Atrial fibrillation: epidemiology, screening and digital health

Genetic insights into the causal relationship between air pollutants and atrial fibrillation: a Mendelian randomization study

Previous observational studies reported associations between air pollutants and atrial fibrillation (AF), but their causal relationships remain unclear. We conducted a two-sample Mendelian randomization (MR) analysis using genome-wide association studies (GWAS) summary data from the UK Biobank and IEU Open GWAS databases to investigate the genetic causality between air pollutants and AF. Air pollutants were subdivided into nitrogen dioxide (NO2) and particulate matter (PM2.5 and PM10), with single-nucleotide polymorphisms (SNPs) associated with each pollutant identified as instrumental variables (IVs). Subsequently, MR methods including MR-Egger, weighted median, inverse variance weighted (IVW), simple mode, and weighted mode were applied to assess genetic causality, while pleiotropy, heterogeneity, and reliability were also evaluated. IVW findings indicate a consequential correlation between NO2 and increased AF risk, as evidenced by an odds ratio (OR 1.948 [95% confidence interval [CI] 1.011-3.756]; p = 0.046). Conversely, the causal effect of PM2.5 (OR 1.274 [95% CI 0.651-2.493; p = 0.480) and PM10 (OR 1.162 [95% CI 0.891-1.517]; p = 0.268) with AF was not statistically significant. The analysis revealed the absence of pleiotropy (p > 0.05). However, PM2.5 displayed significant heterogeneity (p = 0.2385), whereas NO2 (p = 0.5365) and PM10 (p = 0.7789) did not. This MR analysis suggested a causal effect of NO2 on AF, but not for PM2.5 or PM10.

Atrial Cardiomyopathy in Atrial Fibrillation: Mechanistic Pathways and Emerging Treatment Concepts

Atrial fibrillation (AF) is increasingly recognized not merely as an arrhythmia, but as a clinical manifestation of atrial cardiomyopathy (AtCM)-a progressive, multifaceted disease of the atrial myocardium involving structural, electrical, mechanical, and molecular remodeling. AtCM often precedes AF onset, sustains its perpetuation, and contributes to thromboembolic risk independently of rhythm status. Emerging evidence implicates diverse pathophysiological drivers of AtCM, including inflammation, epicardial adipose tissue, metabolic dysfunction, oxidative stress, ageing, and sex-specific remodeling. The NLRP3 inflammasome has emerged as a central effector in atrial inflammation and remodeling. Gut microbial dysbiosis, lipid dicarbonyl stress, and fibro-fatty infiltration are also increasingly recognized as contributors to arrhythmogenesis. AtCM is further linked to atrial functional valve regurgitation and adverse outcomes in AF. Therapeutically, substrate-directed strategies-ranging from metabolic modulation and immunomodulation to early rhythm control-offer promise for altering the disease trajectory. This review synthesizes mechanistic insights into AtCM and discusses emerging therapeutic paradigms that aim not merely to suppress arrhythmia but to modify the underlying substrate. Recognizing AF as a syndrome of atrial disease reframes management strategies and highlights the urgent need for precision medicine approaches targeting the atrial substrate.

Association of Social Disconnection With the Incidence and Prognosis of Atrial Fibrillation: A Multistate Analysis

BACKGROUND

Social disconnection, including loneliness and social isolation, is associated with increased morbidity and death. However, its impact on the incidence and prognosis of atrial fibrillation (AF) remains inconclusive.

METHODS AND RESULTS

The present prospective cohort study enrolled 418 656 participants without AF and cardiovascular disease from the UK Biobank. A loneliness scale was constructed with 2 domains (loneliness feeling, inability to confide) and social isolation scale was constructed with 3 domains (living alone, lack of social support, and lack of social activity). We used a multistate model to analyze the impacts of the 2 scales on the progression from baseline to incident AF and subsequent major adverse cardiovascular events and further to death. Over a median follow-up of 14.7 years, 25 539 participants developed incident AF, among whom 7283 developed incident major adverse cardiovascular events, and 5165 died. Social isolation and loneliness scales were associated with both a higher incidence and worse prognosis of AF, with hazard ratios per 1-point increase of 1.06 (95% CI, 1.04-1.09) for the loneliness scale and 1.03 (95% CI, 1.02-1.05) for the social isolation scale for incident AF, and 1.12 to 1.14 for the loneliness scale (all P<0.001) and 1.12 to 1.27 for the social isolation scale (all P<0.001) after AF development. Loneliness feeling and living alone may be important contributors.

CONCLUSIONS

Loneliness and social isolation were both associated with a higher incidence and a worse prognosis of AF but to different extents. These observations highlight the importance of integrating social connection into the prevention and management of AF.

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.

Atrial fibrillation and ischemic stroke in cancer: the latest scientific evidence, current management, and future directions

Atrial fibrillation is the most common cardiac arrhythmia and is a major risk factor for ischemic stroke. Atrial fibrillation and ischemic stroke are major cardiovascular complications in cancer patients, who have a higher burden and worse outcomes than the general population. Clinical risk stratification scores for stroke and bleeding, commonly used in the general population to estimate thromboembolic and bleeding risk, respectively, are less well validated in cancer patients, who have historically been excluded in clinical trials. There is a lack of consensus opinion on how to effectively risk-stratify cancer patients based on the currently available tools and a need for cancer-specific scores that offer a tailored approach to each patient in order to more effectively stratify ischemic stroke and bleeding risk in this cohort of patients. Cancer-mediated physiologic changes and adverse effects of antineoplastic therapy have been implicated as etiologies of the increased risk for both atrial fibrillation and ischemic stroke. Risk stratifying scores such as CHA2DS2-VASc and HAS-BLED, commonly used in the general population, are less well validated in cancer patients. There is a need for cancer-specific scores that can more effectively stratify ischemic stroke and bleeding risk in cancer patients, although given the heterogeneity of cancers, whether a "one score fits all" is uncertain.

Low blood flow velocity in the left atrial appendage in sinus rhythm as a predictor of atrial fibrillation: results of a prospective cohort study with 3 years of follow-up

BACKGROUND

Atrial fibrillation (AF) is a common cause of cardioembolic stroke and can lead to severe and recurrent cerebrovascular events. Thus, identifying patients suffering from cardioembolic events caused by undetected AF is crucial. Previously, we found an association between increasing stroke severity and a decreasing left atrial appendage (LAA) blood flow velocity below 60 cm/s.

METHODS

This was a prospective single-center cohort study including hospitalized patients who underwent a transesophageal echocardiography (TEE) in sinus rhythm. The participants were divided into two groups (≥ 60 cm/s;<60 cm/s) based on their maximum LAA blood flow velocity. The results of the cardiovascular risk assessment and 24- to 72-hour ECG Holter were recorded. Follow-up appointments were scheduled at 3, 6, 12, 24 and 36 months. The primary endpoint was new-onset AF. The statistics included a Cox-proportional-hazard-model and a binary logistic regression. Numerical data or categorical data were analyzed with the Mann-Whitney U test or chi-square test.

RESULTS

A total of 166 patients were recruited. The median LAA blood flow velocity was 64 cm/s. New-onset AF was diagnosed in 22.9% of the patients. An LAA blood flow velocity ≤ 60 cm/s was associated with a threefold increased risk of new-onset AF (35.8% vs. 11.5%; HR3.56; CI95%1.70-7.46; p < 0.001), independently according to a multivariate analysis (p = 0.035). Furthermore, a decreasing LAA blood flow velocity was associated with an increased risk of new-onset AF (OR1.043; CI95%1.021-1.069; p < 0.001).

CONCLUSION

A low LAA blood flow velocity (≤ 60 cm/s) in sinus rhythm is prospectively associated with an increased risk of new-onset AF. Additional simple LAA-TEE examinations could help to identify patients who benefit from more accurate cardiac rhythm monitoring.

Clinical prediction study on the risk of atrial fibrillation in hypertensive patients based on metabolism, inflammation, and gender differences

This study aimed to explore the risk factors for atrial fibrillation (AF) within one year after discharge in hypertensive patients and to construct a corresponding predictive model. This single-center, retrospective study included 566 patients admitted with hypertension. Patients were divided into two groups: those who developed AF within one year after discharge and those who did not. Variables were selected for multivariate regression analysis using univariate regression and variance inflation factor (VIF) analysis. Subgroup analysis was performed by gender to explore the predictive value of the variables, and a nomogram was constructed. The total sample was randomly divided into a training set and a validation set (7:3 ratio). The discrimination and calibration of the predictive model were evaluated using receiver operating characteristic (ROC) and calibration curves. Patients who developed AF within one year had significantly higher levels of white blood cells (WBC), neutrophils (NEUT), lymphocytes (LYMPH), creatinine (Scr), fasting blood glucose (FBG), triglycerides (TG), lipoprotein(a) [Lp(a)], glycated hemoglobin (HbA1c), neutrophil-to-lymphocyte ratio (NLR), and triglyceride-glucose (TyG) index compared to those who did not (P < 0.05). Males, smokers, and diabetic patients were more prevalent in the AF group (P < 0.05). Logistic regression analysis showed that male gender, Lp(a), HbA1c, NLR, and the TyG index were independent predictors of AF within one year after discharge in hypertensive patients. The nomogram constructed showed an area under the ROC curve (AUC) of 0.793 in the training set and 0.740 in the validation set. The calibration curves indicated good fit (P = 0.726 in the training set; P = 0.489 in the validation set). Male, Lp(a), HbA1c, NLR, and the TyG index are independent risk factors for AF within one year of discharge in hypertensive patients. The nomogram model constructed has high predictive accuracy. This study suggests that individualized management strategies should be employed based on these risk factors in clinical practice.

Assessment of Blood Endothelial Cell Biomarkers in Women and Men with Abnormal Body Mass and Paroxysmal Atrial Fibrillation Based on CHA2DS2-VASC Score: A Retrospective Study

Endothelial dysfunction (ED) promotes and maintains atrial fibrillation (AF). Using a CHA2DS2-VASc score in women and men with paroxysmal AF, we aimed to determine which patients' ED would be more pronounced. We recruited 47 females and 48 males (mean BMI 31 kg/m2 and 30 kg/m2, respectively) with paroxysmal AF and abnormal body mass and divided them into those with low (F < 3; M < 2) and high (F ≥ 3; M ≥ 2) CHA2DS2-VASC score. The blood samples were taken before AF ablation. Using Elisa tests, we measured tissue plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), vascular cell adhesion molecule 1 (sVCAM-1), intercellular adhesion molecule (sICAM-1), von Willebrand factor (vWF), and thrombomodulin (sTM). ED was more pronounced in females, expressed by higher endothelial cell marker concentrations: sVCAM-1 and sTM in low scores and sICAM-1 in high scores, CHA2DS2-VASc. Females were characterized by postmenopausal status, higher risk of thrombosis, lower GFR, and more frequent treatment with antiarrhythmic drugs. In contrast, males have only higher suppression of tumorigenicity 2 (ST2). In conclusion, women with paroxysmal AF exhibited more pronounced ED compared to men, regardless of their CHA2DS2-VASc scores. The soluble pro-inflammatory adhesion molecules and thrombomodulin emerge as the most sensitive biomarkers of ED elevated in females.

Artificial Intelligence in Atrial Fibrillation: From Early Detection to Precision Therapy

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, associated with significant morbidity, mortality, and healthcare burden. Despite advances in AF management, challenges persist in early detection, risk stratification, and treatment optimization, necessitating innovative solutions. Artificial intelligence (AI) has emerged as a transformative tool in AF care, leveraging machine learning and deep learning algorithms to enhance diagnostic accuracy, improve risk prediction, and guide therapeutic interventions. AI-powered electrocardiographic screening has demonstrated the ability to detect asymptomatic AF, while wearable photoplethysmography-based technologies have expanded real-time rhythm monitoring beyond clinical settings. AI-driven predictive models integrate electronic health records and multimodal physiological data to refine AF risk stratification, stroke prediction, and anticoagulation decision making. In the realm of treatment, AI is revolutionizing individualized therapy and optimizing anticoagulation management and catheter ablation strategies. Notably, AI-enhanced electroanatomic mapping and real-time procedural guidance hold promise for improving ablation success rates and reducing AF recurrence. Despite these advancements, the clinical integration of AI in AF management remains an evolving field. Future research should focus on large-scale validation, model interpretability, and regulatory frameworks to ensure widespread adoption. This review explores the current and emerging applications of AI in AF, highlighting its potential to enhance precision medicine and patient outcomes.

Latent Class Analysis for the Identification of Phenotypes Associated with Increased Risk in Atrial Fibrillation Patients: The COOL-AF Registry

Patients with atrial fibrillation (AF) often have clinical complexity phenotypes. Latent class analysis (LCA) is based on the concept of modeling of both observed and unobserved (latent) variables. We hypothesized that LCA can help in identification of AF patient groups with different risk profiles and identify patients who benefit most from the Atrial fibrillation Better Care (ABC) pathway.We studied non-valvular AF patients in the prospective multicenter COOL-AF registry. The outcomes were all-cause death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. Components of CHA2DS2-VASc score, HAS-BLED score, and ABC pathway were recorded.A total of 3,405 patients were studied. We identified 3 LCA groups from 42 variables: LCA class 1 (n = 1,238), LCA class 2 (n = 1,790), and LCA class 3 (n = 377). Overall, the incidence rates of composite outcomes, death, SSE, major bleeding, and heart failure were 8.69, 4.21, 1.51, 2.27, and 2.84 per 100 person-years, respectively. When compared to LCA class 1, hazard ratios (HR) of composite outcome of LCA classes 3 and 2 were 3.86 (3.06-4.86) and 2.31 (1.91-2.79), respectively. ABC pathway compliance was associated with better outcomes in LCA classes 2 and 3 with the HR of 0.63 (0.51-0.76) and 0.57 (0.39-0.84), but not in LCA class 1.LCA can identify patients who are at risk of developing adverse clinical outcomes. The implementation of holistic management based on the ABC pathway was associated with a reduction in the composite outcomes as well as the individual outcomes.

Long-term outcomes of pace-and-ablate strategy in patients with atrial fibrillation

BACKGROUND

The pace-and-ablate strategy is second -line therapy to obtain rate control in patients with persistent symptomatic atrial fibrillation (AF) when other treatment options fail. This study aims to evaluate long-term effects on clinical outcomes following pace-and-ablate strategy in AF patients.

METHODS

This retrospective study includes patients who underwent successful pacemaker implantation (right ventricular pacing (RVP) or cardiac re-synchronization therapy (CRT)) followed by atrioventricular node ablation (AVNA) between 2010 and 2020. Patients were treated according to the prevailing guidelines. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization (HFH). Secondary endpoints were individual outcomes of all-cause mortality, HFH, and left-ventricular ejection fraction (LVEF) change.

RESULTS

Two hundred ninety-eight patients were included, 162 undergoing RVP, and 136 receiving CRT, with a median follow-up of 5.8 years [4.1-8.0]. The primary endpoint occured in 47% of the RVP group and 49% of the CRT group (p = 0.206). All-cause mortality occurred in 36% of the RVP group and in 45% of the CRT group (p = 0.005). HFH occurred in 22% of the RVP group and in 15% of the CRT group (p = 0.328), with 17(10%) upgrades to CRT in the RVP group. Median LVEF in the RVP group remained stable (56% [49-60] to 53% [43-57]; p = 0.081), while it improved in the CRT group (31% [22-38] to 43% [32-51]; p < 0.001).

CONCLUSION

Mortality and HFH in patients with AF managed through a pace-and-ablate strategy are high. Reassuringly, LVEF deterioration requiring upgrade to CRT is uncommon in patients undergoing RVP with normal baseline LVEF before AVNA. CRT improves LVEF in patients with reduced LVEF before AVNA.

The use of cardiac imaging in patients undergoing atrial fibrillation ablation

Cardiac imaging (CI), including echocardiography, multidetector computed tomography (MDCT), and cardiac magnetic resonance (CMR), is gaining increasing interest to aid atrial fibrillation (AF) ablation procedures, from pre-procedural planning to intra-procedural guidance. Transthoracic echocardiography is widely used for imaging, especially for preprocedural assessment, while transesophageal and intracardiac echocardiography (ICE) are used for intraprocedural guidance during transseptal puncture. Cardiac MDCT, leveraging its high spatial resolution, offers a detailed anatomical visualization of cardiac chambers and adjacent structures; moreover, left atrial wall thickness assessed by MDCT may guide radiofrequency energy titration to enhance procedural safety and efficiency. At the same time, CMR allows for detailed myocardial tissue characterization and the detection of fibrosis. ICE, MDCT, and CMR also permit intra-procedural image integration with electroanatomical maps, allowing to be aware of a greater amount of intra-procedural real-time information regarding the anatomy and the local characteristics of the tissue in contact with the ablation catheter. One of the primary objectives of performing CI-aided AF ablations is to increase procedural safety and to permit more personalized procedures, according to the characteristics of each patient. This review offers a comprehensive overview of the current applications of CI during the different phases of AF ablation and explores the potential future applications of CI in this context.

Major clinical outcomes in symptomatic vs. asymptomatic atrial fibrillation: a meta-analysis

BACKGROUND AND AIMS

Current guidelines suggest that asymptomatic atrial fibrillation (AF) is independently associated with increased risks of stroke and mortality compared with symptomatic AF. Considering that recent investigations have provided conflicting results, the present study aimed to evaluate the association between symptom status and clinical outcomes in patients with AF.

METHODS

Medline, Cochrane Library, and Scopus were searched until 25 March 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using random-effects meta-analyses.

RESULTS

Thirty-six studies (217 850 participants) were included. Based on the frequentist analysis, symptomatic individuals had no significant difference in the risk of all-cause mortality [hazard ratio (HR) .97, 95% confidence interval (CI) .80-1.17], cardiovascular mortality (HR 1.04, 95% CI .72-1.49), thromboembolism (HR 1.06, 95% CI .87-1.28), stroke (HR 1.06, 95% CI .84-1.34), hospitalization (HR 1.34, 95% CI .89-2.02), and myocardial infarction (HR .98, 95% CI .70-1.36), compared to the asymptomatic group. Symptomatic patients had a 33% increased risk of new-onset heart failure (HR 1.33, 95% CI 1.19-1.49) and a 30% lower risk of progression to permanent AF (HR .70, 95% CI .54-.89). The Bayesian analysis yielded comparable results, yet the association between symptom status and new-onset heart failure was not significant (HR 1.27, 95% credible interval .76-1.93; Bayes factor = 1.2). Symptomatic patients had higher odds of receiving antiarrhythmic drugs (odds ratio [OR] 1.64, 95% CI 1.33-2.03) and ablation therapy (OR 1.47, 95% CI 1.06-2.05) compared to asymptomatic cases.

CONCLUSIONS

The risk of major clinical outcomes did not differ between individuals with and without AF-related symptoms. Asymptomatic patients had a greater hazard of progression to permanent AF.

Pulsed Field Versus High-Power Short-Duration Radiofrequency Ablation in Atrial Fibrillation: A Meta-Analysis

BACKGROUND

Atrial fibrillation, which has increased in prevalence by 33% over the past two decades, affects 59 million people worldwide. It is treated using thermal and nonthermal techniques like radiofrequency, cryoballoon, laser, and pulsed-field ablation (PFA). This meta-analysis is the first to compare PFA with high-power short-duration radiofrequency ablation (HPSD-RFA).

METHODS

We comprehensively searched PubMed, Cochrane Central, and ScienceDirect from inception to August 2024. In Review Manager 5.4.1, we pooled risk ratios (RRs) and weighted mean difference (WMD) along with 95% confidence intervals for dichotomous and continuous outcomes, respectively, and employed a random effects model. Study quality was assessed via the Newcastle-Ottawa Scale, and funnel plots were used to evaluate the risk of publication bias.

RESULTS

Seven studies with a total of 1538 patients were analyzed in this meta-analysis. PFA was associated with a shorter total procedural time (MD = -36.39 min; 95% CI: [-46.23, -26.55]; p < 0.00001; I2 = 90%), left atrial dwell time (MD = -33.22 min; 95% CI: [-53.21, -13.23]; p = 0.001; I2 = 93%), and a longer fluoroscopy time compared to the HPSD-RFA (MD = 9.06 min; 95% CI: [6.13, 11.99]; p < 0.00001; I2 = 96%). Other outcomes were comparable between the two arms.

CONCLUSION

PFA outperforms HPSD ablation in terms of procedural efficiency outcomes except for the total fluoroscopy time. Still, both techniques are comparable regarding safety and arrhythmia control outcomes.

Hypertension Exacerbates Endothelial Dysfunction in Patients With Atrial Fibrillation

Atrial fibrillation (AF) and hypertension (HT) often coincide and both are independently associated with endothelial dysfunction. We tested the hypothesis that brachial artery flow-mediated dilation (FMD), an indicator of endothelial health, will be poorer in AF patients with HT (AF + HT) than AF without concurrent HT. In a cross-sectional design study, AF (n = 29; mean 70 years; 9 females) and AF + HT (n = 33; 68 years (p = 0.302); 14 females) patients underwent Duplex-Doppler ultrasound imaging of brachial artery diameter and flow velocity during baseline (2 min), distal tourniquet cuff inflation (5 min), and following cuff deflation (3 min). The peak increase in artery diameter following cuff deflation was taken as FMD and analyzed as absolute, percentage change, FMD and shear-rate area-under-the-curve (SRAUC; FMD-to-SRAUC) ratio, and using SRAUC as a covariate (FMDSRAUC). Body mass index (BMI) was used as an additional covariate for between-group comparisons of vascular data. Mean arterial pressure was higher in the AF + HT versus the AF group (median [interquartile range] 93 [85-99] vs. 84 [80-90] mm Hg, respectively; p < 0.05). Baseline brachial artery diameters were similar (p > 0.05). FMD was lower in AF + HT than AF patients (3.36 [1.69-5.21] vs. 4.98 [2.96-7.11] %, respectively; p < 0.05). Similar group differences were observed in absolute FMD, FMD-to-SRAUC ratio and FMDSRAUC (p < 0.05). AF patients with concurrent HT exhibit poorer endothelium-dependent vasodilation compared to AF patients, indicating that the presence of comorbid HT exacerbates endothelial dysfunction in AF patients.

Ambulatory atrial fibrillation detection and quantification by wristworn AI device compared to standard holter monitoring

Timely detection of atrial fibrillation (AF) is crucial for the prevention of serious consequences such as stroke and heart failure, yet it remains challenging due to its often asymptomatic or paroxysmal nature. Wearable devices with artificial intelligence algorithms offer promising solutions. AF detection by the CardioWatch 287-2 (CW2), a wrist-worn photoplethysmography (PPG) and single-lead ECG device, was compared to 24-h Holter. Patient compliance, AF prevalence and AF burden were evaluated for 27 additional days. Data from 150 participants (mean age 64 ± 12 SD; 41% female) were analysed. The CW2's PPG and single-lead ECG algorithms achieved a specificity ≥98% and sensitivity ≥95% for AF detection, and 99% correlation for AF burden, compared to 24-h Holter. AF prevalence increased from 14.7% (24-h Holter) to 26.7% (28-day CW2). Thus, the wrist-worn device showed promising performance in detecting AF and determining AF burden. The trial was registered on ClinicalTrials.gov (NCT05899959) on June 2, 2023.

Prognostic differences between pre-existing atrial fibrillation in chronic kidney disease and new-onset atrial fibrillation at hemodialysis initiation: a retrospective single-center cohort study

Atrial fibrillation (AF) can develop in patients with chronic kidney disease. However, the impact of new-onset AF in patients who are initiated on hemodialysis remains unclear. We categorized 254 patients who were started on hemodialysis into three groups: those with pre-existing AF, those with new-onset AF, and those without AF. Statistical analyses were performed to evaluate the associations between patient characteristics and survival outcomes. AF was observed in 42 patients (16.5%), of whom 19 (7.5%) had pre-existing AF and 23 (9.1%) developed new-onset AF at the initiation of hemodialysis. Multivariate logistic regression models showed that only low serum albumin levels were associated with AF (P = 0.04). Age- and other factors-adjusted multivariable Cox regression models indicated that AF, particularly pre-existing AF, was an independent risk factor for death after dialysis initiation (hazard ratio [HR]: 2.28, 95% confidence interval [CI]: 1.39-3.74, P = 0.001; HR: 3.05, 95% CI: 1.64-5.66, P = 0.004, respectively). However, new-onset AF was not significantly associated with mortality (HR: 1.43, 95% CI: 0.74-2.78, P = 0.28). These findings suggest that pre-existing AF before hemodialysis initiation has a crucial impact on patient prognosis.

New-Onset Atrial Fibrillation in Patients with Pacemakers and the Implications of Hepatic Impairment

(1) Background: Atrial fibrillation (A Fib) is a common arrhythmia that affects millions of people worldwide and is characterized by irregular and often rapid heartbeats that can cause stroke. The aim of our study was to assess the importance of predictors for the occurrence of atrial fibrillation in patients with cardiac pacemakers and to analyze their impact on these patients, especially the impact of hepatic impairment. (2) Methods: This study is an observational, retrospective study, including 182 patients who were implanted with a dual-chamber pacemaker (DDD), with no known history of A Fib. (3) Results: We identified as predictors for the occurrence of atrial fibrillation in patients with cardiac pacemakers, DDD with rate response mode, NYHA class III of heart failure, as well as the presence of hepatic impairment (HI). Analysis of echocardiographic parameters of the left atrium revealed a larger left atrial volume as well as a larger left atrial area compared to patients who had a much smaller area at baseline and who did not experience any atrial fibrillation at follow-up. The fact that there were no statistically significant differences between the two groups of patients in terms of left atrial ejection fraction at baseline was very interesting. Patients in the A Fib group had a higher percentage of atrial pacing at the 9-month follow-up (86.23 ± 22.19%) compared to patients in the group without A Fib (44.92 ± 29.99%, p < 0.0001) and had a 9-month follow-up rate of A Fib of 25.806% vs. 2.247% in those with a low percentage of atrial pacing (p < 0.0001). The percentage of ventricular pacing at the 9-month follow-up, the observations were almost similar. (4) Conclusions: The importance of pacemakers in detecting subclinical episodes of atrial fibrillation remains crucial for the prevention of embolic events in these patients. Hepatic impairment may be a risk factor for the occurrence of atrial fibrillation in patients with pacemakers, but it can also create significant problems in stroke prevention.

Residual risk prediction in anticoagulated patients with atrial fibrillation using machine learning: A report from the GLORIA-AF registry phase II/III

BACKGROUND

Although oral anticoagulation decreases the risk of thromboembolism in patients with atrial fibrillation (AF), a residual risk of thrombotic events still exists. This study aimed to construct machine learning (ML) models to predict the residual risk in these patients.

METHODS

Patients with newly diagnosed non-valvular AF were collected from the Global Registry on Long-Term Oral Anti-Thrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) registry. To predict the residual risk of the composite outcome of thrombotic events (defined as ischemic stroke, systemic embolism, transient ischemic attack and myocardial infarction), we constructed four prediction models using the logistic regression (LR), random forest, light gradient boosting machine and extreme gradient boosting machine ML algorithms. Performance was mainly evaluated by area under the receiver-operating characteristic curve (AUC), g-means and F1 scores. Feature importance was evaluated by SHapley Additive exPlanations.

RESULTS

15,829 AF patients (70.33 ± 9.94 years old, 55% male) taking oral anticoagulation were included in our study, and 641 (4.0%) had residual risk, sustaining thrombotic events. In the test set, LR had the best performance with higher AUC trend of 0.712. RF has highest g-means of 0.295 and F1 score of 0.249. This was superior when compared with the CHA2DS2-VA score (AUC 0.698) and 2MACE score (AUC 0.696). Age, history of TE or MI, OAC discontinuation, eGFR and sex were identified as the top five factors associated with residual risk.

CONCLUSION

ML algorithms can improve the prediction of residual risk of anticoagulated AF patients compared to clinical risk factor-based scores.

The impact of clinical phenotypes of coronary artery disease on outcomes in patients with atrial fibrillation: A post-hoc analysis of GLORIA-AF registry

BACKGROUND

Coronary artery disease (CAD) and atrial fibrillation (AF) often coexist, but the impact of clinical phenotypes of CAD on outcomes in AF patients in the non-vitamin K antagonist oral anticoagulant drugs (NOACs) era is less well understood.

METHODS

This was a post-hoc of the GLORIA-AF registry, a global, multicenter, prospective AF registry study. Patients were divided into three groups: prior history of myocardial infarction (MI)/unstable angina group (Group 1); stable angina group (Group 2); and a control group without stable angina or history of MI/unstable angina. The primary endpoint was the composite of all-cause death or stroke, and the safety endpoint was major bleeding.

RESULTS

A total of 24,827 patients were included in this analysis (median age was 71 (IQR, 64-78) years; 55% male) and 5394 (21.7%) had CAD. During a follow-up of 2 years, the incidence of the primary endpoint was 5.99 (95% CI, 5.33, 6.71) per 100 patient-years in Group 1, 4.04 (95% CI, 3.55, 4.70) per 100 patient-years in Group 2, and 2.79 (95% CI, 2.62, 2.96) per 100 patient-years in the control group (p < .001). Compared the control group, the adjusted hazard ratio of the primary composite endpoint in Groups 1 and 2 were 1.58 (95% CI, 1.37, 1.83, p < .001) and 1.22 (95% CI, 1.04, 1.43, p = .012), respectively. Among anticoagulated patients with AF and CAD, NOACs were associated with a reduced risk of the primary composite endpoint and major bleeding, compared with vitamin K antagonists (VKA).

CONCLUSIONS

CAD was prevalent in patients with AF, and clinical phenotypes of CAD influenced outcomes in patients with AF, with a history of MI/unstable angina being associated with a significantly increased risk of CV events, compared to stable angina. NOACs were superior to VKA in terms of the effectiveness and safety outcomes in patients with AF and concomitant CAD.

Digital health programme following rhythm control in patients with atrial fibrillation: comprehensive disease management by self-monitoring, coaching, and telemedicine

Aims

Digital health is becoming increasingly powerful and available but is frequently not effectively integrated into daily practice. A hybrid programme was developed to provide holistic diagnostic and therapeutic patient care in atrial fibrillation.

Methods and results

Patients (n = 68) were recruited at the electrophysiology centre following successful interventional restoration of sinus rhythm. The 12-month programme consists of the key modalities: (i) self-recording of one-lead electrocardiograms (ECGs), (ii) short-term remote ECG diagnosis and medical advice by video consultation, and (iii) App-based education on lifestyle and risk factor optimization with video consultation. Patients recorded 29 092 ECGs, averaging 1.42 ECGs/day. Recurrent arrhythmia was found and confirmed in 39 patients. In all cases, arrhythmia was first diagnosed based on wearable ECG over the platform, rather than by standard in-office ECG/Holter. No false positive occurred. Patients with recurred arrhythmia were treated by pulmonary vein isolation (n = 17), electric cardioversion (n = 17), antiarrhythmic medication (n = 5), or other interventional procedures (n = 1). Most patients (n = 30) scheduled a video consultation over the App as the first medical touchpoint after arrhythmia occurrence. In 21 patients with arterial hypertension, systolic blood pressure was reduced by 8.0 ± 8.6 mmHg (mean ± SD), P < 0.01. In 25 patients with obesity (body mass index ≥ 30), body weight was reduced by 3.6 ± 5.5 kg (mean ± SD), P < 0.01.

Conclusion

This real-world analysis indicates that the hybrid holistic programme is applicable in daily practice and is actively followed by patients and improves diagnostic and therapeutic outcomes. These promising data need to be confirmed in a controlled randomized study.

Raw photoplethysmogram waveforms versus peak-to-peak intervals for machine learning detection of atrial fibrillation: Does waveform matter?

BACKGROUND

Machine learning-based analysis can accurately detect atrial fibrillation (AF) from photoplethysmograms (PPGs), however the computational requirements for analyzing raw PPG waveforms can be significant. The analysis of PPG-derived peak-to-peak intervals may offer a more feasible solution for smartphone deployment, provided the diagnostic utility is comparable.

AIMS

To compare raw PPG waveforms and PPG-derived peak-to-peak intervals as input signals for machine learning detection of AF.

METHODS

We developed specialized neural networks for raw waveform and peak-to-peak interval analyses and trained them on 7,704 PPGs from 106 patients from the TeleCheck-AF project. We evaluated the neural networks on 48,912 PPGs from 416 patients from the VIRTUAL-SAFARI project. We recorded computational requirements, sensitivity, positive predictive value (PPV), and F1 score.

RESULTS

With 1.6 million trainable parameters, the waveform model was more than 100 times as complex as the interval model (15,513 parameters) and required 19 times more computational power. In external validation, metrics were comparable between the interval and waveform models. For the interval model vs. the waveform model, sensitivity was 91.7 % vs. 81.9 % (p=0.4), PPV was 80.5 % vs. 84.5 % (p=0.3), and F1 score was 85.6 % vs. 81.3 % (p=0.5), respectively.

CONCLUSION

PPG-derived peak-to-peak intervals and PPG waveforms were equivalent as input signals to neural networks in terms of accurate AF detection. The reduced computational requirements of the interval model make it a more suitable option for deployment on digital end-user devices such as smartphones.

Strategies for the prevention of ischemic stroke in atrial fibrillation in East Asia: clinical features, changes and challenges

East Asian populations exhibit a high burden of atrial fibrillation (AF) and AF-related ischemic strokes. The countries/regions in East Asia have diversities regarding patient characteristics and varying patient care represented by different adherence rates to the ABC (Atrial Fibrillation Better Care) pathway. Two changes, "from non-anticoagulation to direct oral anticoagulants (DOACs)" and "from lower dosing to appropriate dosing DOACs", have been identified in East Asia and have been temporally linked to improved clinical outcomes in AF patients. Additional efforts are necessary to further reduce the stroke risk among AF patients, including increased communication with other specialists/societies, the initiation of prospective studies or clinical trials in Asia, and the implementation of evidence-based holistic or integrated care management based on the ABC pathway.

Sacubitril-Valsartan Lowers Atrial Fibrillation Recurrence and Left Atrial Volume Post-catheter Ablation: Systematic Review and Meta-Analysis

INTRODUCTION

In patients with atrial fibrillation (AF) who have undergone catheter ablation, the comparative effectiveness of sacubitril-valsartan (SV) versus ACE inhibitors (ACEi) or angiotensin-receptor blockers (ARB) in preventing AF recurrence remains unclear. The purpose of the present systematic review and meta-analysis is to determine whether SV offers superior outcomes in this clinical setting.

METHODS

This study systematically reviewed PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating SV's efficacy in preventing AF recurrence after catheter ablation. Outcomes included AF recurrence and structural remodeling assessed via left ventricular ejection fraction (LVEF) and left atrial volume index (LAVi), with statistical analyses performed using Review Manager 5.1.7 and heterogeneity assessed via I2 statistics.

RESULTS

The analysis comprised 642 patients from three RCTs and one PMC (319 SV-treated). SV significantly reduced AF recurrence [risk ratios (RR) 0.54; 95% confidence intervals (CI) 0.41-0.70; p < 0.00001; I2 = 0%), a trend also observed when considering RCTs exclusively (RR 0.58; 95% CI 0.41-0.84; p = 0.004; I2 = 0%). Moreover, SV demonstrated a notable reduction in LAVi [mean deviation (MD) -5.34 mL/m2; 95% CI -8.77 to -1.91; p = 0.002; I2 = 57%] compared with ARB, alongside a significant improvement in LVEF (MD 1.83%; 95% CI 1.35-2.32; p < 0.00001; I2 = 0%). Subgroup analyses among patients with hypertension and LVEF < 50% also indicated lower AF recurrence with SV.

CONCLUSION

SV therapy exhibited superior efficacy in reducing AF recurrence compared with ACEi or ARB and demonstrated superior outcomes in attenuating atrial structural remodeling after catheter ablation. These findings underscore the potential of SV as a therapeutic option for patients with AF undergoing catheter ablation, highlighting its efficacy in mitigating AF recurrence and structural remodeling.

REGISTRATION

PROSPERO identifier number CRD42024497958.

Exercise-based cardiac rehabilitation for patients with atrial fibrillation: a narrative review

The role of physical activity (i.e. any bodily movement that requires energy expenditure) and exercise (i.e. planned, structured, and repetitive physical activity to improve/maintain fitness) in the primary and secondary prevention of atrial fibrillation (AF) is increasingly recognized. Physical activity has been associated with lower risks to develop AF and associated complications (e.g. stroke, heart failure, and myocardial infarction). Exercise-based cardiac rehabilitation (ExCR) is increasingly examined in the treatment of AF and sometimes combined with rhythm control strategies (e.g. catheter ablation). Nonetheless, several important clinical, practical, and mechanistic questions remain not fully understood. This state-of-the-art review first provides a contemporary update on the evidence base for the clinical effects of ExCR in AF. Despite the ongoing need for high-quality studies, existing randomized controlled trials and cohort studies suggest ExCR reduces AF burden, lowers risks for major adverse cardiovascular events, and improves health-related quality of life. Second, to facilitate implementation of ExCR, we have observed comparable effects of distinct exercise protocols (e.g. type of training and centre-/home-based) and discussed similarity of effectiveness across patient characteristics (e.g. age, sex, and AF subtype). Critically, we have discussed potential barriers that may prohibit the uptake of ExCR for patients with AF, categorized at clinician- (e.g. referral and training), patient- (e.g. motivation, transportation, and psychosocial factors), and system-levels (e.g. insurance and resources). Third, we have summarized the potential mechanisms underlying these effects of ExCR, classified by their potential role in reducing AF burden (e.g. atrial/ventricular function, autonomic balance, and inflammation) and lowering risks for adverse events (e.g. modifiable risk factors, vascular function, and thrombogenesis). Based on the increasing evidence for clinical benefits, e.g. improved health-related quality of life and better clinical outcomes, we advocate stronger focus on regular physical activity and referral to multidisciplinary ExCR for sustainable lifestyle changes within the ESC AF-CARE pathway for the prevention and treatment of AF.

Prevention of New-Onset Heart Failure in Atrial Fibrillation: The Role of Pharmacological Management

Atrial fibrillation (AF) is the most common type of chronic arrythmia, with a lifetime prevalence of one in every three to five individuals above the age of 45 years. The higher heart rate, abnormal rhythm and inflammation caused by AF lead to changes in the function and structure of the heart. This, over time, can culminate in heart failure. In patients with AF, the lifetime prevalence of new-onset heart failure is twice that of stroke. The development of new-onset heart failure in AF is associated with high mortality. Despite the emphasis that AF guidelines put on preventing cardiovascular comorbidities, there is limited evidence regarding pharmacological therapies to prevent incident heart failure in individuals with AF. Specifically, the association between the use of rate control agents and incident heart failure in this population is unknown. Whilst rhythm control may reduce the risk of heart failure, the comparative effect of each pharmacological agent is not clear. In select subgroups of patients with AF, the choice of direct-acting oral anticoagulants and their optimal dosing has been attributed to a lower risk of new-onset heart failure. Future research is needed to identify an evidence-based approach to minimizing the development of heart failure in patients with AF.

Late Coronary-cameral Fistula Formation Between Circumflex Coronary Artery and Left Atrial Appendage Following Implantation of an Amulet Closure Device

An 80-year-old patient presented with a rare complication: a late coronary-cameral fistula following implantation of an Amulet (Abbott) left atrial appendage occlusion device. Microperforations from the device's anchoring tines have previously been suggested as a possible mechanism of fistula formation, a complication reported in two other cases. We propose an alternative theory of potential collateralisation of the threatened appendage from the nearby circumflex artery.

Diagnostic accuracy of ECG smart chest patches versus PPG smartwatches for atrial fibrillation detection: a systematic review and meta-analysis

INTRODUCTION

Atrial fibrillation (AF), the most common form of cardiac arrhythmia, is associated with significant morbidity, mortality, and financial burden. Traditional diagnostic methods, such as 12-lead electrocardiograms (ECG), have limitations in detecting intermittent AF episodes. Consequently, smart wearables have been introduced to enhance continuous AF monitoring. This systematic review and meta-analysis aimed to evaluate and compare the diagnostic accuracy of ECG smart chest patches and photoplethysmography (PPG)- based smartwatches in AF detection.

METHODS

From august 16-20, 2024, a comprehensive search was conducted across PubMed/MEDLINE, DOAJ, AJOL, and the Cochrane Library. Original studies assessing the performance of ECG smart chest patches and PPG smartwatches in detecting AF were included. Studies were screened based on predefined inclusion and exclusion criteria, and the most relevant were finally included. For ECG smart chest patches and PPG smartwatches groups, random-effects model was used to pool these performance metrics. Statistical analyses were performed using Jamovi 2.3.28, with a significance threshold of p < 0.05.

RESULTS

A total of 15 studies were included in the current systematic review and meta-analysis. ECG smart chest patches demonstrated a pooled sensitivity of 96.1% [(95% CI: 91.3-100.8), (I² = 94.59%)], and a pooled specificity of 97.5% [(95% CI: 94.7-100.2), (I² = 79.1%)]. PPG smartwatches showed a pooled sensitivity of 97.4% [(95% CI: 96.5-98.3), (I² = 3.16%)], and a pooled specificity of 96.6% [(95% CI: 94.9-98.3), (I² = 75.94%)]. Comparatively, both ECG smart chest patches and PPG smartwatches exhibited excellent performance in atrial fibrillation detection, with PPG smartwatches showing slightly higher sensitivity and ECG chest patches exhibiting marginally greater specificity.

CONCLUSION

Both ECG smart chest patches and PPG smartwatches are highly effective for detecting atrial fibrillation. However, further advancements are needed to match their accuracy with that of standard diagnostic methods and achieve comprehensive digital cardiac monitoring.

Monitoring heart rhythms in adult males with X-linked ichthyosis using wearable technology: a feasibility study

The rare dermatological condition X-linked ichthyosis (XLI) is associated with a substantially-increased risk of cardiac arrhythmias. Arrhythmias predispose to multiple serious health conditions, and there is a need to identify them at an early stage, ideally using non-invasive, convenient, cost-effective, and reliable wearable technology methods. We tested the feasibility of monitoring heart rhythms using an Apple Watch in five adult males from the United Kingdom diagnosed with XLI. Participants returned routine electrocardiogram (ECG) traces from the watch three times per week for eight weeks (plus any traces associated with 'watch alerts' indicating arrhythmic episodes) for cardiologist review. Participant feedback was also obtained on the perceived usability/wearability of the watch/app, and on the study requirements. Participants were generally happy with the study conduct, found the watch/app straightforward to use, and there was a > 95% data return rate. Minor protocol improvements were suggested. There were few issues reported with wearability of the watch. Three participants exhibited no ECG abnormalities, but two presented with ventricular ectopic beats (VEs). Only one watch 'alert' ECG was returned, and this was considered normal sinus rhythm, suggesting the possibility of 'false positive' calls. Based on our small sample, smartwatch-based screening for cardiac rhythm abnormalities in the high-risk male XLI population appears useful, feasible, and acceptable to patients and a larger-scale clinical trial is warranted. Potentially, such devices may be more suited to detecting persistent abnormalities rather than unpredictable, acute, arrhythmic episodes. The high VE burden in some participants with XLI is consistent with septal defects underlying arrhythmia risk.

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.

Paroxysmal atrial fibrillation is associated with poor sleep quality: Tamagawa cross-sectional study on the relationship between lifestyle and atrial fibrillation (TAMAGAWA-AF study)

Background

Quality of life (QOL) is reduced in patients with atrial fibrillation (AF). However, data regarding the association between sleep quality, one of the major components of QOL, and AF are insufficient. This cross-sectional study aimed to elucidate whether sleep quality is reduced in patients with AF.

Methods

We recruited 2054 consecutive outpatients (64 ± 10 years, 1089 men) who had regularly presented to 26 clinics affiliated with the Tamagawa Medical Association, Tokyo, Japan. The patients were divided into paroxysmal AF (PaAF), persistent or permanent AF (PeAF), and non-AF groups. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). The global PSQI score was calculated according to the answer to each question, and poor sleep quality was defined as a global PSQI score ≥6 points. Logistic regression analysis was used to obtain odds ratio for poor sleep quality in the PaAF and PeAF groups, relative to the non-AF group.

Results

The PaAF group showed significantly increased odds ratio for poor sleep quality (1.49, 95% confidence interval 1.02-2.17), after adjusting for multiple potential confounders. In contrast, no significant odds ratio for poor sleep quality was observed in the PeAF group (1.09, 95% confidence interval 0.70-1.71). Among the PSQI components, poor subjective sleep quality and sleep disturbances were the main determinants of poor sleep quality in the PaAF group.

Conclusion

Sleep quality was found to be reduced in patients with PaAF, and this may be attributed to poor subjective sleep quality and sleep disturbances.

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

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

Demographic trends in mortality with older population due to atrial fibrillation and flutter from 1999-2020

Atrial fibrillation (AF)/atrial flutter (AFL) is the most common sustained cardiac arrhythmia. The known risk factors for developing AF/AFL include age, structural heart disease, hypertension, diabetes mellitus, or hyperthyroidism. This study aims to attribute the trends in AF/AFL-related mortalities over the past two decades 1999-2020 concerning race and sex and disparity among them. To the best of our knowledge, this is the first study that estimates the trends and mortality due to AF/AFL from 1999-2020 in older adults in the United States. In this 21-year analysis of mortality data, we found a constant increase in mortality rates due to AF/AFL in older adults. From 1999 to 2020, the overall mortality in older adults aged 65 and above, regardless of sex and race, is found to be almost doubled i.e. about a 50.2% increase in the number of deaths due to AF/AFL. Furthermore, other confounding risk factors such has obesity, prior myocardial infarction, inflammation, hypertension, birth weight, diabetes mellitus, hyperthyroidism, hormone replacement therapy in menopausal women increases the risk in the occurrence or recurrent occurrence of AF.

An approach to fluoroless radiofrequency atrial fibrillation ablation

Atrial fibrillation is the most prevalent arrhythmia with a lifetime risk of nearly 30%. It can be associated with reduced quality of life and complications such as heart failure and stroke. Pulmonary vein isolation (PVI) is the most effective treatment for rhythm control. It has initially been performed with fluoroscopic catheter guiding. The advent of three-dimensional (3D) electro-anatomical mapping has significantly reduced the need for fluoroscopy. More recently, intracardiac echography (ICE) techniques have been used to eliminate the need for x-rays. Additional advantages include providing electrophysiology lab personnel with a lead-free working environment and avoiding radiation exposure for both patients and physicians. ICE may also enhance the safety of the procedure by enabling a safe trans-septal puncture and the early recognition of cardiac tamponade. In this article, we present our approach to fluoroless radiofrequency PVI using ICE and 3D electro-anatomical mapping.

Electrographic Flow Mapping Provides Prognosis for AF Ablation Outcomes Across Two Independent Prospective Patient Cohorts

Background/Objectives: Electrographic flow (EGF) mapping allows for the visualization and quantification of atrial fibrillation (AF) wavefront propagation patterns. EGF-identified sources were shown in the randomized controlled FLOW-AF trial to significantly increase the likelihood of AF recurrence within 1 year if left unablated. Electrographic flow consistency (EGFC) additionally measures the stability of observed wavefront patterns, such that patients with more organization have a healthier substrate and lower recurrence. Source presence and EGFC can be used collectively to assign mechanistic phenotypes to AF patients. Methods: The patient phenotypes, treatment modalities, and outcomes in FLOW-AF were compared with those of patients in the ensuing AF-FLOW Global Registry, which was conducted by separate physicians at discrete clinical centers. Results: Patients with low EGFC (≤0.62) had a 12-month freedom from AF (FFAF) of 46%, while those with a high mean EGFC (>0.62) had a FFAF of 81%. Right atrial EGFC was correlated with left atrial EGFC, and the highest recurrence occurred in those with biatrial low EGFC. Source presence also affected the recurrence rates in both trials, such that the presence of EGF-identified sources in PVI-only patients lowered the FFAF from 65% to 36%, but the elimination of sources produced a 30% absolute increase in FFAF from 36% to 66%. Conclusions: Patient outcomes by EGF-based AF phenotype were consistent across two cohorts of patients from separate clinical trials at distinct centers. Patients with a high EGFC and no sources post-procedure had the best outcomes. EGF mapping provides insights into underlying disease pathophysiology and may be employed prospectively to predict recurrence.

Frailty and Its Associated Factors in Patients With Atrial Fibrillation: A Cross-Sectional Study

This study aimed to investigate the prevalence of frailty and its predictors among Taiwanese patients with atrial fibrillation (AF). A cross-sectional study was conducted, enrolling 188 AF patients aged over 20 years from a medical center in northern Taiwan. Participants were recruited from September 1 to December 30, 2022. Structured questionnaires were used to gather data on demographics, disease characteristics, Study of Osteoporotic Fractures Index, Short Portable Mental Status Questionnaire, Mini Nutritional Assessment Short-Form, Chinese Version Pittsburgh Sleep Quality Index, and Hospital Anxiety and Depression Scale. Among Taiwanese AF patients, over two-thirds were at risk of frailty, with susceptibility increasing with age. Key potential predictors included sex, cognitive function, nutritional status, sleep quality, and depression, jointly explaining 47.6% of the variation, with nutritional status being the most significant. These findings underscore the importance of comprehensive assessment and management strategies to address frailty in AF patients and improve overall health outcomes.

Association of atrial fibrillation with lamotrigine: An observational cohort study

BACKGROUND

Drug-induced atrial fibrillation (AF) is recognized as an important causal association. Lamotrigine (LTG) is a widely prescribed neurological agent with Class IB antiarrhythmic properties at therapeutically relevant concentrations. The United States Food and Drug Administration has issued a warning for a higher risk of LTG proarrhythmic events in patients with structural heart disease (SHD) and/or myocardial ischemia. This study evaluated the incidence of AF with LTG use.

METHODS

A retrospective observational study was performed using a large healthcare claims database of adult participants analyzing 2 years AF incidence. The analytic cohort included adult participants with bipolar I disorder (BPD), partial seizures (PSZ), or generalized tonic-clonic seizures (GTSZ). Exposure to LTG was compared with commonly prescribed alternative agents as the control comparators (CTR). Participants were free from supraventricular or ventricular arrhythmias during the 6 months baseline period prior to the index LTG or CTR date. Kaplan-Meier estimator calculated 2 years cumulative AF incidence, with participants censored at last enrollment, treatment switching, or discontinuation. The AF association hazard ratios (HR) for LTG versus CTR were adjusted for baseline characteristics.

RESULTS

The analytic cohort with BPD, PSZ, and GTSZ consisted, respectively, of 150,470 LTG versus 204,704 CTR, 9565 LTG versus 21,595 CTR, and 5505 LTG versus 15,513 CTR patients. In a predominantly middle-aged female population at baseline, the prevalence of cardiovascular conditions was low. The 12 months cumulative incidence of AF for LTG versus CTR was 0.764% versus 0.642% among BPD, 0.833% versus 0.646% among PSZ, and 0.585% versus 0.338% among GTSZ, respectively. The adjusted 365-day HR [95% confidence interval CI] of AF for LTG versus CTR in the BPD, PSZ, and CTSZ groups was 1.257 [1.088-1.453], 1.651 [1.104-2.468], and 1.451 [0.770-2.734], respectively.

CONCLUSIONS

In adult AF-naïve participants, LTG has a strong association with increased AF risk compared with commonly prescribed alternatives.

Wearables and Atrial Fibrillation: Advances in Detection, Clinical Impact, Ethical Concerns, and Future Perspectives

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with a significantly increased risk of stroke, heart failure, and mortality. Early diagnosis and management are crucial to mitigating these risks. Wearable devices such as smartwatches and fitness bands, enhanced by advanced artificial intelligence (AI) algorithms, offer a promising solution for early AF detection due to their accessibility, ease of use, and cost-effectiveness. Although the ability of these algorithms to identify AF has been authorized, critical questions remain about their integration into clinical practice, ethical implications, and long-term benefits. This review uniquely explores the intersection of wearable technology and AF management, providing a detailed analysis of current evidence, emerging trends, and the challenges associated with these innovations.

Utility of Loneliness Status to Risk Stratification and Prediction of Recurrent Atrial Fibrillation After Catheter Ablation

INTRODUCTION

Socioeconomic determinants are increasingly important factors in the integrated management of atrial fibrillation (AF). The impact of loneliness status on AF recurrence remains unclear.

METHODS

We conducted a cohort study based on patients with AF undergoing catheter ablation from 2017 to 2022. The Chinese version of the De Jong Gierveld scale (DJGLS) for evaluating loneliness degree was used. Multivariate Cox regression was performed to identify the independent risk factors for recurrent AF. A multivariate model was used to estimate the hazard ratio (HR) with 95% confidence interval (CI) when adjusting the known risk covariates in several kinds of subgroups.

RESULTS

Nine hundred fifty-five patients with AF and mean age > 65 years finished long-term follow-up. The AF cluster with severe/extreme loneliness tended to live alone according to DJGLS scores. Multivariate Cox regression showed that loneliness status is an independent risk factor for AF recurrence by using a multivariate model with adjustments of some covariates (moderate loneliness: HR 2.02; 95% CI 1.47-2.77, P < 0.001; severe/extreme loneliness: HR 5.28; 95% CI 3.56-7.84, P < 0.001). Survival analysis demonstrated that patients with AF with a more severe degree of loneliness are more likely to have AF recurrence in the long-term follow-up (log-rank test, P < 0.001). Restricted cubic spline (RCS) showed a mainly non-linear relationship between feeling lonely and AF recurrence (P overall < 0.001, P non-linear = 0.195). Receiver-operator characteristic curve (ROC) and time-dependent ROC curve indicated that the diagnostic value of loneliness status in predicting AF recurrence is stable and acceptable.

CONCLUSION

A more severe degree of loneliness was positively associated with increased risk of AF recurrence. Loneliness status showed an acceptable diagnostic value in discriminating AF recurrence as an independent tripartite variable.

Current Strategies for Atrial Fibrillation Prevention and Management: Taming the Commonest Cardiac Arrhythmia

Atrial fibrillation (AF) is the commonest cardiac arrhythmia, constituting a major cause of morbidity and mortality, with an age-dependent incidence and prevalence ranging from 1-2% in the general population to ~10% in persons aged >60 years. The global prevalence of AF is rapidly increasing, mostly due to the aging population. If not properly and timely managed, this arrhythmia adversely affects left ventricular function, increases the risk of stroke five-fold, impairs quality of life, and shortens longevity. There is a genetic, hence non-modifiable, predisposition to the arrhythmia, while several life-style and cardiometabolic inciting factors, such as hypertension, heart failure, coronary disease, metabolic syndrome, alcohol use, and thyroid disorders, can be addressed, attesting to the importance of a holistic approach to its management. Thromboembolism is a serious consequence of AF, which could lead to a disabling stroke or have a lethal outcome. The risk of a thromboembolic complication can be estimated as based on a scoring system that takes into consideration the patient's age, previous thromboembolic events, and clinical comorbidities. In addition, rapid AF could affect cardiac performance, leading to an elusive type of arrhythmia- induced cardiomyopathy and heart failure with grave consequences if undetected and untreated. Furthermore, AF may cause silent brain infarcts and/or its hemodynamic perturbations can account for a type of dementia that needs to be taken into account, emphasizing the need for AF screening and prevention strategies. All these issues are herein detailed, the causes of the arrhythmia are tabulated, and an algorithm illustrates our current approach to its management.