, S-LAAO was associated with lower events of ischemic stroke or systemic embolism and all-cause mortality when compared to the non-LAAO group.

Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation: An Evaluation of Cohorts With and Without Structural Heart Disease

BACKGROUND

Pulmonary vein isolation (PVI) is the most widely adopted strategy for paroxysmal atrial fibrillation (PAF) ablation. Limited evidence on acute results and late outcomes of cryoballoon (CB)-PVI in patients with structural heart disease (SHD) exist. The aim of this analysis was to compare acute procedural results and the 1-year recurrence rate of a single CB-PVI procedure in a PAF population with and without SHD.

METHOD

From April 2012 to May 2017, a total of 2,031 patients with AF underwent CB-PVI and were followed prospectively in the framework of the One Shot TO Pulmonary vein isolation (1STOP) ClinicalService project, involving 36 Italian cardiology centres. We identified patients with SHD according to criteria proposed by current ESC guidelines: left ventricular (LV) systolic or diastolic dysfunction, long-standing hypertension with LV hypertrophy, and/or other structural heart disease. Data on procedural outcomes and long-term freedom from AF recurrence were evaluated.

RESULTS

Our population consisted of 1,452 patients, of whom 282 (19.4%) were classified as having SHD. Compared to non-SHD patients, the SHD cohort was older (mean ± standard deviation, 62.9 ± 9.0 vs 58.2 ± 11.4 years; p < 0.001), was more frequently male (79.1% vs 69.8%; p < 0.002), had a higher thrombo-embolic risk (CHA₂DS₂VASc ≥2: 63.4% vs 40.2%; p < 0.001), had a higher body mass index (27.7 ± 3.9 vs 26.4 ± 3.9 kg/m²; p < 0.001), had a larger atrial diameter (43.8 ± 7.0 vs 40.2 ± 5.8 mm; p < 0.001), and had a lower LV ejection fraction (57.2 ± 7.7% vs 60.7 ± 6.0%; p < 0.001). At the time of ablation, 73% of patients were on class Ic or III anti-arrhythmic drugs. Procedure time (106.9 ± 41.5 vs 112.1 ± 46.8 min; p = 0.248), fluoroscopic time (28.7 ± 14.7 vs 28.6 ± 15.2 min; p = 0.819), and complication rate (3.9% vs 4.8%; p = 0.525) were not different between the SHD and non-SHD cohorts. However, the acute success rate (98.9% vs 97.7%; p = 0.016) was higher in patients with SHD. After a follow-up of 13.4 ± 12.8 months, freedom from symptomatic recurrence was 78.0% for SHD and 78.4% for non-SHD (p = 0.895). Recurrence rate was not related to either left atrial size or LVEF. In the SHD cohort, Class Ic or III anti-arrhythmic drugs treatment decreased from 70.7% of patients before ablation to 28.7% of patients after CB-PVI (p = 0.001).

CONCLUSIONS

CB-PVI was extensively applied to treat patients with PAF. Unlike previous PVI experiences, the acute success and recurrence rate after a single procedure was not related to the presence of SHD or to the degree of cardiac remodelling. Further studies are required to define whether CB-PVI has a useful role in patients with a significantly reduced ejection fraction as those patients were under-represented in the current population.

Change in Prescribing for Secondary Prevention of Stroke and Coronary Heart Disease in Finnish Nursing Homes and Assisted Living Facilities

BACKGROUND

One quarter of residents in long-term care facilities (LTCFs) have a diagnosis of CHD or stroke and over half use at least one preventative cardiovascular medication. There have been no studies that have investigated the longitudinal change in secondary preventative cardiovascular medication use in residents in LTCFs over time.

OBJECTIVE

The aim of this study was to investigate the change in cardiovascular medication use among residents with coronary heart disease (CHD) and prior stroke in nursing homes (NHs) and assisted living facilities (ALFs) in Finland over time, and whether this change differs according to dementia status.

METHODS

Three comparable cross-sectional audits of cardiovascular medication use among residents aged 65 years and over with CHD or prior stroke in NHs in 2003 and 2011 and ALFs in 2007 and 2011 were compared. Logistic regression analyses adjusted for gender, age, mobility, cancer and length of stay were performed to examine the effect of study year, dementia and their interaction on medication use.

RESULTS

Cardiovascular medication use among residents with CHD (NHs: 89% vs 70%; ALFs: 89% vs 84%) and antithrombotic medication use among residents with stroke (NHs: 72% vs 63%; ALFs: 78% vs 69%) declined between 2003 and 2011 in NHs and 2007 and 2011 in ALFs. Decline in the use of diuretics, nitrates and digoxin were found in both groups and settings. Cardiovascular medication use among residents with CHD and dementia declined in NHs (88% [95% CI 85-91] in 2003 vs 70% [95% CI 64-75] in 2011) whereas there was no change among people without dementia. There was no change in cardiovascular medication use among residents with CHD in ALFs with or without dementia over time. Antithrombotic use was lower in residents with dementia compared with residents without dementia in NHs (p < 0.001) and ALFs (p = 0.026); however, the interaction between dementia diagnosis and time was non-significant.

CONCLUSIONS

The decline in cardiovascular medication use in residents with CHD and dementia suggests Finnish physicians are adopting a more conservative approach to the management of cardiovascular disease in the NH population.

Increasing Level of Interleukin-1β in Epicardial Adipose Tissue Is Associated with Persistent Atrial Fibrillation

Epicardial adipose tissue (EAT) is associated with the pathogenesis of atrial fibrillation (AF). The role of local inflammation in persistent AF is unclear. The purpose of this study was to assess the relationship between regional interleukin-1β (IL-1β) and persistent AF. Thirty-seven persistent AF patients underwent coronary artery bypass grafting surgery were enrolled. Patients without a history of AF (n = 37), but received the same surgery matched by age, gender, and body mass index, were enrolled in the control group. EAT thickness was measured by echocardiography. We obtained blood and EAT samples at open-heart surgery. In each patient, serum and EAT levels of IL-1β and adiponectin were measured. The EAT thickness in patients with persistent AF was significantly greater than that in the control group (5.6 ± 1.1 versus 5.0 ± 1.3 mm, P = 0.02). The mRNA level of IL-1β was higher in persistent AF group than the control group (4.94 ± 1.69 versus 2.93 ± 0.91, P < 0.01). Adiponectin expression decreased in persistent AF patients (7.04 ± 2.21 versus 8.63 ± 2.95, P = 0.01). There were no significant differences in plasma levels of IL-1β and adiponectin between the 2 groups. Multiple logistic regression analysis showed that IL-1β was an independent risk factor of persistent AF. These findings suggested that regional IL-1β in EAT was an independent risk factor of persistent AF, which may promote the persistence of AF. [Figure: see text].

An Internet-Based Cognitive Behavioral Therapy Program Adapted to Patients With Cardiovascular Disease and Depression: Randomized Controlled Trial

BACKGROUND

Depression is a common cause of reduced well-being and prognosis in patients with cardiovascular disease (CVD). However, there is a lack of effective intervention strategies targeting depression.

OBJECTIVE

The study aimed to evaluate the effects of a nurse-delivered and adapted internet-based cognitive behavioral therapy (iCBT) program aimed at reducing depression in patients with CVD.

METHODS

A randomized controlled trial was conducted. A total of 144 patients with CVD with at least mild depression (Patient Health Questionnaire-9 [PHQ-9] score ≥5) were randomized 1:1 to a 9-week program of iCBT (n=72) or an active control participating in a Web-based discussion forum (online discussion forum [ODF], n=72). The iCBT program, which included 7 modules, was adapted to fit patients with CVD. Nurses with an experience of CVD care provided feedback and a short introduction to cognitive behavioral therapy. The primary outcome, depression, was measured using PHQ-9. Secondary outcomes were depression measured using the Montgomery-Åsberg Depression Rating Scale-self-rating version (MADRS-S), health-related quality of life (HRQoL) measured using Short Form 12 (SF-12) survey and EuroQol Visual Analogue Scale (EQ-VAS), and the level of adherence. An intention-to-treat analysis with multiple imputations was used. Between-group differences in the primary and secondary outcomes were determined by the analysis of covariance, and a sensitivity analysis was performed using mixed models.

RESULTS

Compared with ODF, iCBT had a significant and moderate treatment effect on the primary outcome depression (ie, PHQ-9; mean group difference=-2.34 [95% CI -3.58 to -1.10], P<.001, Cohen d=0.62). In the secondary outcomes, compared with ODF, iCBT had a significant and large effect on depression (ie, MADRS-S; P<.001, Cohen d=0.86) and a significant and moderate effect on the mental component scale of the SF-12 (P<.001, Cohen d=0.66) and the EQ-VAS (P<.001, Cohen d=0.62). Overall, 60% (n=43) of the iCBT group completed all 7 modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study owing to a high risk of suicide or deterioration in depression.

CONCLUSIONS

Nurse-delivered iCBT can reduce depression and improve HRQoL in patients with CVD, enabling treatment for depression in their own homes and at their preferred time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02778074; https://clinicaltrials.gov/ct2/show/NCT02778074.

Focused Update of 2016 Korean Society of Heart Failure Guidelines for the Management of Chronic Heart Failure

The incidence of heart failure (HF) is increasing in South Korea and devising the optimal care plan is crucial to promote appropriate and effective treatment of HF. To this end, the first Korean guideline for management of chronic HF was published in 2016 by the HF research group under the Korean Society of Cardiology (KSC). After this publication, considerable data have been accumulated and a new guideline for the management of HF was published in Europe, and an update regarding pharmacological therapy was published in the United States, which made it warrant to update the Korean guideline. Under this premise, The Clinical Practice Guidelines Committee under the Korean Society of Heart Failure (KSHF) founded in 2018 decided to publish a focused update management guideline for chronic HF and selected 15 topics that need an update regarding the diagnosis, definition, diagnostic algorithm, monitoring, novel biomarkers, drug therapy related to non-vitamin K antagonist oral anticoagulants and angiotensin receptor neprilysin inhibitors, and with respect to comorbidities changes in the guidelines of relevant institutions, such as new guidelines for the management of hypertension, a procedure used to treat severe aortic stenosis, information on sodium glucose co-transporter-2 inhibitor, and that about sleep apnea. Among nonpharmacological therapies, changes to the recommendations for implantable cardioverter defibrillator, cardiac resynchronization therapy, and cardiac rehabilitation were updated. Subsequent and continuous updates based on additional clinical research findings, with continual supervision by the KSHF will be needed.

Impact of Polypharmacy and P-Glycoprotein- and CYP3A4-Modulating Drugs on Safety and Efficacy of Oral Anticoagulation Therapy in Patients with Atrial Fibrillation

PURPOSE

To study whether polypharmacy or drug-drug interactions have differential effect on safety and efficacy in patients treated with direct oral anticoagulants (DOACs) versus warfarin.

METHODS

We performed a systematic review and meta-analysis of studies that randomized patients with atrial fibrillation to DOACs or warfarin stratified by the number of concomitant drugs. Outcomes included stroke or systemic embolism (SE), all-cause mortality, major bleeding, and intracranial hemorrhage. Risk ratios (RR) were calculated and Mantel-Haenszel random effects were applied.

RESULTS

Two high-quality studies were eligible, including 32,465 participants who received apixaban, rivaroxaban, or warfarin, with a median follow-up of 1.9 years. Of participants, 29% used < 5 drugs, 55% used 5-9 drugs, and 16% used ≥ 10 drugs. Drugs interacting with DOACs (P-glycoprotein/CYP3A4) were used by 6460 (20%) of patients. Patients with higher number of drugs (0-4 vs 5-9 vs ≥ 10) had higher rates of mortality (5.8%, 7.9%, 10.0%) and major bleeding (3.4%, 4.8%, 7.7%). Comparative efficacy or safety of DOACs versus warfarin was not affected by polypharmacy status or P-glycoprotein/CYP3A4 inhibitor use. However, the presence of polypharmacy (p = 0.001) or glycoprotein/CYP3A4-modulating drugs (p = 0.03) was correlated with increased risk of major bleeding when compared with warfarin. Overall, DOAC use was associated with a lower risk of stroke/SE (RR, 0.84; 95%CI, 0.74-0.94), all-cause mortality (RR, 0.91; 95%CI, 0.84-0.98), and intracranial hemorrhage (RR, 0.51; 95%CI, 0.38-0.70) compared with warfarin.

CONCLUSIONS

DOACs were more effective than warfarin, and at least as safe. Polypharmacy was associated with adverse outcomes and attenuated the advantage in risk of major bleeding among rivaroxaban users, particularly in the presence of P-glycoprotein/CYP3A4-modulating drugs.

Prevalence and Characteristics of Subclinical Atrial Fibrillation in a Community-Dwelling Elderly Population: The ARIC Study

BACKGROUND

The prevalence of subclinical atrial fibrillation (AF) in the elderly general population is unclear. We sought to define the prevalence of subclinical AF in a community-based elderly population and to characterize subclinical AF and the incremental diagnostic yield of 4 versus 2 weeks of continuous ECG monitoring.

METHODS

We conducted a cross-sectional analysis within the community-based multicenter observational ARIC study (Atherosclerosis Risk in Communities) using visit 6 (2016-2017) data. The 2616 ARIC study participants who wore a leadless, ambulatory ECG monitor (Zio XT Patch) for up to 2 weeks were aged 79±5 years, 42% men, and 26% black. In a subset, 386 participants without clinically recognized AF wore the monitor twice, each time for up to 2 weeks. We characterized the prevalence of subclinical AF (ie, AF detected on the Zio XT Patch without clinically recognized AF) over 2 weeks of monitoring and the diagnostic yield of 4 versus 2 weeks of monitoring.

RESULTS

The prevalence of subclinical AF was 2.5%; the prevalence of subclinical AF was 3.3% among white men, 2.5% among white women, 2.1% among black men, and 1.6% among black women. Subclinical AF was mostly intermittent (75%). Among those with intermittent subclinical AF, 91% had AF burden ≤10% during the monitoring period. In a subset of 386 participants without clinical AF, 78% more subclinical AF was detected by 4 weeks versus 2 weeks of ECG monitoring.

CONCLUSIONS

In our study, the prevalence of subclinical AF was lower than previously reported and monitoring beyond 2 weeks provided substantial incremental diagnostic yield. Future studies should focus on individuals with higher risk to increase diagnostic yield and consider continuous monitoring duration longer than 2 weeks.

Thermodynamic properties of atrial fibrillation cryoablation: a model-based approach to improve knowledge on energy delivery

The objective of this study is to describe a suitable model of atrial fibrillation cryoablation thermodynamic properties. Three different thermal loads were applied to a cylindrical copper element simulating the cryoprobe, thermally coupled with a Peltier stack producing the freezing effect, and in contact with a bovine liver sample. Thermal events occurring inside the samples were measured using mirror image technique. Heat subtracted flux during ice formation and minimum temperature measured at probe-tissue interface were, respectively, 1.33 W cm^-2 and -27.8°C for Sample#0, 1.88 W cm^-2 and -35.6°C for Sample#1 and 1.82 W cm^-2 and 1.44 W cm^-2 before and after the ice trigger, respectively, and -29.3°C for Sample#2. Ice trigger temperature was around -8.5°C for Sample#0 and Sample#2, and -10.4°C for Sample#1. In all the investigated samples, ice front penetration was proportional to the square root of time and its velocity depended on the heat flux subtracted. The fraction of the useful energy spent for ice formation was less than 60% for Sample#0, and about 80% for Sample#1 and for Sample#2, before the reduction of the removed heat flux. Freezing time exceeding a cut-off, according to the heat subtracted flux, does not improve the procedure effectiveness and is detrimental to the surrounding tissues.

Female sex as a risk factor for ischaemic stroke varies with age in patients with atrial fibrillation

Objectives

Female sex is an inconsistent ischaemic stroke risk factor in patients with atrial fibrillation (AF). We hypothesised that the ischaemic stroke risk varies with age among women compared with men.

Methods

We retrieved the patients with newly diagnosed AF during 2001–2013 from Taiwan’s National Health Insurance Research Database. Patients with missing information, age <20 years, history of valvular heart disease and surgery, rheumatic heart disease, hyperthyroidism or anticoagulation and/or antiplatelet use were excluded. Propensity score matching (PSM) included patient comorbidities, medications and index date stratified by age and sex groups. Primary outcome was defined as ischaemic stroke at follow-up.

Results

After exclusion criteria, 87 369 men and 71 853 women remained for analysis (aged 73.1±14.4 years). After 1:1 PSM, we included 59 583 men (aged 73.5±13.7 years) and 59 583 women (aged 73.4±13.8 years) for analysis. We also stratified patients by age. The ischaemic stroke risk varied with age in women compared with men: lower in the ≤55 years (subdistribution HR (SHR)=0.75, 95% CI 0.62 to 0.90) and 56–65 years (SHR=0.87, 95% CI 0.78 to 0.98) groups, neutral in the 66–75 years group (SHR=1.01, 95% CI 0.94 to 1.08) and adverse in the >75 years group (SHR=1.14, 95% CI 1.09 to 1.19).

Conclusions

The female/male ischaemic stroke risk ratio varied with age. Only women aged >75 years had a higher risk, whereas women aged <65 years had a lower risk compared with men. These findings challenge the ‘sex category’ component of the CHA2DS2-VASc score, used to make decision regarding anticoagulation treatment in AF patients.