The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

Atrial arrhythmias following lung transplantation: A state of the art review

Lung transplantation (LT) is now an accepted therapy for end stage lung disease in appropriate patients. Atrial arrhythmias (AA) can occur after LT. Early AA after LT are most often atrial fibrillation, whereas late arrhythmias which occur many months or years after LT are often atrial tachycardia. The causes of AA are multifactorial. The review begins with a brief history of LT and AA. This review further describes the pathophysiology of the AA. The risk factors, incidence, recipient characteristics including intra-operative factors are elaborated on. Since there are no clear and specific guidelines on the management of atrial arrhythmia following LT, the recommended guidelines on the management of AA in general are often extrapolated and used in the setting of post LT arrhythmia. The strategy of rate control vs rhythm control is discussed. The pros and cons of various drug regimen, need for direct current cardioversion and catheter ablation therapies are considered. Possible methods to prevent or reduce the incidence of AA after LT are considered. The impact of AA on the short-term and long-term outcomes following LT is discussed.

Left atrial appendage occlusion in atrial fibrillation: shaping the future of stroke prevention

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of thromboembolic events, particularly ischemic stroke. The left atrial appendage (LAA) is the predominant site of thrombus formation in patients with AF, making it a crucial target for stroke prevention strategies. Left atrial appendage occlusion (LAAO) has emerged as an important therapeutic alternative to oral anticoagulation, particularly in patients with contraindications to long-term anticoagulant therapy. This review examines the role of LAAO in AF management, discussing current indications, patient selection, procedural techniques, and clinical outcomes. We also explore the latest evidence from major clinical trials and real-world studies, highlighting the efficacy and safety of LAAO compared to standard anticoagulation. Additionally, we consider the unresolved questions and the potential future directions for this intervention, including emerging technologies and the integration of LAAO into broader AF management protocols. Our review underscores the growing importance of LAAO in reducing thromboembolic risk in AF patients, particularly those unable to tolerate traditional anticoagulation, and offers insights into the ongoing evolution of this treatment modality in clinical practice.

Left atrial appendage occlusion study III - kidney substudy

BACKGROUND

Optimal anticoagulation in patients with chronic kidney disease and atrial fibrillation is unclear. Effect of left atrial appendage occlusion may differ in these patients. We conducted a secondary analysis of the Left Atrial Appendage Occlusion Study (LAAOS III) to investigate METHODS: LAAOS III randomized 4811 participants with atrial fibrillation undergoing cardiac surgery. Baseline serum creatinine measurement was available for 4768 participants (99.9%). We estimated the Glomerular Filtration Rate (eGFR) using the 2021 Chronic Kidney Disease -Epidemiology Collaboration equation. We investigated the effect of left atrial appendage occlusion using Cox-proportional hazards model with baseline kidney function as continuous and categorical variables.

RESULTS

Among 4768 participants, 67.5% were men and the median age was 71.2 years. Occluding the left atrial appendage demonstrated similar effects after adjusting for eGFR; occlusion was associated with significant reduced risk of stroke compared to no occlusion (HR0.67, 95%CI 0.53-0.85, p=0.001). There was no difference in all-cause mortality (HR0.99, 95%CI 0.88-1.12, p=0.88), cardiovascular deaths (HR0.93, 95%CI 0.80-1.09, p=0.36), hospitalizations for heart failure (HR1.13, 95%CI 0.91-1.39, p=0.27), major bleeding (HR0.92, 95%CI 0.78-1.10, p=0.37), and myocardial infarction (HR0.86, 95%CI 0.59-1.27, p=0.45). The p-value for interaction for eGFR was not significant for any outcome.

CONCLUSION

The effects of surgical left atrial appendage occlusion in participants with impaired kidney function was consistent with findings from LAAOS III. Left atrial appendage occlusion was associated with reduced stroke without increased risk of serious adverse events.

Left Atrial Appendage Occlusion and Its Role in Stroke Prevention

Atrial fibrillation is a frequent cardiac arrhythmia and is associated with an increased risk of cardioembolic stroke. The left atrial appendage is a finger-like extension originating from the main body of the left atrium and the main location of thrombus formation in patients with atrial fibrillation. Surgical or percutaneous left atrial appendage occlusion (LAAO) aims at preventing clot formation in the left atrial appendage. Here, we describe available surgical and percutaneous approaches to achieve LAAO and discuss the available evidence for LAAO in patients with atrial fibrillation. We discuss the role of LAAO and its role in stroke prevention in frequent scenarios in cerebrovascular medicine: LAAO as a potential alternative to oral anticoagulation in patients with a history of intracranial hemorrhage, and LAAO as a promising add-on therapy to direct oral anticoagulant therapy in patients with breakthrough stroke despite anticoagulation. Finally, we provide an outlook on currently ongoing trials that will provide further evidence in the next years.

Amiodarone Prophylaxis against postoperative atrial fibrillation in off-pump coronary artery bypass

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, with incidence increasing based on surgical complexity. While the CHA₂DS₂-VASc score has been validated to predict POAF risk, standardized prophylactic strategies remain unclear. This study evaluates the safety and efficacy of a low-dose oral amiodarone protocol for POAF prevention in high-risk patients undergoing isolated OPCAB procedures.

OBJECTIVE

To evaluate the impact of low-dose amiodarone prophylaxis against POAF in high-risk patients undergoing OPCAB procedures.

METHODS

This IRB-approved prospective study included all adult inpatients undergoing isolated OPCAB procedures at a single tertiary care facility between June 2018-June 2021 identified as high risk for POAF (preoperative CHA2DS2VASc score > 2). Patients treated with amiodarone prophylaxis were compared to a retrospective historical control group which underwent similar OPCAB procedures in the same center prior to the implementation of amiodarone prophylaxis. Preoperative hospitalized inpatients received a weight-adjusted dose of oral amiodarone on each preoperative day until the day prior to surgery. Patients who were inadequately loaded (<1 g) received 150 mg of amiodarone intravenously in the operating room. Patients with intraoperative symptomatic bradycardia received temporary prophylactic epicardial pacing wires. Postoperatively, all patients received an amiodarone regimen of 200 mg orally twice daily, continued for 15 doses or until discharge. Multivariate logistic models were used to determine the effect of low-dose oral amiodarone prophylaxis on new-onset POAF.

RESULTS

A 10.7 % reduction in incidence of POAF requiring treatment was noted in the study group (OR=0.4; 95 % CI [0.167-0.958], p = 0.04), as well as a 12 % decrease in patients requiring AF treatment at discharge (p = 0.017), and significantly reduced time to extubation. All baseline characteristics and safety parameters were similar between groups.

CONCLUSIONS

The use of a low-dose amiodarone prophylaxis regimen led to significant reduction in new POAF, without apparent adverse effects. This regimen may be considered safe, effective, and feasible for implementation in high-risk OPCAB patients. Further studies in on-pump CABG and valvular patients are needed.

Patients' views on stroke prevention for atrial fibrillation after an intracerebral haemorrhage: a qualitative study

AIM

(i) To explore the attitudes of patients with atrial fibrillation (AF) towards oral anti-coagulation (OAC) for stroke prevention post-intracerebral haemorrhage (ICH) and (ii) to explore factors that influence patients' decision-making process for stroke prevention.

METHODS AND RESULTS

Patients with documented diagnosis of AF and history of a non-traumatic ICH, who were eligible for long-term OAC were recruited from eight hospitals in England, using purposive sampling. Data were collected using semi-structured interviews and analysed using Framework analysis. Twelve patients (mean (SD) age 76.2 (6.6) years; 9 men) were recruited. Patients' main priority was to maintain an acceptable quality of life (QoL), reflected by the main theme 'Living my life as normal'. When deciding to accept or decline OAC for stroke prevention, patients were influenced by the following: (i) The individual, meaning factors relating to individuals' personal attitudes towards health and healthcare, (ii) Medical factors, encompassing factors relating to patients' trust in medical expertise and patients' information-seeking behaviours, and (iii) Social factors, highlighting the influence of patients' social support network on patients' decision-making.

CONCLUSION

Patients' decision-making for stroke prevention for AF post-ICH was influenced by individual, medical, and social factors. At the heart of patients', decision-making were concerns with maintaining an acceptable QoL. The study findings help nurses and other healthcare professionals to better understand what matters to patients who are eligible for stroke prevention for AF post-ICH, thus promoting more effective shared decision making.

What is the impact of dynamic score reassessment for stroke and bleeding risk outcome prediction in atrial fibrillation patients?

INTRODUCTION

Dynamic reassessment of stroke and bleeding risks is a cornerstone of patient-centered care in atrial fibrillation (AF) management. Unlike traditional approaches that evaluate these risks only at diagnosis or at initiation of oral anticoagulation, current evidence emphasizes periodic reassessment due to the evolving nature of risks.

AREAS COVERED

Stroke and bleeding risks in AF patients are influenced by aging, new comorbidities, and worsening health conditions, requiring updates to management plans to optimize outcomes. Dynamic increases in CHA2DS2-VASc (or the sex-less CHA2DS2-VA) and HAS-BLED scores are associated with heightened risks of stroke and bleeding, underscoring the need for regular reassessment. Addressing modifiable risk factors such as hypertension, renal dysfunction, and concurrent medications is key to improving outcomes. Although several guidelines now recommend risk reassessment at least annually, optimal timing remains unclear. Evidence supports more frequent reassessments for low-risk stroke patients (every 4 months) and high-risk bleeding patients (within 4-6 weeks) to promptly identify changes requiring intervention.

EXPERT OPINION

Despite its benefits, challenges remain regarding risk reassessment, including the lack of universally applicable intervals and the complexity of multidisciplinary evaluations. Future advancements in artificial intelligence tools are expected to enhance risk reassessment by enabling more precise, personalized, and dynamic patient management.

Cardioversion and the Risk of Subsequent Stroke or Systemic Embolism and Death in Emergency Department Patients With Acute Atrial Fibrillation or Flutter

Objectives

Guideline recommendations for the emergency department cardioversion of patients with acute atrial fibrillation/flutter have recently changed. This was related to several studies that found a higher-than-expected risk of subsequent stroke or systemic embolism in cardioverted atrial fibrillation/flutter patients. We sought to confirm an elevated rate of stroke, systemic embolism, or death following emergency department cardioversion to normal sinus rhythm compared with similar patients who were not converted.

Methods

This retrospective cohort study combined 4 datasets of atrial fibrillation/flutter patients seen at 25 emergency departments in Ontario, Canada, 2000-2012, who were all eligible for cardioversion. We linked patients to province-wide datasets to determine the primary outcome, a composite of stroke, systemic embolism, or all-cause death. To adjust for baseline differences between patients who cardioverted vs those who did not, we used overlap weights based on the propensity score. The latter included 28 variables, including oral anticoagulant prescriptions.

Results

Of 2521 patients, 2060 (81.7%) converted to sinus rhythm in the emergency department, and 1055 (41.8%) left on anticoagulation. Twelve (0.48%) patients met the primary outcome at 30 days and ≤5 (≤0.2%) at 7 days. In the weighted sample, at 30 days, the primary outcome occurred in 0.37% (95% CI, 0.04%-0.78%) of cardioverted patients vs 0.23% (95% CI, 0.00%-0.60%) in those not cardioverted; the absolute risk increase was 0.13% (95% CI, -0.36% to 0.69%; P = .61), and the number needed to harm was 747.

Conclusion

In atrial fibrillation/flutter patients eligible for cardioversion at 25 emergency departments, the rate of subsequent stroke or systemic embolism and death was very low. After adjusting for risk factors and post-conversion oral anticoagulant use, the rate of subsequent stroke and systemic embolism and death was not significantly higher in patients who cardioverted vs those who did not.

Apixaban vs rivaroxaban in patients with atrial fibrillation at high or low bleeding risk: A population-based cohort study

BACKGROUND

Despite many atrial fibrillation (AF) patients being at risk of bleeding, very limited data are available on bleeding rates of different direct oral anticoagulants based on the spectrum of bleeding risk.

OBJECTIVE

We aimed to compare the risk of major bleeding and thromboembolic events with apixaban vs rivaroxaban for AF patients stratified by bleeding risk.

METHODS

We conducted a population-based, retrospective cohort study of all adult patients (66 years or older) with AF in Ontario, Canada, who were treated with apixaban or rivaroxaban between April 1, 2011, and March 31, 2020. Bleeding risk was estimated by the HAS-BLED score, with high bleeding risk defined as a score of ≥3. The primary safety outcome was major bleeding, and the primary efficacy outcome was thromboembolic events. Comparisons were adjusted for baseline comorbidities by inverse probability of treatment weighting.

RESULTS

This study included 18,156 AF patients with high bleeding risk and 55,186 AF patients with low bleeding risk. Apixaban use was more common in patients with high bleeding risk; 63% of high-risk patients used apixaban compared with 56% of low-risk patients. Apixaban users had lower rates of major bleeding in high-risk patients (2.9% vs 4.2% per year; hazard ratio [HR], 0.69; 95% CI, 0.58-0.81) and in low-risk patients (1.8% vs 2.9% per year; HR, 0.63; 95% CI, 0.56-0.70) compared with rivaroxaban. There were no differences in rates of thromboembolic events, 3.1% vs 3.0% per year (HR, 1.02; 95% CI, 0.86-1.22) in high-risk patients and 1.9% vs 1.9% per year (HR, 1.00; 95% CI, 0.89-1.14) in low-risk patients.

CONCLUSION

In older AF patients with high or low bleeding risk, treatment with apixaban was associated with lower rates of major bleeding with no difference in risk for thromboembolic events compared with rivaroxaban.

Relevance of Targeting Oxidative Stress, Inflammatory, and Pro-Resolution Mechanisms in the Prevention and Management of Postoperative Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF can lead to severe complications, including stroke, myocardial infarction, and sudden death. AF risk factors include pathological aging and conditions such as obesity, diabetes, and hypertension. Clinical data revealed that cardiothoracic and non-cardiothoracic surgeries are also important risk factors for AF. Post-operative AF (POAF) is associated with important public health costs caused by increased hospitalization, frequent emergency room visits, and enhanced healthcare utilization, which altogether lead to a low quality of life for the patients. Hence, POAF is a major clinical challenge, and there is an urgent need for the development of novel therapeutic strategies. Interestingly, evidence from clinical and fundamental research converges to identify cardiac oxidative stress and atrial inflammation as the common denominators of all AF risk factors. Unresolved inflammation is suspected to provoke cardiac fibrosis, which is an important contributor to cardiac arrhythmias and AF. Antioxidant, anti-inflammatory, and pro-resolution strategies may help to combat post-operative cardiac remodeling and POAF. This article aims to review the current scientific evidence supporting the role of inflammation in the pathogenesis of POAF and explore potential novel therapeutic strategies to prevent and mitigate inflammation in the management of AF.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exercise and Fitness Quantification in Clinical Practice: Why and How; and Where Are We Going?

Exercise and fitness quantification is increasingly recognized as a critical component in clinical practice, particularly within preventive cardiology. In this article we explore the multifaceted importance of exercise quantification in clinical settings, addressing preventive care, cost-effectiveness, psychosocial benefits, treatment planning, and monitoring progress. Quantifying exercise habits allows clinicians to evaluate risk profiles, prescribe tailored interventions, and monitor patient progress. The methodologies for exercise quantification are discussed. In preventive cardiology, adherence to guidelines from organizations such as the American Heart Association, the European Society of Cardiology, and the Canadian Cardiovascular Society is emphasized, with particular focus on high-intensity interval training and the central role of physical therapists/kinesiologists. Special populations, such as weekend warriors, those reflecting the "fat and fit" concept, athletes, and those at risk of overtraining syndrome, are considered in prescribing exercise. Future directions in exercise and fitness quantification include the integration of advanced wearable technology, personalized medicine, telemedicine, and promotion of active, walkable communities. The incorporation of behavioral science is highlighted as a missing component that can enhance long-term adherence to exercise regimens through motivation, behavior change techniques, patient-centered approaches, and continuous monitoring and feedback. This comprehensive approach aims to optimize cardiovascular health and overall well-being through individualized, evidence-based exercise interventions that are both effective and sustainable.

Atrial Fibrillation Ablation in Heart Failure with Reduced Ejection Fraction

Multiple randomized clinical trials have demonstrated catheter ablation in heart failure with reduced ejection fraction reduces mortality and hospitalization as well as improves ventricular function, quality of life, and functional status. Catheter ablation has been shown to be superior to alternative rate and rhythm control strategies in these outcomes. Guidelines strongly support the use of catheter ablation to maintain sinus rhythm in patients with atrial fibrillation and heart failure.

Shared Decision-Making Aid for Stroke-Prevention Strategies in Patients With Atrial Fibrillation Receiving Maintenance Hemodialysis (SIMPLIFY-HD): A Mixed-Methods Study

Background

Recent atrial fibrillation guidelines recommend shared decision-making between clinicians and patients when choosing stroke-prevention therapies. Although decision aids improve patients' knowledge and decisional conflicts, there is no decision aid for stroke-prevention strategies in people with atrial fibrillation receiving hemodialysis.

Objective

The objective was to develop and field test the first decision aid for Atrial Fibrillation in HemoDialysis (AFHD-DA) for stroke prevention in atrial fibrillation and hemodialysis.

Design

This is a sequential 3-phase mixed-methods study following the International Patient Decision Aid Standards and the Ottawa Decision Support Framework.

Setting

This study was conducted in 2 ambulatory hemodialysis centers in Montreal and Laval (Canada).

Participants

Adults with atrial fibrillation receiving hemodialysis and clinicians (physicians, pharmacists, or nurse practitioners) involved in their care.

Methods

In phase 1, we conducted systematic and 2 rapid reviews and formed the steering committee to pilot the first version of AFHD-DA. In phase 2, we refined the AFHD-DA through 4 rounds of focus groups and interviews, using a qualitative analysis of transcripts and a descriptive analysis of acceptability and usability scores. In phase 3, we field-tested the decision aid during 16 simulated clinical consultations. We assessed decisional conflict and patient knowledge using before-and-after paired t-tests and compared the proportion of patients with high decisional conflict using McNemar's test. We used the Ottawa Hospital preparation for decision-making scale and participants' feedback to evaluate how AFHD-DA facilitated shared decision-making.

Results

We enrolled 8 patients and 10 clinicians in phase 2. The predefined usability and acceptability thresholds (68 and 66, respectively) were reached. Theme saturation was achieved in the fourth round of focus groups and interviews. Four major themes emerged: acceptability, usability, decision-making process, and scientific value of the decision aid. Sixteen patients and 10 clinicians field-tested the decision aid in phase 3. In clinical settings, AFHD-DA significantly decreased the mean decisional conflict score from 41.0 to 13.6 (P < .001) and the proportion of patients with decisional conflicts from 81.3 to 18.8% (P = .002). It improved the patients' mean knowledge score from 62.7 to 76.6 (P = .001), and 81% of patients and 90% of clinicians felt highly prepared for decision-making. Clinical consultations lasted, on average, 21 minutes (standard deviation = 8).

Limitations

The main limitations were the low quality of existing literature, the small number of participants, and the absence of a control group.

Conclusions

The decision aid facilitated time-efficient shared decision-making between clinicians and patients, improved patients' knowledge, and reduced decisional conflict around selecting a stroke-prevention strategy for patients with atrial fibrillation receiving hemodialysis.

Practices of low value or unnecessary practices in vascular prevention

BACKGROUND

Low-value practices are avoidable interventions that provide no health benefits. The objective of this study was to conduct a narrative review of the recommendations for practices of low value-care in vascular prevention.

METHODS

A narrative review of all low value-care recommendations for vascular prevention published in the main European and North American scientific societies for clinical practice guidelines between 2014 and 2024 was carried out.

RESULTS

A total of 38 clinical practice guidelines and consensus documents from international organizations in the United States, Canada, the United Kingdom, and Europe were reviewed, 28 of which included between 1 and 20 recommendations on practices of low value-care in vascular prevention. The total number of recommendations was 141. The American Heart Association is the society that offers the largest number of recommendations of low value-care, with 39 recommendations (27.7%) in 5 clinical practice guidelines (13.2% of the total guidelines with recommendations). The guideline for the management of arterial hypertension of the European Society of Hypertension is the guideline that concentrates the largest number of recommendations of low value-care in a single guideline, with 20 recommendations (14.2% of the total guidelines with recommendations).

CONCLUSIONS

There are more and more guidelines that explicitly describe diagnostic or pharmacological activities of low value-care or Do Not Do Class III or recommendation D. Some guidelines agree, but others show clear discrepancies, which can illustrate the uncertainty of the scientific evidence and the differences in its interpretation.

Integrated Care in Atrial Fibrillation: A Multidisciplinary Approach to Improve Clinical Outcomes and Quality of Life

Background: Atrial fibrillation (AF) is the most common arrhythmia globally, associated with serious complications such as stroke and heart failure, as well as significant impacts on patients' quality of life. Objectives: This theoretical article explores the role of integrated care in the management of AF, highlighting the need for a multidisciplinary approach that goes beyond rhythm and heart rate control. Methods: Through a review of the literature, this article explores the prevalence of AF, the challenges of diagnosis, the socioeconomic and psychological impact, as well as the benefits of integrating medical, psychological, and social interventions, drawing on insights from studies about integrative care in AF. Results: The findings highlight the challenges of managing AF, including its high prevalence, complex diagnosis, and significant socioeconomic and psychological impacts on patients. Integrated care models, combining medical, psychological, and social interventions, improve treatment adherence, reduce complications like stroke and heart failure, and enhance patient quality of life. Conclusions: Integrated care models hold significant promise in improving outcomes in AF patients through structured, multidisciplinary approaches. Evidence supports reductions in cardiovascular events, hospitalizations, and mortality when adhering to clinical guidelines, emphasizing patient education, and implementing individualized care strategies. Despite challenges, like regional disparities and suboptimal implementation, the integration of multidisciplinary teams and emerging technologies offers a way to enhance care delivery and accessibility. Future efforts should focus on personalizing care, promoting professional collaboration, and taking advantage of technological advances to optimize AF management and promote sustainable health systems.

The Society of Thoracic Surgeons Preoperative Beta Blocker Working Group Interim Report

BACKGROUND

Atrial fibrillation (AF) occurs commonly after cardiac surgery and is associated with multiple adverse outcomes. Older randomized trials suggested that perioperative β- blockade reduced postoperative AF, and The Society of Thoracic Surgeons (STS) coronary artery bypass grafting (CABG) composite measure includes β-blocker administration preoperatively within 24 hours of surgery and at discharge. However, some more recent studies suggest preoperative β-blockade has limited value and question its continuation as an STS quality measure.

METHODS

In 2022, an STS Preoperative Beta Blocker Working Group was formed with representatives from the STS and the Society of Cardiovascular Anesthesiologists. Published randomized trials, observational studies, societal guidelines, and the current state of available data from the STS Adult Cardiac Surgery Database (ACSD) were reviewed.

RESULTS

Review of existing studies reveals substantial heterogeneity or insufficient detail regarding specific β-blockers used, timing of initiation, management of patients on chronic β-blockade, and whether other proarrhythmic or antiarrhythmic drugs were used concurrently. Further, β-blocker data currently collected in the STS ACSD lack sufficient granularity.

CONCLUSIONS

Because a new randomized trial seems unlikely, the Working Group believes that more granular data on real-world practice would facilitate assessment of the value of preoperative β-blockade in the current era, development of best practice recommendations, and evaluation of their continued appropriateness as an STS quality metric. STS ACSD participants have been invited to participate in a voluntary survey whose additional data, when linked to STS ACSD records, will better delineate contemporary β-blocker practice and outcomes.

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.

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.

Efficacy and safety of anti-thrombotic therapy after surgical mitral valve repair: a scoping review

BACKGROUND

Mitral valve repair (MVr) is the gold standard treatment for degenerative mitral regurgitation, yet there is ongoing controversy regarding optimal anti-thrombotic therapy post-MVr. This scoping review aimed to summarise current evidence on the safety and efficacy of anti-thrombotic therapy after MVr, identify knowledge gaps and propose a future study design.

METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, the WHO International Clinical Trials Registry Platform and bibliographies of included trials, guidelines and other reviews from inception to 17 September 2024. Randomised controlled trials (RCT) and cohort and case-control studies assessing any anti-thrombotic therapy with any outcomes after MVr were included. Using a predefined collection form, two authors independently extracted data on study characteristics and results were summarised narratively into themes based on the PICO elements.

RESULTS

Of 1296 screened references, we included 11 studies (10 cohort and one non-inferiority RCT). All studies compared vitamin K antagonist (VKA) to an anti-platelet, direct oral anti-coagulant or no anti-thrombotic therapy for median duration of 90 days. Thromboembolic and bleeding event incidences ranged from 0% to 14.3% and 0% to 9.1%, respectively. Seven studies reported no difference in thromboembolic events, and three reported reduced rates with VKA compared with control, while results for bleeding events varied widely. The RCT found edoxaban was non-inferior to warfarin for thromboembolic outcomes, but not for bleeding. Substantial methodological and clinical heterogeneity, high risk of bias and insufficient mitigation of confounders, such as concomitant atrial fibrillation, were prevalent across studies.

CONCLUSION

Based on this scoping review, existing literature on anti-thrombotic therapy after MVr is inconclusive due to design limitations. We proposed a study design for a pragmatic RCT that addresses prior study limitations and that could provide definitive evidence to guide anti-thrombotic management in MVr patients.

Caregiving for patients with atrial fibrillation: a systematic review of the scientific literature

AIMS

Caregiving processes and outcomes have been increasingly articulated in the cardiovascular literature, particularly in heart failure and coronary artery disease, but there has been no synthesis on caregiving for a patient with atrial fibrillation (AF). This review synthesizes scientific evidence that describes caregiving in the context of AF, with the aim of informing future research priorities for AF caregiving or clinical approaches that may support caregivers.

METHODS AND RESULTS

Informed by PRISMA guidelines, we conducted a mixed-methods systematic review with a data-based convergence design using a thematic synthesis approach. All studies that examined factors related to caregiving for patients with AF, as either a descriptive, predictor, or outcome variable, were included. After the search, data from 13 studies were abstracted; half of the studies (53%) were of low-to-moderate quality. Changes to the family unit and feelings of uncertainty are common post-AF; a subset of caregivers struggle with mental health challenges, particularly those who are unwell themselves or those who provide several hours of care to patients with more advanced symptoms or limitations. Informational support for caregivers appears to be lacking but is desired to better adapt to the changes or consequences incurred from AF.

CONCLUSION

This review complements findings from previous reviews conducted in other cardiovascular disease subgroups. As there is still limited high-quality research on caregiving in an AF context, additional research is required to adequately inform supportive programming for caregivers of patients with AF, if indicated.

REGISTRATION

PROSPERO: CRD4202339778.

Comparison of the Latest ESC, ACC/AHA/ACCP/HRS, and CCS Guidelines on the Management of Atrial Fibrillation

The introduction of evidence-based and structured guidelines has undoubtedly improved the care of cardiologic patients and in many cases simplified decision-making for the treatment team. The European Society of Cardiology in collaboration with the European Association for Cardio-Thoracic Surgery, the American College of Cardiology, the American Heart Association, the American College of Clinical Pharmacy, and the Heart Rhythm Society, and the Canadian Cardiovascular Society/Canadian Heart Rhythm Society have developed guidelines for the management of patients with atrial fibrillation. Because all 3 guidelines refer to almost the same scientific data, their recommendations are undoubtedly largely in agreement. Nevertheless, there are some interesting differences based on different interpretations of the same study, different publication dates, or differences in local conditions and health care resources. The following article aims at lining out these similarities and differences.

Predicting the Propensity of Atrial Cardiopathy and Paroxysmal Atrial Fibrillation in Patients with Embolic Stroke of Undetermined Source (ESUS)

BACKGROUND

There is still a significant population of patients with embolic stroke of Undetermined Source (ESUS) whose specific attributable cause of the stroke remains unknown.

OBJECTIVES

Our research aimed to assess clinical, electrocardiogram, laboratory, and echocardiographic parameters that may predict the propensity of paroxysmal atrial fibrillation (PAF).

METHODS

We enrolled seventy-five ESUS patients who were in sinus rhythm at the time of stroke diagnosis to undergo in-hospital 7-day Holter monitoring, testing for Pro-BNP, and a standard echocardiographic examination. For statistical analysis, a P-value < 0.05 was considered significant.

RESULTS

The average age of the 75 ESUS patients was 58 years old. 60% of the patients were male, and the most prevalent concomitant condition was hypertension (53.3%). Forty patients had atrial cardiopathy, and 15 patients had PAF episodes. Hypertension and the E/e- > 12 were independent predictors of atrial cardiopathy, with p-values of 0.001 and 0.02, respectively. In patients with atrial cardiopathy, multivariable regression analysis was performed; PTFV > 5000 Mv.ms, LA volume index > 34 ml/m2, and ejection fraction < 45% were significant independent predictors of AF with significant p values of 0.001, < 0.001, and 0.001 respectively.

CONCLUSIONS

In ESUS patients, atrial cardiopathy was prevalent. Hypertension and an E/e- ratio greater than 12 were independent predictors for it. Multivariable regression analysis identified PTFV1 > 5000 mV.ms, LA volume index > 34 ml/m2, and ejection fraction < 45% as independent predictors for new-onset atrial fibrillation.

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.

Cross-Cultural Validation of Knowledge About Atrial Fibrillation and Stroke Prevention Questionnaire: A Cross-Sectional Study Among Chinese Patients With Atrial Fibrillation

AIM

To cross-culturally adapt the Knowledge about Atrial Fibrillation and Stroke Prevention Questionnaire (KAFSP-Q) for Chinese AF patients and validate its effectiveness.

DESIGN

Instrument adaptation and cross-sectional validation.

METHODS

The KAFSP-Q was translated into Chinese by using the forward and back translation method. Experts and patients were invited to revise the questionnaire domains and items. The psychometric properties of the Chinese version of the KAFSP-Q were evaluated, that is, its construct validity, discriminant validity, convergent validity, internal consistency and test-retest reliability.

FINDINGS

The Chinese version of the KAFSP-Q consists of 41 items and six domains, namely, bleeding knowledge, AF complications, stroke risk and stroke prevention, stroke symptoms, AF symptoms and general AF knowledge. The Chinese version of the KAFSP-Q demonstrated acceptable content validity (scale-content validity index = 0.859). The exploratory factor analysis revealed six factors, which accounted for 65.725% of the total variance, and the confirmatory factor analysis revealed acceptable fit indices. The convergent validity was poor, because the average variance extracted coefficient of the six domains was lower than 0.500. The square root of the average variance extracted coefficients was higher than the bivariate correlation between the domains, which indicated an acceptable discriminant validity. Meanwhile, the internal consistency and test-retest reliability were satisfactory (Cronbach's α coefficient = 0.973, intraclass correlation coefficient = 0.872).

CONCLUSIONS

The Chinese version of the KAFSP-Q demonstrates acceptable validity and reliability and can be used as a valuable instrument for AF and stroke prevention knowledge evaluation.

IMPACT

In clinical practice, the Chinese version of the KAFSP-Q can be used to help patients increase their disease management knowledge and engage in effective disease management behaviour. Future research is necessary to confirm the psychometric properties of the questionnaire with samples that are highly representative.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Effectiveness of shared decision making strategies for stroke prevention among patients with atrial fibrillation: cluster randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of multiple decision aid strategies in promoting high quality shared decision making for prevention of stroke in patients with non-valvular atrial fibrillation.

DESIGN

Cluster randomized controlled trial.

SETTING

Six academic medical centers in the United States.

PARTICIPANTS

Patient participants were aged ≥18 with a diagnosis of non-valvular atrial fibrillation, at risk for stroke (CHA2DS2-VASc ≥1 for men, ≥2 for women), and scheduled for a clinical appointment to discuss stroke prevention strategies. Participating clinicians were those who manage stroke prevention strategies for participating patients.

INTERVENTION

Patients were randomized to use a patient decision aid or usual care; clinicians were randomized to use an encounter decision aid or usual care with all participating patients.

MAIN OUTCOME MEASURES

Primary outcome measures were quality of shared decision making measured by OPTION12, knowledge of atrial fibrillation and its management, and decisional conflict.

RESULTS

1117 participants across six sites were included in the analysis. Compared with usual care, the combined use of both the patient decision aid and the encounter decision aid improved the quality of shared decision making (adjusted mean difference 12.1 (95% confidence interval (CI) 8.0 to 16.2; P<0.001), improved patients' knowledge (odds ratio 1.68 (95% CI 1.35 to 2.09; P<0.001), and reduced patients' decisional conflict (adjusted mean difference -6.3 (95% CI -9.6 to -3.1; P<0.001). Statistically significant improvements were also observed with the encounter decision aid alone versus usual care for all three outcomes and with the patient decision aid alone versus usual care for quality of shared decision making and knowledge. No important differences were observed in treatment choices for stroke prevention or in participants' satisfaction. No statistically significant difference in the length of visit across study groups was detected.

CONCLUSION

Patients who received any decision aid (encounter decision aid, patient decision aid, or both) had lower decisional conflict, better shared decision making, and greater knowledge than those receiving no decision aid, except for the effect of the patient decision aid on decisional conflict, which did not reach statistical significance. The study establishes that use of either pre-visit or in-visit decision aids individually or in combination is advantageous compared with usual care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04357288.

Bridging the Gaps in Atrial Fibrillation Management in the Emergency Department

Atrial fibrillation (AF) frequently presents in emergency departments (EDs), contributing significantly to adverse cardiovascular outcomes. Despite established guidelines, ED management of AF often varies, revealing important gaps in care. This review addresses specific challenges in AF management for patients in the ED, including the nuances of rate versus rhythm control, the timing of anticoagulation initiation, and patient disposition. The updated 2024 European Society of Cardiology (ESC) guidelines advocate early rhythm control for select patients while recommending rate control for others; however, uncertainties persist, particularly regarding these strategies' long-term impact on outcomes. Stroke prevention through timely anticoagulation remains crucial, though the ideal timing, especially for new-onset AF, needs further research. Additionally, ED discharge protocols and follow-up care for AF patients are often inconsistent, leaving many without proper long-term management. Integration of emerging therapies, including direct oral anticoagulants and advanced antiarrhythmic drugs, shows potential but remains uneven across EDs. Innovative multidisciplinary models, such as "AF Heart Teams" and observation units, could enhance care but face practical challenges in implementation. This review underscores the need for targeted research to refine AF management, optimize discharge protocols, and incorporate novel therapies effectively. Standardizing ED care for AF could significantly reduce stroke risk, lower readmission rates, and improve overall patient outcomes.

Screening and diagnosis of atrial fibrillation using wearable devices

In recent years, the development and use of various devices for the screening of atrial fibrillation (AF) have significantly increased. Such devices include 12-lead electrocardiogram (ECG), photoplethysmography systems, and single-lead ECG and ECG patches. This review outlines several studies that have focused on the feasibility and efficacy of such devices for AF screening, and summarizes the risks and benefits involved in the initiation of anticoagulant therapy after early detection of AF. We also describe several ongoing trials on unresolved issues associated with AF screening. Overall, this review provides a comprehensive summary of the current state of AF screening and its implications for patient care.

Anticoagulation strategy for patients presenting with ischemic strokes while using a direct oral anticoagulant: A systematic review and meta-analysis

BACKGROUND

While direct-acting oral anticoagulants (DOACs) have established efficacy in reducing the risk of ischemic stroke, they still leave a residual risk of stroke, which may be greater in practice (0.7-2.3%) than in controlled clinical trial settings. This meta-analysis examines four therapeutic approaches following a stroke in patients already on DOACs: continuing with the same DOAC, changing to a different DOAC, increasing the current DOAC dosage, or switching to a vitamin K antagonist (VKA), such as warfarin.

METHODS

Systematic review of literature from the MEDLINE, Embase, and Cochrane databases, was conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The analysis focused on six studies with varied patient demographics, examining as outcomes as recurrent ischemic stroke, intracranial hemorrhage, other bleeding events, and mortality.

RESULTS

Six studies comprising 12,159 patients were included, all of them were observational. Patients who remained on their initial DOAC regimen had a lower risk of experiencing ischemic strokes (risk ratio (RR) 0.55; 95% confidence interval (CI) 0.43-0.70; p < 0.001; I2 = 0%), intracranial hemorrhage (RR 0.37; 95% CI 0.25-0.55; p < 0.001; I2 = 0%), and hemorrhagic events (RR 0.44; 95% CI 0.30-0.63; p < 0.001; I2 = 6%) compared to those who were switched to warfarin, with an increase in mortality rates (hazard ratio (HR) 1.85; 95% CI 1.06-3.24; p = 0.03; I2 = 84%). In contrast, neither changing to a different DOAC nor adjusting the dose proved to be more effective than the original regimen.

CONCLUSION

Post-stroke adjustments to anticoagulation therapy-whether altering the drug or its dosage-do not yield additional benefits. In addition, the results suggest that warfarin may be less effective than DOACs for preventing stroke recurrence, bleeding complications, and death in this patient population.

Postoperative atrial fibrillation following cardiac surgery in severe obesity: the added value of waist circumference

INTRODUCTION

Obesity is an independent risk factor for postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) surgery. POAF in patients with severe obesity (body mass index [BMI] ≥ 35 kg/m2) is less studied. Whether waist circumference (WC) improves prediction of POAF independently of BMI among patients with severe obesity remains unknown.

AIM

To evaluate the risk of POAF, the role of WC in predicting POAF and postoperative complications after CABG surgery in severe obesity.

METHODS

Our cohort included 7995 patients undergoing CABG surgery (2006-19). POAF risk was compared across BMI and WC categories. In patients with severe obesity, the association of an increase in WC with POAF risk was assessed.

RESULTS

763 (9.5%) patients had a BMI ≥ 35 kg/m2. In this group, BMI was 38.5 ± 3.6 kg/m2 and WC was 123.4 ± 10.8 cm. More patients with severe obesity developed POAF compared to patients with a normal BMI (37 vs. 29%, aRR: 1.52[95%CI 1.36-1.72], p < 0.01). Within each BMI category, the risk of POAF was higher per increasing tertile of WC (p < 0.05). Among patients with a BMI ≥ 35 kg/m2, every 10 cm increment in WC was associated with an increased risk of POAF (aRR: 1.16[95%CI 1.08-1.24], p < 0.01). POAF in patients with severe obesity was associated with increased hospital length of stay.

CONCLUSIONS

Severe obesity increases the risk of POAF after CABG surgery. In this subgroup, elevated WC may provide additional prognostic value independently of BMI. Since POAF is associated with adverse long-term outcomes, abdominal obesity by measurement of WC should be assessed and targeted even in patient with severe obesity. Central Illustration Increasing waist circumference associated with increased atrial fibrillation risk post coronary artery bypass grafting. Bar graph of the unadjusted absolute risk and 95% confidence interval of postoperative atrial fibrillation for each tertile of waist circumference per body mass index category. Comparison of postoperative atrial fibrillation risk with chi-square test showing an increasing risk of postoperative atrial fibrillation related to increasing waist circumference within each body mass index category.

ABBREVIATIONS

BMI, body mass index; POAF, postoperative atrial fibrillation; WC, waist circumference.

A randomized controlled implementation study integrating patient self-screening with a remote central monitoring system to screen community dwellers aged 75 years and older for atrial fibrillation

AIMS

Diagnosis of atrial fibrillation (AF) provides opportunities to reduce stroke risk. This study aimed to compare AF diagnosis rates, participant satisfaction, and feasibility of an electrocardiogram (ECG) self-screening virtual care system with usual care.

METHODS AND RESULTS

This randomized controlled implementation study involving community-dwelling people aged ≥75 years was conducted from May 2021 to June 2023. Participants were given a handheld single-lead ECG device and trained to self-record ECGs once daily on weekdays for 12 months. The control group received usual care with their general practitioners in the first 6 months and participated in the subsequent 6 months. Atrial fibrillation diagnosis and participant satisfaction were assessed at 6 months. Two hundred participants (mean age 79.0 ± 3.4 years; 54.0% female; 72.5% urban) were enrolled. Atrial fibrillation was diagnosed in 10/97 (10.3%) intervention participants and 2/100 (2.0%) in the control group (odds ratio 5.6, 95% confidence interval 1.4-37.3, P = 0.03). In the intervention, 80% of AF cases were diagnosed within 3 months. 91/93 (97.9%) intervention participants and 55/93 (59.1%) control-waitlisted participants (P < 0.001) were satisfied with AF screening. Of the expected 20 days per month, the overall monthly median number of days participants self-recorded ECGs was 20 (interquartile range 17-22). Participants were confident using the device (93%), reported it was easy to use (98%), and found screening efficient (96%).

CONCLUSION

Patient-led AF self-screening using single-lead ECG devices with a remote central monitoring system was feasible, acceptable, and effective in diagnosing AF among older people. This screening model could be adapted for implementation, interfacing with integrated care models within existing health systems.

REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12621000184875.

An International Consensus Practical Guide on Left Atrial Appendage Closure for the Non-implanting Physician: Executive Summary

Many patients with atrial fibrillation (AF) who are in need of stroke prevention are not treated with oral anticoagulation or discontinue treatment shortly after its initiation. Despite the availability of direct oral anticoagulants (DOACs), such undertreatment has improved somewhat but is still evident. This is due to continued risks of bleeding events or ischemic strokes while on DOAC, poor treatment compliance, or aversion to anticoagulant therapy. Because of significant improvements in procedural safety over the years left atrial appendage closure (LAAC), using a catheter-based, device implantation approach, is increasingly favored for the prevention of thromboembolic events in AF patients who cannot have long-term oral anticoagulation. This article is an executive summary of a practical guide recently published by an international expert consensus group, which introduces the LAAC devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. This practical guide, aligned with published guideline/guidance, is aimed at those non-implanting physicians who may need to refer patients for consideration of LAAC.

Long-term outcomes of catheter ablation compared with medical therapy in atrial fibrillation

BACKGROUND

The long-term effects of catheter ablation (CA) compared with medical therapy on cardiovascular outcomes for atrial fibrillation (AF) remain undetermined.

OBJECTIVE

Using a population-based cohort, we sought to determine what the association between CA and medical therapy was on these outcomes.

METHODS

By use of Alberta administrative data, patients with AF as the primary diagnosis during hospitalization, emergency department visit, or physician visit were included between October 1, 2008, and March 31, 2018. Based on therapy received, patients were assigned to categories of CA, rate control, or rhythm control with medication. The association of treatment with the primary composite outcome of all-cause death, hospitalization for heart failure, or stroke was examined after adjustment for age, sex, comorbidities, and baseline medications.

RESULTS

Of 39,966 treated AF patients, 2077 (5.2%), 29,467 (73.7%), and 8422 (21.1%) were treated with CA, rate control, and rhythm control with medication, respectively. Patients in the CA group had a lower incidence of the primary outcome (4.0/100 person-years) compared with the rate control group (8.7/100 person-years) or the rhythm control with medication group (6.8/100 person-years) during a median follow-up of 6.3 years. In multivariable analysis, compared with CA, both rate control (hazard ratio, 1.28; 95% confidence interval, 1.09-1.50) and rhythm control with medication (hazard ratio, 1.21; 95% confidence interval, 1.03-1.43) were associated with a higher risk of the primary outcome.

CONCLUSION

In this cohort study, patients who received CA demonstrated a reduction in the risk of long-term adverse cardiovascular outcomes compared with medical therapy in patients with AF, providing some data to indicate the effects of CA in the long-term.

The 2024 European Society of Cardiology Guidelines for Diagnosis and Management of Atrial Fibrillation: A Viewpoint from a Practicing Clinician's Perspective

Atrial fibrillation (AF) is a complex disease requiring a multidomain and (usually) long-term management, thus posing a significant burden to patients with AF, practitioners, and health care system. Unlike cardiovascular conditions with a narrow referral pathway (e.g., acute coronary syndrome), AF may be first detected by a wide range of specialties (often noncardiology) or a general practitioner. Since timely initiated optimal management is essential for the prevention of AF-related complications, a concise and simple guidance is essential for practitioners managing AF patients, regardless of their specialty. Guideline-adherent management of patients with AF has been shown to translate to improved patient outcomes compared with guideline-nonadherent treatment. To facilitate guideline implementation in routine clinical practice, a good guideline document on AF should introduce only evidence-based new recommendations, while avoiding arbitrary changes, which may be confusing to practitioners. Herein, we discuss the main changes in the 2024 European Society of Cardiology (ESC) AF Guidelines relative to the previous 2020 ESC document. Whether the updates and new recommendations issued by the new guidelines will translate in high adherence in clinical practice (and hence improved prognosis of patients with AF) will need to be addressed in upcoming years.

Comparative effectiveness and safety of apixaban and rivaroxaban in older patients with atrial fibrillation: A population-based cohort study

BACKGROUND

There are no clinical trials with a head-to-head comparison between the 2 most commonly used oral anticoagulants (apixaban and rivaroxaban) in patients with atrial fibrillation (AF). The comparative efficacy and safety between these drugs remain unclear, especially in older patients who are at the highest risk for stroke and bleeding.

OBJECTIVE

The purpose of this study was to compare the risk of major bleeding and thromboembolic events between apixaban and rivaroxaban in older patients with AF.

METHODS

We conducted a population-based retrospective cohort study of all adult patients (66 years or older) with AF in Ontario, Canada, who were treated with apixaban or rivaroxaban between April 1, 2011, and March 31, 2020. The primary safety outcome was major bleeding, and the primary efficacy outcome was thromboembolic events. Secondary outcomes included any bleeding. Rates and hazard ratios (HRs) were adjusted for baseline comorbidities with inverse probability of treatment weighting.

RESULTS

This study included 42,617 patients with AF treated with apixaban and 30,725 patients treated with rivaroxaban. After inverse probability of treatment weighting using the propensity score, patients in the apixaban and rivaroxaban groups were well balanced for baseline values of demographic characteristics, comorbidities, and medications; both groups had a similar mean age of 77.4 years, and 49.9% were female. At 1 year, the apixaban group had a lower risk for both major bleeding with an absolute risk reduction at 1 year of 1.1% (2.1% vs 3.2%; HR 0.65; 95% confidence interval [CI] 0.59-0.71]) and any bleeding (8.1% vs 10.9%; HR 0.73; 95% CI 0.69-0.77), with no difference in the risk for thromboembolic events (2.2% vs 2.2%; HR 1.02; 95% CI 0.92-1.13).

CONCLUSION

In patients with AF, 66 years or older, treatment with apixaban was associated with lower risk for major bleeding, with no difference in the risk for thromboembolic events compared with rivaroxaban.

Variability of cardiopulmonary exercise testing in patients with atrial fibrillation and determination of exercise responders to high-intensity interval training and moderate-to-vigorous intensity continuous training

Disabling atrial fibrillation (AF)-related symptoms and different testing settings may influence day-to-day cardiopulmonary exercise testing (CPET) measurements, which can affect exercise prescription for high-intensity interval training (HIIT) and moderate-to-vigorous intensity continuous training (M-VICT) and their outcomes. This study examined the reliability of CPET in patients with AF and assessed the proportion of participants achieving minimal detectable changes (MDC) in peak oxygen consumption (V̇O2peak) following HIIT and M-VICT. Participants were randomized into HIIT or M-VICT after completing two baseline CPETs: one with cardiac stress technologists (CPETdiag) and the other with a research team of exercise specialists (CPETresearch). Additional CPET was completed following 12 weeks of twice-weekly training. The reliability of CPETdiag and CPETresearch was assessed by intraclass correlation coefficient (ICC) and dependent t tests. The MDC score was calculated for V̇O2peak using a reliable change index. The proportion of participants achieving MDC was compared between HIIT and M-VICT using chi-square analysis. Eighteen participants (69 ± 7 years, 33% females) completed two baseline CPETs. The ICCs were significant for all measured variables. However, peak power output (POpeak: 124 ± 40 vs. 148 ± 40 watts, p < 0.001) and HR (HRpeak: 136 ± 22 vs. 148 ± 30 bpm, p = 0.023) were significantly greater in CPETresearch than CPETdiag. Few participants achieved MDC in V̇O2peak (5.6 mL/kg/min) with no difference between HIIT (0%) and M-VICT (10.0%, p = 0.244). POpeak and HRpeak differed significantly in patients with AF when CPETs were repeated under different settings. Caution must be practised when prescribing exercise intensity based on these measures as under-prescription may increase the number of exercise non-responders.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Pulmonary Vein Isolation or Pace and Ablate in Elderly Patients With Persistent Atrial Fibrillation (ABLATE Versus PACE)-Rationale, Methods, and Design

Age is a major risk-factor for atrial fibrillation (AF) and associated hospitalisations. With increasing emphasis on rhythm control, pulmonary vein isolation (PVI) is often suggested, even to elderly patients (≥ 75 years of age). Efficacy of PVI aiming at rhythm control is limited in persistent AF. Pacemaker implantation with atrioventricular node (AVN) ablation may represent a reasonable alternative, with the aim of controlling symptoms and improving quality of life in elderly patients. In this investigator-initiated, randomised, multicentre trial, we test the hypothesis that pacemaker implantation and AVN ablation provides superior symptom control over PVI in elderly patients with symptomatic persistent AF, without any increase in adverse event profile. In the ABLATE Versus PACE (NCT04906668) prospective open-label superiority trial, 196 elderly patients with normal ejection fraction and symptomatic persistent AF despite guideline-indicated medical therapy will be randomised to either cryoballoon PVI (ABLATE) or dual-chamber pacemaker implantation with subsequent AVN ablation (PACE), and followed for a minimum of 12 months. The primary efficacy outcome is a composite end point of rehospitalisation for atrial arrhythmia or cardiac decompensation/heart failure, (outpatient) electrical cardioversion, or upgrade to cardiac resynchronisation therapy owing to worsening of left ventricular ejection fraction to ≤ 35%. Secondary end points include death from any cause, stroke, quality of life, and procedure-related complications. Sample size is designed to achieve 80% power for the primary end point (2-tailed alpha of 5%). ABLATE Versus PACE will determine whether pacemaker implantation and AVN ablation can improve symptom-control in elderly patients with persistent AF over PVI without increasing safety end points.

Risk of Stroke or Systemic Embolism According to Baseline Frequency and Duration of Subclinical Atrial Fibrillation: Insights From the ARTESiA Trial

BACKGROUND

In the ARTESiA trial (Apixaban for the Reduction of Thromboembolism in Patients With Device-Detected Subclinical Atrial Fibrillation), apixaban, compared with aspirin, reduced stroke or systemic embolism in patients with device-detected subclinical atrial fibrillation (SCAF). Clinical guidelines recommend considering SCAF episode duration when deciding whether to prescribe oral anticoagulation for this population.

METHODS

We performed a retrospective cohort study in ARTESiA. Using Cox regression adjusted for CHA2DS2-VASc score and treatment allocation (apixaban or aspirin), we assessed frequency of SCAF episodes and duration of the longest SCAF episode in the 6 months before randomization as predictors of stroke risk and of apixaban treatment effect.

RESULTS

Among 3986 patients with complete baseline SCAF data, 703 (17.6%) had no SCAF episode ≥6 minutes in the 6 months before enrollment. Among 3283 patients (82.4%) with ≥1 episode of SCAF ≥6 minutes in the 6 months before enrollment, 2542 (77.4%) had up to 5 episodes, and 741 (22.6%) had ≥6 episodes. The longest episode lasted <1 hour in 1030 patients (31.4%), 1 to <6 hours in 1421 patients (43.3%), and >6 hours in 832 patients (25.3%). Higher baseline SCAF frequency was not associated with increased risk of stroke or systemic embolism: 1.1% for 1 to 5 episodes versus 1.2%/patient-year for ≥6 episodes (adjusted hazard ratio, 0.89 [95% CI, 0.59-1.34]). In an exploratory analysis, patients with previous SCAF but no episode ≥6 minutes in the 6 months before enrollment had a lower risk of stroke or systemic embolism than patients with at least one episode during that period (0.5% versus 1.1%/patient-year; adjusted hazard ratio, 0.48 [95% CI, 0.27-0.85]). The frequency of SCAF did not modify the reduction in stroke or systemic embolism with apixaban (Pinteraction=0.1). The duration of the longest SCAF episode in the 6 months before enrollment was not associated with the risk of stroke or systemic embolism during follow-up (<1 hour: 1.0%/patient-year [reference]; 1-6 hours: 1.2%/patient-year [adjusted hazard ratio, 1.27 (95% CI, 0.85-1.90)]; >6 hours: 1.0%/patient-year [adjusted hazard ratio, 1.02 (95% CI, 0.63-1.66)]). SCAF duration did not modify the reduction in stroke or systemic embolism with apixaban (Ptrend=0.1).

CONCLUSIONS

In ARTESiA, baseline SCAF frequency and longest episode duration were not associated with risk of stroke or systemic embolism and did not modify the effect of apixaban on reduction of stroke or systemic embolism.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01938248.

Comparison of Therapeutic Effects Between Pulsed Field Ablation and Cryoballoon Ablation in the Treatment of Atrial Fibrillation: A Systematic Review and Meta-analysis

Pulsed field ablation (PFA) is a novel nonthermal ablation technique for the treatment of atrial fibrillation (AF) patients, with safety comparable to traditional catheter ablation surgery. The present study aims to evaluate and compare the procedural efficiency and safety profiles of PFA and cryoballoon ablation (CBA) in the management of AF. We performed a systematic search across PubMed, the Cochrane Library, and Embase databases, encompassing the literature up to February 2024, to inform our systematic review and meta-analysis. When assessing outcome indicators, the risk ratio and its corresponding 95% confidence interval (CI) were calculated for dichotomous variables. For continuous variables, the mean difference (MD) and the associated 95% CI were determined. In this scenario, a relative risk (RR) value of less than 1 and an MD value of less than 0 are deemed favorable for the PFA group. This could translate to a reduced likelihood of procedural complications or enhanced procedural performance within the PFA group. In this analysis, 9 observational studies encompassing 2875 patients with AF were included. Among these, 38% (n = 1105) were treated with PFA, while 62% (n = 1770) received CBA. The results indicated that PFA was associated with a significantly shorter procedural duration compared with CBA, with an MD of -10.49 minutes (95% CI, -15.50 to -5.49; P < 0.0001). Nevertheless, no statistically significant differences were observed when comparing the 2 treatment cohorts concerning fluoroscopy time (MD, 0.71; 95% CI, -0.45 to 1.86; P = 0.23) and the recurrence of atrial arrhythmias during follow-up (RR, 0.95; 95% CI, 0.78-1.14; P = 0.57). In terms of perioperative complications, the PFA group showed a significantly decreased risk of phrenic nerve palsy (RR, 0.15; 95% CI, 0.06-0.39; P < 0.0001) and an increased risk of cardiac tamponade (RR, 3.48; 95% CI, 1.26-9.66; P = 0.02) compared with the CBA group. No significant differences were noted between the PFA and CBA groups regarding the incidence of stroke/transient ischemic attack (RR, 0.99; 95% CI, 0.30-3.22; P = 0.99), vascular access complication (RR, 0.87; 95% CI, 0.36-2.10; P = 0.76), atrial esophageal fistula (RR, 0.33; 95% CI, 0.01-8.13; P = 0.50), and major or minor bleeding events (RR, 0.39; 95% CI, 0.09-1.74; P = 0.22). Our research results indicate that compared with CBA, PFA not only shortens the procedure time but also demonstrates noninferiority in terms of fluoroscopy duration and the recurrence rate of atrial arrhythmias. PFA and CBA have both demonstrated their respective advantages in perioperative complications.

Research priorities for the study of atrial fibrillation during acute and critical illness: recommendations from the Symposium on Atrial Fibrillation in Acute and Critical Care

Atrial fibrillation (AF) is a common arrhythmia encountered in acute and critical illness and is associated with poor short and long-term outcomes. Given the consequences of developing AF, research into prevention, prediction and treatment of this arrhythmia in the critically ill are of great potential benefit, however, study of AF in critically ill patients faces unique challenges, leading to a sparse evidence base to guide management in this population. Major obstacles to the study of AF in acute and critical illness include absence of a common definition, challenges in designing studies that capture complex etiology and assess causality, lack of a clear outcome set, difficulites in recruitment in acute environments with respect to timing, consent, and workflow, and failure to embed studies into clinical care platforms and capitalize on emerging technologies. Collaborative effort by researchers, clinicians, and stakeholders should be undertaken to address these challenges, both through interdisciplinary cooperation for the optimization of research efficiency and advocacy to advance the understanding of this common and complex arrhythmia, resulting in improved patient care and outcomes. The Symposium on Atrial Fibrillation in Acute and Critical Care was convened to address some of these challenges and propose potential solutions.

Anticoagulation for Patients with Atrial Fibrillation Receiving Dialysis: A Pilot Randomized Controlled Trial

Key Points

Background

Atrial fibrillation is common in individuals receiving dialysis. The role of oral anticoagulation in this population is uncertain given its exclusion from previous seminal clinical trials. Our objective was to determine the feasibility of performing a large definitive trial to establish the optimal anticoagulation strategy in individuals with atrial fibrillation receiving dialysis.

Methods

The Strategies for the Management of Atrial Fibrillation in Patients Receiving Dialysis trial was a parallel-group, open-label, allocation-concealed, pilot randomized control trial that took place at 28 centers in Canada and Australia. The trial included adults (18 years or older) undergoing dialysis with a history of nonvalvular atrial fibrillation who met the CHADS-65 criteria. Participants were randomized 1:1:1 to receive dose-adjusted warfarin, apixaban 5 mg twice daily, or no oral anticoagulation and followed for 26 weeks. The primary outcomes evaluated the following measures of feasibility: (1) recruitment of the target population within 2 years from the start of the trial and (2) adherence of >80% of randomized patients to the allocated treatment strategy at the conclusion of follow-up. Secondary outcomes included stroke and bleeding.

Results

From December 2019 to June 2022, 151 patients were enrolled and randomized to apixaban (n=51), warfarin (n=52), or no oral anticoagulation (n=48). Allowing for pauses related to the coronavirus disease pandemic, recruitment was completed in 30 months, and 123 (83%) of participants completed follow-up in their allocated treatment arm. There was one adjudicated stroke event. Eight participants had a major bleeding event (four warfarin, two apixaban, two no oral anticoagulation). Death occurred in 15 participants (nine warfarin, two apixaban, four no oral anticoagulation). Time in the therapeutic range for warfarin recipients was 58% (interquartile range, 47%–70%).

Conclusions

We have demonstrated the feasibility of recruitment and adherence in a trial that compared different anticoagulation strategies in patients with atrial fibrillation receiving dialysis.

Clinical Trial registry name and registration number:

Strategies for the Management of Atrial Fibrillation in Patients Receiving Dialysis (SAFE-D), NCT03987711.

Centre-Specific Variation in Atrial Fibrillation Ablation-Treatment Rates in a Universal Single-Payer Healthcare System

Background

Disparities in atrial fibrillation ablation rates have been studied previously, with a focus on either patient characteristics or systems factors, rather than geographic factors. The impact of electrophysiology (EP) centre practice patterns on ablation rates has not been well studied.

Methods

This population-based cohort study used linked administrative datasets covering physician billing codes, hospitalizations, prescriptions, and census data. The study population consisted of patients who visited an emergency department with a new diagnosis of atrial fibrillation, in the period 2007-2016, in Ontario, Canada. Patient characteristics, including age, sex, medical history, comorbidities, socioeconomic factors, closest EP centre within 20 km, and distance to the nearest centre, were used as predictors in multivariable logistic regression models to assess the relationship between living in a location around specific EP centres and ablation rates.

Results

The cohort included 134,820 patients, of whom 9267 had an ablation treatment during the study period. Patients undergoing ablation treatment were younger, had a lower Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score, lived closer to EP centres, and had fewer comorbidities than those who did not receive ablation treatment. Wide variation occurred in ablation rates, with adjacent census divisions having ablation rates up to 2.6 times higher. Multivariate regression revealed significant differences in ablation rates for patients who lived in a location around certain EP centres. The odds ratios for living in a location closest to specific centres ranged from 0.78 (95% confidence interval: 0.68-0.89) to 1.60 (95% confidence interval:1.34-1.90).

Conclusions

Living near specific EP centres may significantly affect a patient's likelihood of receiving ablation treatment, regardless of factors such as age, gender, socioeconomic status, prior medical history, and distance to EP centres.