Autonomic dysfunction is associated with brief episodes of atrial fibrillation in type 2 diabetes

Long noncoding RNA and messenger RNA profiling in epicardial adipose tissue of patients with new-onset postoperative atrial fibrillation after coronary artery bypass grafting

BACKGROUND

Postoperative atrial fibrillation (POAF) constitutes a significant complication following coronary artery bypass graft surgery (CABG), potentially linked to epicardial adipose tissue (EAT). This investigation seeks to elucidate the association between POAF and EAT at the genetic level.

METHODS

EAT and clinical data from patients undergoing CABG were systematically acquired, adhering to established inclusion and exclusion criteria. Patients were categorized into POAF and Non-POAF groups based on the presence or absence of POAF. High-throughput sequencing data of EAT were subjected to differential expression analysis and gene function assessment. A random selection of long noncoding RNAs (lncRNAs) underwent quantitative real-time polymerase chain reaction (qRT-PCR) for validation of the high-throughput sequencing findings. Coexpression analysis was employed to elucidate the interactions between lncRNAs and messenger RNAs (mRNAs).

RESULTS

RNA sequencing yielded a total of 69,685 transcripts (37,740 coding and 31,945 noncoding sequences), representing 16,920 genes. Within this dataset, 38 mRNAs and 12 lncRNAs exhibited differential expression between the POAF and Non-POAF groups (P < 0.05, fold change > 1.5). The qRT-PCR results for lncRNAs corroborated the sequencing findings (P < 0.01). Functional enrichment analysis of genes and the coexpression network indicated that these differentially expressed RNAs were primarily implicated in processes such as cell growth, differentiation, signal transduction, as well as influencing tissue fibrosis and ion transmembrane transport.

CONCLUSIONS

This study unveils a potential association between myocardial fibrosis and ion channels co-regulated by mRNAs and lncRNAs, closely linked to the emergence of new-onset POAF, after accounting for clinical risk factors. This discovery holds promise for further advances in clinical and fundamental research.

Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment

Type 2 diabetes mellitus (T2DM) is a leading risk factor for cardiovascular complications around the globe and one of the most common medical conditions. Atrial fibrillation (AF) is the most common supraventricular arrhythmia, with a rapidly increasing prevalence. T2DM has been closely associated with the risk of AF development, identified as an independent risk factor. Regarding cardio-vascular complications, both AF and T2DM have been linked with high mortality. The underlying pathophysiology has not been fully determined yet; however, it is multifactorial, including structural, electrical, and autonomic pathways. Novel therapies include pharmaceutical agents in sodium-glucose cotransporter-2 inhibitors, as well as antiarrhythmic strategies, such as cardioversion and ablation. Of interest, glucose-lowering therapies may affect the prevalence of AF. This review presents the current evidence regarding the connection between the two entities, the pathophysiological pathways that link them, and the therapeutic options that exist.

Atrial Fibrillation and Diabetes Mellitus: Dangerous Liaisons or Innocent Bystanders?

Atrial fibrillation (AF) is the most common arrhythmia in adults and diabetes mellitus (DM) is a major risk factor for cardiovascular diseases. However, the relationship between both pathologies has not been fully documented and new evidence supports the existence of direct and independent links. In the myocardium, a combination of structural, electrical, and autonomic remodeling may lead to AF. Importantly, patients with AF and DM showed more dramatic alterations than those with AF or DM alone, particularly in mitochondrial respiration and atrial remodeling, which alters conductivity, thrombogenesis, and contractile function. In AF and DM, elevations of cytosolic Ca²⁺ and accumulation of extra cellular matrix (ECM) proteins at the interstitium can promote delayed afterdepolarizations. The DM-associated low-grade inflammation and deposition/infiltration of epicardial adipose tissue (EAT) enforce abnormalities in Ca²⁺ handling and in excitation-contraction coupling, leading to atrial myopathy. This atrial enlargement and the reduction in passive emptying volume and fraction can be key for AF maintenance and re-entry. Moreover, the stored EAT can prolong action of potential durations and progression from paroxysmal to persistent AF. In this way, DM may increase the risk of thrombogenesis as a consequence of increased glycation and oxidation of fibrinogen and plasminogen, impairing plasmin conversion and resistance to fibrinolysis. Additionally, the DM-associated autonomic remodeling may also initiate AF and its re-entry. Finally, further evidence of DM influence on AF development and maintenance are based on the anti-arrhythmogenic effects of certain anti-diabetic drugs like SGLT2 inhibitors. Therefore, AF and DM may share molecular alterations related to Ca²⁺ mobility, mitochondrial function and ECM composition that induce atrial remodeling and defects in autonomic stimulation and conductivity. Likely, some specific therapies could work against the associated cardiac damage to AF and/or DM.

Role of purinergic receptors in cardiac sympathetic nerve injury in diabetes mellitus

Diabetic cardiac autonomic neuropathy is a common and serious chronic complication of diabetes, which can lead to sympathetic and parasympathetic nerve imbalance and a relative excitation of the sympathetic nerve. Purinergic receptors play a crucial role in this process. Diabetic cardiac sympathetic nerve injury affects the expression of purinergic receptors, and activated purinergic receptors affect the phosphorylation of different signaling pathways and the regulation of inflammatory processes. This paper introduces the abnormal changes of sympathetic nerve in diabetes mellitus and summarizes the recently published studies on the role of several purinergic receptor subtypes in diabetic cardiac sympathetic nerve injury. These studies suggest that purinergic receptors as novel drug targets are of great significance for the treatment of diabetic autonomic neuropathy. This article is part of the Special Issue on "Purinergic Signaling: 50 years".

Neuromodulation therapy for atrial fibrillation

Atrial fibrillation has a multifactorial pathophysiology influenced by cardiac autonomic innervation. Both sympathetic and parasympathetic influences are profibrillatory. Innovative therapies targeting the neurocardiac axis include catheter ablation or pharmacologic suppression of ganglionated plexi, renal sympathetic denervation, low-level vagal stimulation, and stellate ganglion blockade. To date, these therapies have variable efficacy. As our understanding of atrial fibrillation and the cardiac nervous system expands, our approach to therapeutic neuromodulation will continue evolving for the benefit of those with AF.

Prediabetes Is Associated With Increased Risk of Heart Failure Among Patients With Atrial Fibrillation

OBJECTIVE

To evaluate the association between prediabetes and heart failure (HF) and the association of HF with changes in glycemic status.

RESEARCH DESIGN AND METHODS

Patients newly diagnosed with atrial fibrillation (AF) between 2015 and 2018 were divided into three groups (normoglycemia, prediabetes, and type 2 diabetes) according to their baseline glycemic status. The primary outcome was incident HF. The Fine and Gray competing risks model was applied, with death defined as the competing event.

RESULTS

Among 17,943 patients with AF (mean age 75.5 years, 47% female), 3,711 (20.7%) had prediabetes, and 10,127 (56.4%) had diabetes at baseline. Over a median follow-up of 4.7 years, HF developed in 518 (14%) patients with normoglycemia, 646 (15.7%) with prediabetes, and 1,795 (17.7%) with diabetes. Prediabetes was associated with an increased risk of HF compared with normoglycemia (subdistribution hazard ratio [SHR] 1.12, 95% CI 1.03-1.22). In patients with prediabetes at baseline, 403 (11.1%) progressed to diabetes, and 311 (8.6%) reversed to normoglycemia at 2 years. Compared with remaining prediabetic, progression to diabetes was associated with an increased risk of HF (SHR 1.50, 95% CI 1.13-1.97), whereas reversion to normoglycemia was associated with a decreased risk (SHR 0.61, 95% CI 0.42-0.94).

CONCLUSIONS

Prediabetes was associated with an increased risk of HF in patients with AF. Compared with patients who remained prediabetic, those who progressed to diabetes at 2 years experienced an increased risk of HF, whereas those who reversed to normoglycemia incurred a lower risk of HF.

A New Hope: Sodium-Glucose Cotransporter-2 Inhibition to Prevent Atrial Fibrillation

Atrial arrhythmias are common in patients with diabetes mellitus (DM), and despite recent advances in pharmaceutical and invasive treatments, atrial fibrillation (AF) and atrial flutter (AFl) are still associated with substantial mortality and morbidity. Clinical trial data imply a protective effect of sodium-glucose cotransporter-2 inhibitors (SGLT2is) on the occurrence of AF and AFl. This review summarizes the state of knowledge regarding DM-mediated mechanisms responsible for AF genesis and recurrence but also discusses the recent data from experimental studies, published trials and metanalyses.

Management of atrial fibrillation: two decades of progress - a scientific statement from the European Cardiac Arrhythmia Society

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades.

RESULTS

Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction.

CONCLUSIONS

Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.

An Overview of the Cardiorenal Protective Mechanisms of SGLT2 Inhibitors

Sodium-glucose co-transporter 2 (SGLT2) inhibitors block glucose reabsorption in the renal proximal tubule, an insulin-independent mechanism that plays a critical role in glycemic regulation in diabetes. In addition to their glucose-lowering effects, SGLT2 inhibitors prevent both renal damage and the onset of chronic kidney disease and cardiovascular events, in particular heart failure with both reduced and preserved ejection fraction. These unexpected benefits prompted changes in treatment guidelines and scientific interest in the underlying mechanisms. Aside from the target effects of SGLT2 inhibition, a wide spectrum of beneficial actions is described for the kidney and the heart, even though the cardiac tissue does not express SGLT2 channels. Correction of cardiorenal risk factors, metabolic adjustments ameliorating myocardial substrate utilization, and optimization of ventricular loading conditions through effects on diuresis, natriuresis, and vascular function appear to be the main underlying mechanisms for the observed cardiorenal protection. Additional clinical advantages associated with using SGLT2 inhibitors are antifibrotic effects due to correction of inflammation and oxidative stress, modulation of mitochondrial function, and autophagy. Much research is required to understand the numerous and complex pathways involved in SGLT2 inhibition. This review summarizes the current known mechanisms of SGLT2-mediated cardiorenal protection.

Sympathovagal Balance Is a Strong Predictor of Post High-Volume Endurance Exercise Cardiac Arrhythmia

Regular physical activity is important for cardiovascular health. However, high-volume endurance exercise has been associated with increased number of electrocardiogram (ECG) abnormalities, including disturbances in cardiac rhythm (arrhythmias) and abnormalities in ECG pattern. The aim of this study was to assess if heart rate variability (HRV) is associated with ECG abnormalities. Fifteen participants with previous cycling experience completed a 21-day high-volume endurance exercise cycle over 3,515 km. Participants wore a 5-lead Holter monitor for 24 h pre- and post-exercise, which was used to quantify ECG abnormalities and export sinus R-to-R intervals (NN) used to calculate HRV characteristics. As noise is prevalent in 24-h HRV recordings, both 24-h and heart rate collected during stable periods of time (i.e., deep sleep) were examined. Participants experienced significantly more arrhythmias post high-volume endurance exercise (median = 35) compared to pre (median = 12; p = 0.041). All 24-h and deep sleep HRV outcomes were not different pre-to-post high-volume endurance exercise (p &gt; 0.05). Strong and significant associations with arrhythmia number post-exercise were found for total arrhythmia (total arrhythmia number pre-exercise, ρ = 0.79; age, ρ = 0.73), supraventricular arrhythmia (supraventricular arrhythmia number pre-exercise: ρ = 0.74; age: ρ = 0.66), and ventricular arrhythmia (age: ρ = 0.54). As a result, age and arrhythmia number pre-exercise were controlled for in hierarchical regression, which revealed that only deep sleep derived low frequency to high frequency (LF/HF) ratio post high-volume endurance exercise predicted post total arrhythmia number (B = 0.63, R2Δ = 34%, p = 0.013) and supraventricular arrhythmia number (B = 0.77, R2Δ = 69%, p &lt; 0.001). In this study of recreationally active people, only deep sleep derived LF/HF ratio was associated with more total and supraventricular arrhythmias after high-volume endurance exercise. This finding suggests that measurement of sympathovagal balance during deep sleep might be useful to monitor arrhythmia risk after prolonged high-volume endurance exercise performance.

Glycemic control and atrial fibrillation: an intricate relationship, yet under investigation

Atrial fibrillation (AF) and diabetes mellitus (DM) constitute two major closely inter-related chronic cardiovascular disorders whose concurrent prevalence rates are steadily increasing. Although, the pathogenic mechanisms behind the AF and DM comorbidity are still vague, it is now clear that DM precipitates AF occurrence. DM also affects the clinical course of established AF; it is associated with significant increase in the incidence of stroke, AF recurrence, and cardiovascular mortality. The impact of DM on AF management and prognosis has been adequately investigated. However, evidence on the relative impact of glycemic control using glycated hemoglobin levels is scarce. This review assesses up-to-date literature on the association between DM and AF. It also highlights the usefulness of glycated hemoglobin measurement for the prediction of AF and AF-related adverse events. Additionally, this review evaluates current anti-hyperglycemic treatment in the context of AF, and discusses AF-related decision-making in comorbid DM. Finally, it quotes significant remaining questions and sets some future strategies with the potential to effectively deal with this prevalent comorbidity.

Does left atrial epicardial conduction time reflect atrial fibrosis and the risk of atrial fibrillation recurrence after thoracoscopic ablation? Post hoc analysis of the AFACT trial

OBJECTIVES

To determine the association between left atrial epicardial conduction time (LAECT), fibrosis and atrial fibrillation (AF) recurrence after thoracoscopic surgical ablation of persistent AF.

SETTING

Single tertiary care centre in the Netherlands.

PARTICIPANTS

Patients with persistent AF from the randomised Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery (AFACT)-trial were included. Patients eligible for thoracoscopic AF ablation were included, full inclusion and exclusion criteria were previously published. All patients underwent thoracoscopic ablation, encompassing pulmonary vein isolation with an additional roof and trigone lesion. In patients with conduction block across the roof and trigone lesion, LAECT was measured. LAECT was defined as the time to local activation at one side of the roofline on pacing from the opposite side. Collagen fibre density was quantified from left atrial appendage histology.

OUTCOME MEASURES

Primary outcome: AF recurrence during 2 years of follow-up.

RESULTS

121 patients were included, of whom 35(29%) were women, age was 60.4±7.8 and 51% (62) had at least one AF recurrence during 2 years of follow-up. LAECT was longer in patients with versus without AF recurrence (182±43 ms vs 147±29 ms, p<0.001). LAECT was longer in older patients, in patients with a higher body mass index (BMI) and in patients using class IC antiarrhythmic drugs. LAECT was shorter in patients with higher collagen fibre density. A previously failed catheter ablation, LAECT and BMI were independently associated with AF recurrence.

CONCLUSION

LAECT is correlated with collagen fibre density and BMI and is independently associated with AF recurrence in patients with persistent AF. In these patients, LAECT appears to reflect substrate characteristics beyond clinical AF type and left atrial volume.

TRIAL REGISTRATION NUMBER

NCT01091389.

Association of Diabetes With Atrial Fibrillation Phenotype and Cardiac and Neurological Comorbidities: Insights From the Swiss-AF Study

Background

Diabetes is a major risk factor for atrial fibrillation (AF). However, it remains unclear whether individual AF phenotype and related comorbidities differ between patients who have AF with and without diabetes. This study investigated the association of diabetes with AF phenotype and cardiac and neurological comorbidities in patients with documented AF.

Methods and Results

Participants in the multicenter Swiss‐AF (Swiss Atrial Fibrillation) study with data on diabetes and AF phenotype were eligible. Primary outcomes were parameters of AF phenotype, including AF type, AF symptoms, and quality of life (assessed by the European Quality of Life‐5 Dimensions Questionnaire [EQ‐5D]). Secondary outcomes were cardiac (ie, history of hypertension, myocardial infarction, and heart failure) and neurological (ie, history of stroke and cognitive impairment) comorbidities. The cross‐sectional association of diabetes with these outcomes was assessed using logistic and linear regression, adjusted for age, sex, and cardiovascular risk factors. We included 2411 patients with AF (27.4% women; median age, 73.6 years). Diabetes was not associated with nonparoxysmal AF (odds ratio [OR], 1.01; 95% CI, 0.81–1.27). Patients with diabetes less often perceived AF symptoms (OR, 0.74; 95% CI, 0.59–0.92) but had worse quality of life (β=−4.54; 95% CI, −6.40 to −2.68) than those without diabetes. Patients with diabetes were more likely to have cardiac (hypertension [OR, 3.04; 95% CI, 2.19–4.22], myocardial infarction [OR, 1.55; 95% CI, 1.18–2.03], heart failure [OR, 1.99; 95% CI, 1.57–2.51]) and neurological (stroke [OR, 1.39, 95% CI, 1.03–1.87], cognitive impairment [OR, 1.75, 95% CI, 1.39–2.21]) comorbidities.

Conclusions

Patients who have AF with diabetes less often perceive AF symptoms but have worse quality of life and more cardiac and neurological comorbidities than those without diabetes. This raises the question of whether patients with diabetes should be systematically screened for silent AF.

Registration

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02105844.

High Job Burnout Predicts Low Heart Rate Variability in the Working Population after a First Episode of Acute Coronary Syndrome

(1) Background: Job burnout may affect the prognosis of patients with acute coronary syndrome (ACS) through mechanisms involving heart rate variability (HRV). However, no study has yet examined those potential associations. Hence, we conducted the present study to investigate this issue. (2) Method: Participants included patients who presented with a first episode of ACS and who were employed. The Copenhagen Burnout Inventory (CBI) was used to assess job burnout. Twenty-four-hour ambulatory electrocardiography recorded HRV on four occasions, i.e., during the hospitalization and follow-ups at one, six, and 12 months, respectively. (3) Results: A total of 120 participants who at least completed three Holter examinations throughout the study were enrolled in the final analysis. Job burnout scores at baseline were inversely associated with LnSDNN, LnTP, LnHF, LnLF, LnULF, and LnVLF during the consequent one-year follow-up. Each 1 SD increase in job burnout scores predicted a decline ranging from 0.10 to 0.47 in the parameters described above (all p < 0.05), and all relationships were independent of numerous confounders, including anxiety and depression. (4) Conclusion: High job burnout predicted reduced HRV parameters during the one-year period post-ACS in the working population.

Targeting the Autonomic Nervous System for Risk Stratification, Outcome Prediction and Neuromodulation in Ischemic Stroke

Ischemic stroke is a worldwide major cause of mortality and disability and has high costs in terms of health-related quality of life and expectancy as well as of social healthcare resources. In recent years, starting from the bidirectional relationship between autonomic nervous system (ANS) dysfunction and acute ischemic stroke (AIS), researchers have identified prognostic factors for risk stratification, prognosis of mid-term outcomes and response to recanalization therapy. In particular, the evaluation of the ANS function through the analysis of heart rate variability (HRV) appears to be a promising non-invasive and reliable tool for the management of patients with AIS. Furthermore, preclinical molecular studies on the pathophysiological mechanisms underlying the onset and progression of stroke damage have shown an extensive overlap with the activity of the vagus nerve. Evidence from the application of vagus nerve stimulation (VNS) on animal models of AIS and on patients with chronic ischemic stroke has highlighted the surprising therapeutic possibilities of neuromodulation. Preclinical molecular studies highlighted that the neuroprotective action of VNS results from anti-inflammatory, antioxidant and antiapoptotic mechanisms mediated by α7 nicotinic acetylcholine receptor. Given the proven safety of non-invasive VNS in the subacute phase, the ease of its use and its possible beneficial effect in hemorrhagic stroke as well, human studies with transcutaneous VNS should be less challenging than protocols that involve invasive VNS and could be the proof of concept that neuromodulation represents the very first therapeutic approach in the ultra-early management of stroke.

Effect of antidiabetic drugs on the risk of atrial fibrillation: mechanistic insights from clinical evidence and translational studies

Diabetes mellitus (DM) is an independent risk factor for atrial fibrillation (AF), which is the most common sustained arrhythmia and is associated with substantial morbidity and mortality. Advanced glycation end product and its receptor activation, cardiac energy dysmetabolism, structural and electrical remodeling, and autonomic dysfunction are implicated in AF pathophysiology in diabetic hearts. Antidiabetic drugs have been demonstrated to possess therapeutic potential for AF. However, clinical investigations of AF in patients with DM have been scant and inconclusive. This article provides a comprehensive review of research findings on the association between DM and AF and critically analyzes the effect of different pharmacological classes of antidiabetic drugs on AF.

The "Road" to Atrial Fibrillation: The Role of the Cardiac Autonomic Nervous System

At the population level, there is a parallel escalation in the healthcare burden of both, atrial fibrillation (AF) as well its risk factors. Compounding this relationship, AF is associated with escalating burden at an individual level, due its self-perpetuating and progressive nature. The mechanisms by which these risk factors interact to produce atrial remodelling and subsequent AF are unclear. This intersection is critical to the development of strategies to combat this disease at both the individual and population-level. It is well known that AF can manifest from disturbances in autonomic activity. At the population level, there is growing data to suggest a role of the autonomic nervous system in the future incidence of AF. Here, we provide an overview of the association of cardiac autonomic dysfunction with the incidence of AF, review the role of the autonomic nervous system (ANS) as an intermediary between risk factors and the development of AF and finally, we discuss the bidirectional relationship between AF and cardiac autonomic nervous system dysfunction; to determine whether this is implicated in the progression of AF.

Stroke prevention and guideline adherent antithrombotic treatment in elderly patients with atrial fibrillation: A real-world experience

Patients aged ≥75 years with the diagnosis of atrial fibrillation (AF) are at a higher risk of stroke and, according to recent recommendations, should receive oral anticoagulant (OAC) therapy. This study aimed to assess the recommended prophylactic antithrombotic therapy among patients with AF aged ≥ 75 years and its compliance with current guidelines. We also aimed to identify predisposing factors associated with the administration of non-vitamin K antagonist oral anticoagulants (NOACs) in elderly patients with AF.This was a retrospective, single-center observational study. Patients with AF aged ≥75 years hospitalized at a reference cardiology center from 2014 to 2017 were included in the analysis.Among the 1236 eligible patients (43.4% male; mean age, 82 years), OACs were recommended in 90.1% of cases. Of these, 59.8% of patients used NOACs and 40.2% used vitamin K antagonists. Additionally, 3.3% of patients received antiplatelet (AP) therapy and 2.5% were administered low molecular weight heparin. Only 4.5% of patients did not receive any anticoagulant treatment. The majority (89.9%) of patients received relevant prophylactic antithrombotic therapy according to current guidelines; only 1.4% were overtreated and 8.7% were undertreated. The significant predictors of NOAC therapy among patients treated with anticoagulants were non-permanent AF (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.30-2.18, P = .0001), age-by 5 years (OR = 1.33, 95% CI = 1.16-1.52, P = .0001), and glomerular filtration rate-by 5 units (OR = 1.06, 95% CI = 1.02-1.10, P = .0066).A high percentage of AF patients aged ≥75 years receive OACs, mainly NOACs. Most patients are treated according to the current guidelines; under treatment is primarily observed in patients receiving AP therapy. Non-permanent AF, age, and preservation of renal function are significant predictors of NOAC use.

Atrial Fibrillation and Diabetes Mellitus: JACC Review Topic of the Week

Diabetes mellitus is one of the most common chronic medical conditions, and is a risk factor for the development of atrial fibrillation (AF). The presence of diabetes in patients with AF is associated with increased symptom burden and increased cardiovascular and cerebrovascular mortality. The pathophysiology of diabetes-related AF is not fully understood, but is related to structural, electrical, electromechanical, and autonomic remodeling. This paper reviews the complex interaction between diabetes and AF, and explores its effect on the prevention and treatment of AF.

Usefulness of P Wave Duration in Embolic Stroke of Undetermined Source

The investigation of the potential association between ischemic stroke and subclinical atrial fibrillation (SCAF) is important for secondary prevention. We aimed to determine whether SCAF can be predicted by atrial substrate measurement with P wave signal-averaged electrocardiography (SAECG). We recruited 125 consecutive patients with embolic stroke of undetermined source (ESUS) and 125 patients with paroxysmal atrial fibrillation as controls. All participants underwent P wave SAECG at baseline, and patients with ESUS were followed up with Holter monitoring and electrocardiography at baseline, 3, 6, and 12 months after discharge and every 6 months thereafter. In the ESUS group, 32 (25.6%) patients were diagnosed with SCAF during follow-up. There were no significant differences between the groups regarding atrial substrate. P wave duration (PWD) was a significant predictor of SCAF. Stroke recurrence occurred in 22 patients (17.6%), and prolonged PWD (≥ 135 ms) predicted stroke recurrence more robustly than SCAF detection. In ESUS patients, PWD can be a useful biomarker to predict SCAF and to identify patients who are more likely to have a recurrent embolic stroke associated with an atrial cardiopathy. Further research is needed for supporting the utility and applicability of PWD.

Combination of Composite Autonomic Symptom Score 31 and Heart Rate Variability for Diagnosis of Cardiovascular Autonomic Neuropathy in People with Type 2 Diabetes

OBJECTIVE

Cardiovascular autonomic neuropathy (CAN) is a common but severe problem of diabetes, which a timely diagnosis may have important clinical implications. This study was carried out to investigate the diagnostic performance of Composite Autonomic Symptom Score 31 (COMPASS 31) combined with heart rate variability (HRV) for cardiovascular autonomic neuropathy in type 2 diabetes.

METHODS

A total of 103 hospitalized subjects with type 2 diabetes were recruited in the study. All cases received clinical data collection, laboratory examination, and related complication examinations. Cardiovascular autonomic function was assessed using CARTs, COMPASS 31, and HRV analyses. A score of at least 2 based on CARTs was defined as CAN.

RESULTS

Of the 103 subjects with type 2 diabetes, 41.8% were diagnosed with confirmed CAN. Participants with CAN had considerably higher COMPASS 31 scores. The CAN group showed a significant decrease in all HRV indices. COMPASS 31 scores and HRV indices were closely correlated with CARTs (P < 0.05). Receiver operating characteristics (ROC) curve results showed that COMPASS 31 score identified CAN with an AUC value of 0.816, while the AUC values of HRV indices were 0.648 to 0.919, among which SDNN and LF had the best diagnostic value, with the AUC values of 0.919 and 0.865, respectively. When combining COMPASS 31 score with SDNN and LF, the AUC value increased to 0.958, with a sensitivity of 90.7% and a specificity of 86.7%.

CONCLUSIONS

The combination of COMPASS 31 and HRV could improve the diagnostic performance of CAN in type 2 diabetes, which might be conducive to the diagnosis of CAN.

Atrial fibrillation-related stroke in women: Evidence and inequalities in epidemiology, mechanisms, clinical presentation, and management

Background

Atrial fibrillation (AF) is the most common clinical arrhythmia and one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity. Despite substantial advances in (interventional) rhythm control treatment during the last decade, anticoagulation for stroke prevention remains a major component of AF treatment.

Hypothesis

There are important sex‐specific differences in AF‐related stroke, resulting from sex‐specific mechanisms and therapeutic differences.

Methods

This review summarizes available data on sex differences in risk assessment and prevention of stroke and highlights current knowledge gaps in AF‐related stroke mechanisms, prevention and management that warrant further research.

Results

Increased thrombotic risk in women is multifactorial, involving hormonal changes after menopause, structural, endocrine and lifestyle/social factors and their interactions. It is clear from randomized studies that women benefit from anticoagulant treatment and that their bleeding risk is similar to men. Women should therefore receive equivalent treatment to men, based on the validated criteria for anticoagulation therapy. However, women are not represented equally in the large randomized studies and sex‐related information in many fields is lacking.

Conclusions

Female sex is an established risk factor for stroke in AF patients. The evidence for sex‐specific differences in stroke risk assessment and stroke prevention is accumulating. However, the underlying biological mechanisms remain incompletely understood and further studies are required in order to decrease AF‐related morbidity and mortality.

Is ablation to atrial fibrillation termination of persistent atrial fibrillation the end point?: A systematic review and meta-analysis

BACKGROUND

The ideal ablation strategy and end point for persistent atrial fibrillation (AF) have not been well founded. Defining periprocedural AF termination as the end point of catheter ablation is still controversial. This meta-analysis aimed to analyze the differences between periprocedural AF termination and non-termination in the long-term AF recurrence rate and postoperative complications.

METHODS

Randomized controlled trials (RCTs) were identified by a systematic search of electronic databases including PubMed, EMBASE, and Cochrane library from January 2008 to August 2019. The primary outcome was freedom from AF or any atrial arrhythmia without antiarrhythmic drugs at the long-term (≥12 months) follow-up. The secondary outcome was overall postoperative complication rates. The risk ratio (RR) with 95% confidence interval (CI) was pooled for these outcomes. A forest plot, fixed-effects model or random-effect model, Q test, I statistic, and Egger funnel plot were used in the statistical analysis.

RESULTS

Fourteen RCTs were included in this meta-analysis. Overall, no significant difference was found in freedom from AF at the long-term follow-up between patients in whom AF termination was achieved and not achieved (RR = 0.93, 95% CI = 0.78-1.09, P = .36, I = 69%). Patients with AF non-termination had a lower complication occurrence rate than those with AF termination (RR = 1.74, 95% CI = 1.11-2.73, P = .02, I = 0%).

CONCLUSION

Our meta-analysis suggests that AF termination is not a reliable procedural end point during ablation of persistent AF.

Pathological Role of Advanced Glycation End Products (AGEs) and their Receptor Axis in Atrial Fibrillation

Accumulating evidence has shown that the incidence of atrial fibrillation (AF) is higher in patients with diabetes, especially those with poor glycemic control or long disease duration. Nonenzymatic glycation of amino acids of proteins, lipids, and nucleic acids has progressed under normal aging process and/or diabetic condition, which could lead to the formation and accumulation of advanced glycation end products (AGEs). AGEs not only alter the tertiary structure and physiological function of macromolecules, but also evoke inflammatory and fibrotic reactions through the interaction of cell surface receptor for AGEs (RAGE), thereby being involved in aging-related disorders. In this paper, we briefly review the association of chronic hyperglycemia and type 1 diabetes with the risk of AF and then discuss the pathological role of AGE-RAGE axis in AF and its thromboembolic complications.

Recurrent event survival analysis predicts future risk of hospitalization in patients with paroxysmal and persistent atrial fibrillation

Background

In patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PeAF) symptom burden and fear of hospital readmission are major causes of reduced quality of life. We attempted to develop a prediction model for future atrial fibrillation hospitalization (AFH) risk in PAF and PeAF patients including all previously experienced AFHs in the analysis, as opposed to time to first event.

Methods

Recurrent event survival analysis was used to model the impact of past AFHs on the risk of future AFHs. A recurrent event was defined as a hospitalization due to a new episode of AF. Death or progression to permanent AF were included as competing risks.

Results

We enrolled 174 patients with PAF or PeAF, mean follow up duration was 1279 days, and 325 AFHs were observed. Median patient age was 63.0 (IQR 52.2–68.0), 29% had PAF, and 71% were male. Highly significant predictors of future AFH risk were PeAF (HR 3.20, CI 2.01–5.11) and number of past AFHs observed (HR for 1 event: 2.97, CI 2.04–4.32, HR for ≥2 events: 7.54, CI 5.47–10.40).

Conclusion

In PAF and PeAF patients, AF type and observed AFH frequency are highly significant predictors of future AFH risk. The developed model enables risk prediction in individual patients based on AFH history and baseline characteristics, utilizing all events experienced by the patient. This is the first time recurrent event survival analysis has been used in AF patients.

Cardiac syncope recurrence in type 2 diabetes mellitus patients vs. normoglycemics patients: The CARVAS study

STUDY HYPOTHESIS

Cardiac autonomic dysfunction might lead to higher vaso vagal syncope (VVS) recurrence rate in type 2 diabetes mellitus (T2DM) patients vs. non diabetics patients.

BACKGROUND

VVS recurrence might be due to alterations of autonomic system function, as assessed by heart rate variability (HRV). To date, in this study we investigated the correlation between HRV alterations and VVS recurrence at 12 months of follow up in T2DM vs. non T2DM patients.

MATERIALS AND METHODS

In a prospective multicenter study we studied a propensity score matching (PSM) analysis of 121 T2DM vs. 121 non T2DM patients affected by VVS.

RESULTS

T2DM vs. non T2DM patients had at baseline a higher rate of HRV dysfunction, and this was linked to higher rate of VVS recurrence at 12 months of follow up (p < 0.05). Blood pressure alterations and lower LF/HF ratio were linked to higher rate of all cause syncope recurrence, and of vasodepressor, cardio inhibitory, and mixed syncope recurrence (p < 0.05). Anti hypertensive drug therapies increased the number of vasodepressor and mixed syncope events (p < 0.05); alterations of heart rate increased syncope recurrence and mixed syncope recurrence events (p < 0.05). Finally, T2DM was linked to higher rate of VVS recurrence, and specifically of vasodepressor and mixed VVS recurrence (p < 0.05).

CONCLUSIONS

T2DM patients have alterations of the autonomic nervous system, as result of cardiac autonomic neuropathy. However, T2DM diagnosis and autonomic dysfunction assessed by HRV alterations predicted VVS recurrence.

The Association Between Diabetes Mellitus and Atrial Fibrillation: Clinical and Mechanistic Insights

A number of clinical studies have reported that diabetes mellitus (DM) is an independent risk factor for Atrial fibrillation (AF). After adjustment for other known risk factors including age, sex, and cardiovascular risk factors, DM remains a significant if modest risk factor for development of AF. The mechanisms underlying the increased susceptibility to AF in DM are incompletely understood, but are thought to involve electrical, structural, and autonomic remodeling in the atria. Electrical remodeling in DM may involve alterations in gap junction function that affect atrial conduction velocity due to changes in expression or localization of connexins. Electrical remodeling can also occur due to changes in atrial action potential morphology in association with changes in ionic currents, such as sodium or potassium currents, that can affect conduction velocity or susceptibility to triggered activity. Structural remodeling in DM results in atrial fibrosis, which can alter conduction patterns and susceptibility to re-entry in the atria. In addition, increases in atrial adipose tissue, especially in Type II DM, can lead to disruptions in atrial conduction velocity or conduction patterns that may affect arrhythmogenesis. Whether the insulin resistance in type II DM activates unique intracellular signaling pathways independent of obesity requires further investigation. In addition, the relationship between incident AF and glycemic control requires further study.

Catheter ablation of atrial fibrillation-A key role in heart failure therapy?

Atrial fibrillation (AF) and heart failure (HF) are epidemic cardiac diseases and are often detected in the same patient. Recent evidence suggests that this is not a mere coincidence but that the strategy of AF treatment may impact HF development. This review comprehensively summarizes current trial data on rhythm and rate control strategies in atrial fibrillation with a special focus on catheter ablation of AF in HF patients. For a long time, rate and rhythm control strategies for AF have been regarded as equal regarding long term mortality. Decision making has been based on the symptoms of patients. Current trials, however, show that the treatment strategy of AF and its effectiveness may significantly impact survival of HF patients. The benefits of rhythm control in HF patients may have been masked by side effects of antiarrhythmic drugs. If rhythm control, however, is achieved by catheter ablation, a reduction of HF related mortality can be observed. As catheter ablation of AF may reduce mortality in HF patients, AF ablation should be preferred over medical treatment in HF patients. In general, HF patients may profit most from rigorous AF treatment.

Early characteristics of fulminant myocarditis vs non-fulminant myocarditis: A meta-analysis

BACKGROUND

Fulminant myocarditis (FM) is a sub-category myocarditis. Its primary characteristic is a rapidly progressive clinical course that necessitates hemodynamic support. FM can be difficult to predict at the onset of myocarditis. The aim of this meta-analysis was to identify the early characteristics in FM compared to those of non-fulminant myocarditis (NFM).

METHODS

We searched the databases of MEDLINE, EMBASE, CENTRAL, for studies comparing FM with acute NFM from January 1, 2000 to June 1, 2018. The baseline variables were compared in each study. Mean differences (MD) and relative ratios (RR) were calculated.

RESULTS

Seven studies (158 FM patients and 388 NFM patients) were included in the analysis. The FM group had significantly lower systolic blood pressure (SBP), higher creatine kinase (CK), wider QRS duration, lower left ventricular ejection fraction (LVEF), thicker left ventricular posterior wall diameter (LVPWd), higher incidence of ST depression, ventricular tachycardia/ventricular fibrillation (Vt/Vf) and syncope, less incidence of chest pain than the NFM groups. There was no difference in terms of heart rate (HR), c-reactive protein (CRP), fever, dyspnea, white blood cells (WBC), atrioventricular block (AVB), Q waves, ST elevation, interventricular septum diameter (IVSd), or end-diastolic left ventricular diameter (LVEDd) between FM and NFM.

CONCLUSION

We found that the lower SBP, higher CK, wider QRS duration, lower LVEF, thicker LVPWd, higher incidence of ST depression, Vt/Vf and syncope as well as lower incidence of chest pain were early characteristics of FM.

The Role of the Autonomic Nervous System on Cardiac Rhythm during the Evolution of Diabetes Mellitus Using Heart Rate Variability as a Biomarker

Heart rate variability (HRV) is highly influenced by the Autonomic Nervous System (ANS). Several illnesses have been associated with changes in the ANS, thus altering the pattern of HRV. However, the variability of the heart rhythm is originated within the Sinus Atrial Node (SAN) which has its own variability. Still, although both oscillators produce HRV, the influence of the SAN on HRV has not yet been exhaustively studied. On the other hand, the complications of diabetes mellitus (DM), for instance, nephropathy, retinopathy, and neuropathy, increase cardiovascular morbidity and mortality. Traditionally, these complications are diagnosed only when the patient is already suffering from the negative symptoms these complications implicate. Consequently, it is of paramount importance to develop new techniques for early diagnosis prior to any deterioration on healthy patients. HRV has been proved to be a valuable, noninvasive clinical evidence for evaluating diseases and even for describing aging and behavior. In this study, several ECGs were recorded and their RR and PP intervals were analyzed to detect the interpotential interval (ii) of the SAN. Additionally, HRV reduction was quantified to identify alterations in the nervous system within the nodal tissue via measuring the SD1/SD2 ratio in a Poincaré plot. With 15 years of DM development, the data showed an age-dependent increase in HRV due to the axon retraction of ANS neurons from its effectors. In addition, these alterations modify the heart rhythm-producing fatal arrhythmias. Therefore, it is possible to avoid the consequences of DM identifying alterations in SAN previous to its symptomatic appearance. This could be used as an early diagnosis indicator.

Seizure-like activities in patients with head-up tilt test-induced syncope

The purpose of this study was to assess the prevalence and the characteristics of seizure-like activities during head-up tilt test (HUT)-induced syncope, in patients with suspected vasovagal syncope (VVS). We also evaluated the differences in hemodynamic parameters between patients with and without seizure-like activities.A total of 71 patients with suspected VVS, who showed syncope during HUT between October 2010 and May 2013, were analyzed. Electrocardiogram and hemodynamic parameters were continuously monitored during HUT. We also performed video recording of patients during HUT to identify eyeball deviation or seizure-like limb movements.In all, 47 patients (66.2%) showed seizure-like activities at the time of syncope during HUT, 14 patients presented eyeball deviation, without abnormal limb movements, and 33 patients showed abnormal limb movements, such as myoclonic or tonic-clonic activities, as well as eyeball deviation. Upon comparison of the 2 groups with or without seizure-like activities, patients showing seizure-like activities presented a significantly lower heart rate at the time of syncope in HUT (38.51 ± 16.81 vs 49.67 ± 20.12, P < .05). Also, upon comparison within patients showing seizure-like activities, the patients who showed abnormal limb movements with eyeball deviation demonstrated a significantly lower systolic blood pressure and cardiac output at the time of syncope (34.30 ± 12.24 vs 49.00 ± 14.14, P < .05; 0.58 ± 0.40 vs 1.32 ± 0.97, P < .05).Seizure-like activities were observed in high percentage in about 66% of patients during HUT-induced syncope. The occurrence of seizure-like activities was associated with more severe transient hemodynamic changes, such as lower heart rate, systolic blood pressure, and cardiac output at the time of the HUT-induced syncope.

2018 Korean Guideline of Atrial Fibrillation Management

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.

The safety and efficacy of second-generation cryoballoon ablation plus catheter ablation for persistent atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Growing evidence suggests that second-generation cryoballoon ablation (2G-CB) is effective in patients with persistent atrial fibrillation (PerAF). The cornerstone of atrial fibrillation (AF) ablation is pulmonary vein isolation (PVI). The purpose of this study was to summarize the available data on the safety and mid-term (≥ 12 months) effectiveness of a 'PVI-only' strategy vs. a 'PVI-plus' strategy using 2G-CB in patients with PerAF.

METHODS

We searched the PubMed, EMBASE and Cochrane library databases for studies on 2G-CB for PerAF. Group analysis was based on the ablation approach: 'PVI-only' versus 'PVI-plus', the latter of which involved PVI plus other substrate modifications. Studies showing clinical success rates at a follow-up (FU) of ≥ 12 months were included. Complication rates were also assessed. Data were analyzed by applying a fixed effects model.

RESULTS

A total of 879 patients from 5 studies were analyzed. After a mid-term FU of 27 months, the overall success rate of 2G-CB for PerAF was 66.1%. In the 'PVI-plus' group, the success rate was 73.8%. In the 'PVI-only' group, the success rate was 53.6%. No heterogeneity was noted among studies (I2 = 0.0%, P = 0.82). Complications occurred in 5.2% of patients (P = 0.93), and the rate of phrenic nerve (PN) injury was 2.8% (P = 0.14). Vascular assess complications were the most frequent at 1.6% (P = 0.33). No death or myocardial infarction was reported.

CONCLUSION

'PVI-plus' involving 2G-CB seems to be safe and effective for treating PerAF.

Atrial Fibrillation Recurrence and Peri-Procedural Complication Rates in nMARQ vs. Conventional Ablation Techniques: A Systematic Review and Meta-Analysis

Background and Objectives: Atrial fibrillation is a common abnormal cardiac rhythm caused by disorganized electrical impulses. AF which is refractory to antiarrhythmic management is often treated with catheter ablation. Recently a novel ablation system (nMARQ) was introduced for PV isolation. However, there has not been a systematic review of its efficacy or safety compared to traditional ablation techniques. Therefore, we conducted this meta-analysis on the nMARQ ablation system.

Methods: PubMed and EMBASE were searched up until 1st of September 2017 for articles on nMARQ. A total of 136 studies were found, and after screening, 12 studies were included in this meta-analysis.

Results: Our meta-analysis shows that the use of nMARQ was associated with higher odds of AF non-recurrence (n = 1123, odds ratio = 6.79, 95% confidence interval 4.01–11.50; P < 0.05; I² took a value of 83%). Moreover, the recurrence rate of AF using nMARQ was not significantly different from that of traditional ablation procedures (n = 158 vs. 196; OR = 0.97, 95% confidence interval:0.59–1.61). No significant difference in complication rates was observed between these groups (RR: 0.86; 95% CI: 0.37–1.99; P > 0.05). There were four reported mortalities in the nMARQ group compared to none in the conventional ablation group (relative risk: 1.58; 95% CI: 0.09–29.24; P > 0.05).

Conclusions: AF recurrence rates are comparable between nMARQ and conventional ablation techniques. Although general complication rates are similar for both groups, the higher mortality with nMARQ suggests that conventional techniques should be used for resistant AF until improved safety profiles of nMARQ can be demonstrated.

Percutaneous closure versus medical therapy for stroke with patent foramen Ovale: a systematic review and meta-analysis

BACKGROUND

Patent foramen ovale (PFO) closure has emerged as a secondary prevention option in patients with PFO and cryptogenic stroke. However, the comparative efficacy and safety of percutaneous closure and medical therapy in patients with cryptogenic stroke and PFO remain unclear.

METHODS

Randomized controlled trials (RCTs) and comparative observational studies that compared PFO closure against medical therapy, each with a minimal of 20 patients in the closure arm and 1-year follow-up were included.

RESULTS

We analyzed 6961 patients from 20 studies (5 RCTs and 15 observational studies) with a median follow-up of 3.1 years. Moderate-quality evidence showed that PFO closure was associated with a significantly lower incidence of the composite outcome of ischemic stroke, transient ischemic attack (TIA), or all-cause death (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.38 to 0.85; P = 0.006), mainly driven by lower incidence of stroke (OR: 0.39; 95% CI: 0.24 to 0.63; P < 0.001). The numbers needed to treat were 43 and 39 for the composite outcome and recurrent ischemic stroke respectively. PFO closure increased the risks for atrial fibrillation or atrial flutter (OR: 5.74; 95% CI: 3.08 to 10.70; P < 0.001; high-quality evidence) and pulmonary embolism (OR: 3.03; 95% CI: 1.06 to 8.63; P = 0.038; moderate-quality evidence), with the numbers needed to harm being 30 and 143 respectively. The risks for TIA, all-cause death, and major bleeding were not statistically different. Analyses limited to RCTs showed similar findings, as did a series of other subgroup analyses.

CONCLUSION

In conclusion, PFO closure reduced the incidences of stroke and the composite outcome of ischemic stroke, TIA, or all-cause death, but increased risks for atrial fibrillation or atrial flutter and pulmonary embolism compared with medical therapy.

Treatment of Human Urinary Kallidinogenase Combined with Maixuekang Capsule Promotes Good Functional Outcome in Ischemic Stroke

Aims: To evaluate the clinical efficacy of Human Urinary Kallidinogenase (HUK) and Maixuekang capsule in the treatment of acute ischemic stroke (AIS) patients.

Methods: In this study, from January 2016 to July 2016, 60 patients with acute ischemic stroke were enrolled and 56 patients with complete information of whom 21 patients received HUK+ basic treatment (HUK group), 16 patients received HUK+ Maixuekang capsule + basic treatment (HUK+ Maixuekang group), 19 patients received basic treatment (control group). 0.15 PNA unit of HUK injection plus 100 ml saline in intravenous infusion was performed in the HUK group and HUK+ Maixuekang group, with once a day for 14 consecutive days. 0.75 g Maixuekang capsules were taken in HUK+ Maixuekang group, with three times a day for 14 consecutive days. The National Institutes of Health Stroke Scale (NIHSS) scores in three groups were analyzed 7 days after treatment. The modified Rankin Scale (mRS) scores in three groups were analyzed 12 month after the treatment.

Results: No difference was found in the NIHSS scores, age, gender, and comorbidities between three groups before treatment (p > 0.05). Seven days after treatment, the NIHSS scores in the HUK group and HUK+ Maixuekang group were significantly decreased than before (p _HUK = 0.001, p _{HUK+Maixuekang} < 0.001), and lower than that in the control group (p _HUK = 0.032; p _{HUK+Maixuekang} < 0.001). Twelve months after treatment, good functional outcome rate (12 month mRS score ≤ 2) in the HUK group and HUK+ Maixuekang group was significantly higher than that in the control group (p _HUK = 0.049, p _{HUK+Maixuekang} = 0.032).

Conclusion: The treatment of HUK or HUK combined with Maixuekang capsule can effectively improve the neurological function and promote long-term recovery for AIS patients.

Diabetes and Associated Cardiovascular Complications in American Indians/Alaskan Natives: A Review of Risks and Prevention Strategies

Diabetes mellitus (DM) is the seventh leading cause of death in the United States and the leading cause of death in the U.S. American Indian/Alaskan Natives (AI/ANs), who comprise only 2% of the total population. The AI/AN population has a high prevalence of DM in adults aged 20 years or older and is developing DM at a younger age than the general U.S.

POPULATION

DM is a major risk factor for cardiovascular disease (CVD), and mortality from CVD is higher in AI/ANs than the general population, as is the prevalence of stroke and 1-year poststroke mortality for both genders when compared to non-Hispanic whites. A genome-wide scan found a number of chromosome linkages in the AI/AN population that suggest that genetic factors may contribute to their high risk of DM and CVD. Importantly, studies also suggest that in addition to race/ethnicity, cultural norms and historic conditions play important roles in the prevalence of DM and CVD in this population. Therefore, multiple factors should be taken into consideration when establishing prevention programs to decrease the prevalence of obesity, diabetes, and CVD incidence among adults and children in the AI/AN population. Prevention programs should focus on behavioral risk factors and lifestyle changes like encouraging smoking cessation, healthy diet, and increased physical activity while taking into consideration cultural, economic, and geographic factors.

Usefulness of HATCH score in the prediction of new-onset atrial fibrillation for Asians

The HATCH score (hypertension <1 point>, age >75 years <1 point>, stroke or transient ischemic attack <2 points>, chronic obstructive pulmonary disease <1 point>, and heart failure <2 points>) was reported to be useful for predicting the progression of atrial fibrillation (AF) from paroxysmal to persistent or permanent AF for patients who participated in the Euro Heart Survey. The goal of the current study was to investigate whether the HATCH score was a useful scheme in predicting new-onset AF. Furthermore, we aimed to use the HATCH scoring system to estimate the individual risk in developing AF for patients with different comorbidities. We used the "Taiwan National Health Insurance Research Database." From January 1, 2000, to December 31, 2001, a total of 670,804 patients older than 20 years old and who had no history of cardiac arrhythmias were enrolled. According to the calculation rule of the HATCH score, 599,780 (score 0), 46,661 (score 1), 12,892 (score 2), 7456 (score 3), 2944 (score 4), 802 (score 5), 202 (score 6), and 67 (score 7) patients were studied and followed for the new onset of AF. During a follow-up of 9.0 ± 2.2 years, there were 9174 (1.4%) patients experiencing new-onset AF. The incidence of AF was 1.5 per 1000 patient-years. The incidence increased from 0.8 per 1000 patient-years for patients with a HATCH score of 0 to 57.3 per 1000 patient-years for those with a HATCH score of 7. After an adjustment for the gender and comorbidities, the hazard ratio (95% confidence interval) of each increment of the HATCH score in predicting AF was 2.059 (2.027-2.093; P < 0.001). The HATCH score was useful in risk estimation and stratification of new-onset AF.

Global longitudinal strain predicts incident atrial fibrillation and stroke occurrence after acute myocardial infarction

Patients with acute myocardial infarction are at increased risk of developing atrial fibrillation. We aimed to evaluate whether speckle tracking echocardiography improves risk stratification for atrial fibrillation in these patients.The study comprised of 373 patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. Patients had an echocardiogram performed at a median of 2 days after their STEMI. The echocardiograms consisted of conventional measurements and myocardial strain analysis by speckle tracking from 3 apical projections. The endpoint was a composite of new-onset atrial fibrillation and ischemic stroke. At a median follow-up time of 5.5 years (interquartile range 4.9, 6.1 years), 44 patients developed the endpoint (atrial fibrillation: n = 24, ischemic stroke: n = 24, both: n = 4). Patients who reached the endpoint had significantly reduced systolic function by the left ventricular ejection fraction (LVEF) (43% vs 46%; P = 0.042) and global longitudinal strain (10.9% vs 12.6%; P = 0.004), both being univariable predictors. However, only global longitudinal strain remained a significantly independent predictor (hazard ratio 1.12, 95% confidence interval 1.00; 1.25, P = 0.042, per 1% decrease) after multivariable adjustment for baseline predictors (age, sex, diabetes, hypertension, diastolic dysfunction, and LVEF) using Cox regression. Furthermore, global longitudinal strain resulted in significantly higher c-statistics for prediction of outcome compared with LVEF <45% (0.63 vs 0.52; P = 0.026). When stratified into tertiles of global longitudinal strain, it became evident that patients in the lowest tertile mediated this signal with a 2-fold increased risk compared with the highest tertile (hazard ratio 2.10, 95% confidence interval 1.04; 4.25).Global longitudinal strain predicts atrial fibrillation after STEMI and may add valuable information which can help facilitate arrhythmia detection in these patients.

New-onset ventricular arrhythmias post radiofrequency catheter ablation for atrial fibrillation

As a new complication, new-onset ventricular arrhythmias (VAs) post atrial fibrillation (AF) ablation have not been well defined. This prospective study aimed to describe the details of new-onset VAs post AF ablation in a large study cohort.One thousand fifty-three consecutive patients who underwent the first radiofrequency catheter ablation for AF were enrolled. All patients had no evidence of pre-ablation VAs. New-onset VAs were defined as new-onset ventricular tachycardia (VT) or premature ventricular contractions (PVC) ≥1000/24 h within 1 month post ablation.There were 46 patients (4.4%) who had 62 different new-onset VAs, among whom 42 were PVC alone, and 4 were PVC coexisting with nonsustained VT. Multivariate analysis showed that increased serum leukocyte counts ≥50% post ablation were independently associated with new-onset VAs (OR: 1.9; 95% CI: 1.0-3.5; P = 0.043). The median number of PVC was 3161 (1001-27,407) times/24 h. Outflow tract VAs were recorded in 35 (76.1%) patients. No significant differences were found in origin of VAs (P = 0.187). VAs disappeared without any treatment in 6 patients (13.0%). No VAs-related adverse cardiac event occurred.The study revealed a noticeable prevalence but relatively benign prognosis of new-onset VAs post AF ablation. Increased serum leukocyte counts ≥50% post ablation appeared to be associated with new-onset VAs, implying that inflammatory response caused by ablation might be the mechanism.

A meta-analysis for efficacy and safety evaluation of transcatheter left atrial appendage occlusion in patients with nonvalvular atrial fibrillation

OBJECTIVES

This meta-analysis was conducted to evaluate the efficacy and safety of transcatheter left atrial appendage (LAA) occlusion in patients with nonvalvular atrial fibrillation.

METHODS

The randomized controlled trials (RCT) or observational studies with any transcatheter LAA occlusion devices were searched in PubMed, Embase, and Cochrane library from inception to November 2015. The incidence rates from individual studies were combined to evaluate the procedural efficacy and safety, including all-cause death, cardiac/neurological death, stroke, transient ischemic attack (TIA), thrombosis, hemorrhagic complications, and pericardial effusion/tamponade.

RESULTS

Thirty-eight studies involving 3585 patients and 6 different occlusion devices were eligible for our inclusion criteria. The procedural failure rate for LAA closure was 0.02 (95% CI: 0.02-0.03). The all-cause mortality was 0.03 (95% CI: 0.02-0.03) and cardiac/neurological mortality was 0 (95% CI: 0.00-0.01). The stroke/TIA rate was estimated only 0.01 (95% CI: 0.01-0.01). The incidence of thrombus on devices was 0.01 (95% CI: 0.01-0.02). The major hemorrhagic complication rate was estimated 0.01 (95% CI: 0.00-0.01). Pericardial effusion/tamponade was estimated 0.02 (95% CI: 0.02-0.03). No heterogeneity was observed for above pooled estimates (I = 0). In devices subgroups analysis, the all-cause mortality and cardiac/neurological mortality of PLAATO group were the highest (P = 0.01 and P < 0.01 respectively), whereas the incidence of thrombus on devices in the ACP group was the highest (P < 0.01). In follow-up period subgroups analysis, there were significant differences in all-cause death, stroke/TIA, major hemorrhage, and pericardial effusion/tamponade events between the shorter and longer follow-up period subgroups (P < 0.05). However, the differences among the subgroups were numerically small.

CONCLUSIONS

the pooled data demonstrated that transcatheter LAA occlusion was effective and safe in the patients with nonvalvular atrial fibrillation who were not suitable for lifelong antithrombotic therapy.

KCNN2 polymorphisms and cardiac tachyarrhythmias

Potassium calcium-activated channel subfamily N member 2 (KCNN2) encodes an integral membrane protein that forms small-conductance calcium-activated potassium (SK) channels. Recent studies in animal models show that SK channels are important in atrial and ventricular repolarization and arrhythmogenesis. However, the importance of SK channels in human arrhythmia remains unclear. The purpose of the present study was to test the association between genetic polymorphism of the SK2 channel and the occurrence of cardiac tachyarrhythmias in humans. We enrolled 327 Han Chinese, including 72 with clinically significant ventricular tachyarrhythmias (VTa) who had a history of aborted sudden cardiac death (SCD) or unexplained syncope, 98 with a history of atrial fibrillation (AF), and 144 normal controls. We genotyped 12 representative tag single nucleotide polymorphisms (SNPs) across a 141-kb genetic region containing the KCNN2 gene; these captured the full haplotype information. The rs13184658 and rs10076582 variants of KCNN2 were associated with VTa in both the additive and dominant models (odds ratio [OR] 2.89, 95% confidence interval [CI] = 1.505-5.545, P = 0.001; and OR 2.55, 95% CI = 1.428-4.566, P = 0.002, respectively). After adjustment for potential risk factors, the association remained significant. The population attributable risks of these 2 variants of VTa were 17.3% and 10.6%, respectively. One variant (rs13184658) showed weak but significant association with AF in a dominant model (OR 1.91, CI = 1.025-3.570], P = 0.042). There was a significant association between the KCNN2 variants and clinically significant VTa. These findings suggest an association between KCNN2 and VTa; it also appears that KCNN2 variants may be adjunctive markers for risk stratification in patients susceptible to SCD.

An observational study of the association among interatrial adiposity by computed tomography measure, insulin resistance, and left atrial electromechanical disturbances in heart failure

Excessive visceral adiposity, hypothesized to be a key mediator in metabolic derangements, has recently been shown to exert toxic effects on cardiac structure and function. Data regarding the mechanistic link between regional adiposity, left atrial (LA) electromechanical remodeling, and heart failure with preserved ejection fraction (HFpEF) have been lacking.Various visceral adiposity measures, including pericardial fat (PCF), thoracic periaortic (TAT) fat, regional inter-atrial fat (IAF), and atrioventricular groove fat (AV Groove Fat), were assessed by multidetector computed tomography in 2 study cohorts (an annual health survey cohort and an outpatient cohort). We related such measures to cardiometabolic profiles in health survey cohort and LA electromechanical indices in our outpatient cohort, with Cox proportional hazards performed to examine the temporal trends of heart failure (HF).In our annual health survey cohort (n = 362), all 4 adiposity measures were positively related to unfavorable anthropometrics and systemic inflammation (high-sensitivity C-reactive protein) (all P < 0.05). In addition, both greater IAF and AV Groove Fat were positively associated with higher fasting glucose, HbA1c levels, and insulin resistance (all P < 0.05). In the outpatient cohort, the HFpEF group demonstrated the greatest adiposity measures, with greater IAF (≥8.2 mm, hazard ratio: 4.11, 95% confidence interval: 1.50-11.32) associated with reduced LA strain (ß-coef: -0.28), higher LA stiffness (ß-coef: 0.23), and longer P wave duration (ß-coef: 0.23) in multivariate models (all P < 0.05), and further related to higher HF hospitalization during follow-up.We therefore propose a possible pathophysiologic link among greater visceral adiposity, systemic inflammation, cardiometabolic risks, and HFpEF. Regional adiposity, especially IAF, was tightly linked to altered LA electromechanical properties and likely plays a key role in HF prognosis.

Autonomous control of cardiovascular reactivity in patients with episodic and chronic forms of migraine

BACKGROUND

The autonomous cardiovascular control can contribute to progression of migraine. However, current data on cardiovascular reactivity in migraine, especially severe forms, are essentially contradictory. The main aim of this study was to compare the autonomous regulation of circulation in patients with episodic and chronic migraine and healthy subjects.

METHODS

Seventy three migraine patients (mean age 35 ± 10) including episodic migraine (51 patients, 4-14 headache days/months) and chronic migraine (22 patients, ≥15 headache days/month) along with age-match control (71 healthy voluntaries) were examined. The autonomic regulation of circulation was examined with the tilt-table test, a deep breathing and Valsalva Maneuver, handgrip test, cold-stress vasoconstriction, arterial baroreflex and blood pressure variability.

RESULTS

The changes in heart rate induced by deep breathing, Valsalva Maneuver, and blood pressure in tilt-table test in patients with migraine did not differ from the control group. In contrast, the values of cold-stress-vasoconstriction forearm blood-flow reactivity (p <0.001), the increase in diastolic blood pressure in handgrip test (p <0.001), mean blood pressure in the late stage of the second phase of Valsalva Maneuver (p <0.001) and blood pressure variability (p <0.005) were all higher in patients with migraine than in the control group.

CONCLUSION

Thus, both episodic and chronic migraine are associated with significant disturbances in autonomous control resulting in enhanced vascular reactivity whereas the cardiac regulation remains largely unchanged.