Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study

Risk calculator for incident atrial fibrillation across a range of prediction horizons

BACKGROUND

The increasing burden of atrial fibrillation (AF) emphasizes the need to identify high-risk individuals for enrolment in clinical trials of AF screening and primary prevention. We aimed to develop prediction models to identify individuals at high-risk of AF across prediction horizons from 6-months to 10-years.

METHODS

We used secondary-care linked primary care electronic health record data from individuals aged ≥30 years without known AF in the UK Clinical Practice Research Datalink-GOLD dataset between January 2, 1998 and November 30, 2018; randomly divided into derivation (80%) and validation (20%) datasets. Models were derived using logistic regression from known AF risk factors for incident AF in prediction periods of 6 months, 1-year, 2-years, 5-years, and 10-years. Performance was evaluated using in the validation dataset with bootstrap validation with 200 samples, and compared against the CHA2DS2-VASc and C2HEST scores.

RESULTS

Of 2,081,139 individuals in the cohort (1,664,911 in the development dataset, 416,228 in the validation dataset), the mean age was 49.9 (SD 15.4), 50.7% were women, and 86.7% were white. New cases of AF were 7,386 (0.4%) within 6 months, 15,349 (0.7%) in 1 year, 38,487 (1.8%) in 5 years, and 79,997 (3.8%) by 10 years. Valvular heart disease and heart failure were the strongest predictors, and association of hypertension with AF increased at longer prediction horizons. The optimal risk models incorporated age, sex, ethnicity, and 8 comorbidities. The models demonstrated good-to-excellent discrimination and strong calibration across prediction horizons (AUROC, 95%CI, calibration slope: 6-months, 0.803, 0.789-0.821, 0.952; 1-year, 0.807, 0.794-0.819, 0.962; 2-years, 0.815, 0.807-0.823, 0.973; 5-years, 0.807, 0.803-0.812, 1.000; 10-years 0.780, 0.777-0.784, 1.010), and superior to the CHA2DS2-VASc and C2HEST scores. The models are available as a web-based FIND-AF calculator.

CONCLUSIONS

The FIND-AF models demonstrate high discrimination and calibration across short- and long-term prediction horizons in 2 million individuals. Their utility to inform trial enrolment and clinical decisions for AF screening and primary prevention requires further study.

Strength together: examining risk and protective factors associated with dementia and cognitive impairment in Aboriginal and Torres Strait Islander peoples through harmonisation of landmark studies

BACKGROUND

Rates of dementia for Aboriginal and Torres Strait Islander peoples are three to five times greater compared to non-Indigenous Australians, with earlier age of onset. However, the risk and protective factors that drive these higher rates vary across existing cohort studies, with minimal findings on the role of vascular risk factors beyond stroke. Harmonisation of data across studies may offer greater insights through enhanced diversity and strengthened statistical capabilities. This study aims to combine three landmark cohort studies of Aboriginal and Torres Strait Islander participants to better understand the determinants of cognitive health and dementia.

METHODS/DESIGN

Three cohort studies - the Kimberley Healthy Adults Project (KHAP, N = 363), Koori Growing Old Well Study (KGOWS, N = 336) and Torres Strait Dementia Prevalence Study (TSDPS, N = 274) - share a similar research methodology with demographic, medical history, psychosocial factors, cognitive tests and consensus clinical diagnoses of cognitive impairment and dementia. Associations between risk and protective factors of interest and the presence of dementia and/or cognitive impairment diagnoses will be evaluated by univariable and multivariable logistic regression in a harmonised cross-sectional cohort of 898 participants. Factors associated with incident dementia and/or cognitive impairment will be assessed in a subset of KHAP (n = 189) and KGOWS participants (n = 165) who were available in longitudinal follow-up, after exclusion of those with baseline dementia or cognitive impairment. Analyses in relation to outcome measure of death or dementia will be conducted to account for the competing risk of death. Logistic regression will be used to evaluate the association between the individual components of the 16-component Kimberley Indigenous Cognitive Assessment (KICA) tool and the presence of dementia and cognitive impairment determined by independent consensus diagnoses. Multivariable binary logistic regression will be used to adjust for the effect of confounding variables. Results will be reported as odds ratios (OR) with 95% confidence intervals (95% CI).

DISCUSSION

Greater understanding of risk and protective factors of dementia and cognitive impairment relevant to Aboriginal and Torres Strait Islander peoples may improve approaches across the life course to delay cognitive decline and reduce dementia risk.

Association Between Remnant Cholesterol and Risk of Incident Atrial Fibrillation: Population-Based Evidence From a Large-Scale Prospective Cohort Study

BACKGROUND

Evidence for the relationship between remnant cholesterol (RC) and incident atrial fibrillation (AF) risk remains sparse and limited.

METHODS AND RESULTS

Participants were enrolled between 2006 and 2010 and followed up to 2021. The multivariable Cox proportional hazards model was used to examine the relationship between RC quartiles and risk of incident AF. Subgroup analyses and sensitivity analyses were performed to explore the potential modification of the association and the robustness of the main findings. A total of 422 316 participants (mean age, 56 years; 54% women) were included for analyses. During a median follow-up of 11.9 years (first quartile-third quartile, 11.6-13.2 years), there were 24 774 AF events documented with an incidence of 4.92 events per 1000 person-years (95% CI, 4.86-4.98). Participants in higher RC quartiles had a lower risk of incident AF than those in the lowest quartile (first quartile): hazard ratio (HR)=0.96 (95% CI, 0.91-1.00) for second quartile; HR=0.92 (95% CI, 0.88-0.96) for third quartile; and HR=0.85 (95% CI, 0.81-0.89) for fourth quartile (P for trend <0.001). The association between RC quartiles and risk of incident AF was stronger in participants aged ≥65 years, in men, and in participants without history of diabetes when compared with control groups (P<0.001 for interaction).

CONCLUSIONS

On the basis of data from this large-scale prospective cohort study, elevated RC was associated with a lower risk of incident AF.

Modifiable lifestyle factors and lifetime risk of atrial fibrillation: longitudinal data from the Korea NHIS-HealS and UK Biobank cohorts

BACKGROUND

The reason for higher incidence of atrial fibrillation (AF) in Europe compared with East Asia is unclear. We aimed to investigate the association between modifiable lifestyle factors and lifetime risk of AF in Europe and East Asia, along with race/ethnic similarities and disparities.

METHODS

1:1 propensity score matched pairs of 242,763 East Asians and 242,763 White Europeans without AF were analyzed. Modifiable lifestyle factors considered were blood pressure, body mass index, cigarette smoking, diabetes, alcohol consumption, and physical activity, categorized as non-adverse or adverse levels. Lifetime risk of AF was estimated from the index age of 45 years to the attained age of 85 years, accounting for the competing risk of death.

RESULTS

The overall lifetime risk of AF was higher in White Europeans than East Asians (20.9% vs 15.4%, p < 0.001). The lifetime risk of AF was similar between the two races in individuals with non-adverse lifestyle factor profiles (13.4% vs 12.9%, p = 0.575), whereas it was higher in White Europeans with adverse lifestyle factor profiles (22.1% vs 15.8%, p < 0.001). The difference in the lifetime risk of AF between the two races increased as the burden of adverse lifestyle factors worsened (1 adverse lifestyle factor; 4.3% to ≥ 3 adverse lifestyle factors; 11.2%). Compared with East Asians, the relative risk of AF in White Europeans was 23% and 62% higher for one (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.16-1.29) and ≥ 3 adverse lifestyle factors (HR 1.62, 95% CI 1.51-1.75), respectively.

CONCLUSIONS

The overall higher lifetime risk of AF in White Europeans compared with East Asians might be attributable to adverse lifestyle factors. Adherence to healthy lifestyle factors was associated with the lifetime risk of AF of about 1 in 8 regardless of race/ethnicity.

Prediction of incident chronic kidney disease in community-based electronic health records: a systematic review and meta-analysis

Background

Chronic kidney disease (CKD) is a major global health problem and its early identification would allow timely intervention to reduce complications. We performed a systematic review and meta-analysis of multivariable prediction models derived and/or validated in community-based electronic health records (EHRs) for the prediction of incident CKD in the community.

Methods

Ovid Medline and Ovid Embase were searched for records from 1947 to 31 January 2024. Measures of discrimination were extracted and pooled by Bayesian meta-analysis, with heterogeneity assessed through a 95% prediction interval (PI). Risk of bias was assessed using Prediction model Risk Of Bias ASsessment Tool (PROBAST) and certainty in effect estimates by Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

Results

Seven studies met inclusion criteria, describing 12 prediction models, with two eligible for meta-analysis including 2 173 202 patients. The Chronic Kidney Disease Prognosis Consortium (CKD-PC) (summary c-statistic 0.847; 95% CI 0.827-0.867; 95% PI 0.780-0.905) and SCreening for Occult REnal Disease (SCORED) (summary c-statistic 0.811; 95% CI 0.691-0.926; 95% PI 0.514-0.992) models had good model discrimination performance. Risk of bias was high in 64% of models, and driven by the analysis domain. No model met eligibility for meta-analysis if studies at high risk of bias were excluded, and certainty of effect estimates was 'low'. No clinical utility analyses or clinical impact studies were found for any of the models.

Conclusions

Models derived and/or externally validated for prediction of incident CKD in community-based EHRs demonstrate good prediction performance, but assessment of clinical usefulness is limited by high risk of bias, low certainty of evidence and a lack of impact studies.

Simple risk scoring using sinus rhythm electrocardiograms predicts the incidence of atrial fibrillation in the general population

Atrial fibrillation (AF) is an arrhythmic disease. Prediction of AF development in healthy individuals is important before serious complications occur. We aimed to develop a risk prediction score for future AF using participants' data, including electrocardiogram (ECG) measurements and information such as age and sex. We included 88,907 Japanese participants, aged 30-69 years, who were randomly assigned to derivation and validation cohorts in a ratio of 1:1. We performed multivariate logistic regression analysis and obtained the standardised beta coefficient of relevant factors and assigned scores to them. We created a score based on prognostic factors for AF to predict its occurrence after five years and applied it to validation cohorts to assess its reproducibility. The risk score ranged from 0 to 17, consisting of age, sex, PR prolongation, QT corrected for heart rate prolongation, left ventricular hypertrophy, premature atrial contraction, and left axis deviation. The area under the curve was 0.75 for the derivation cohort and 0.73 for the validation cohort. The incidence of new-onset AF reached over 2% at 10 points of the risk score in both cohorts. Thus, in this study, we showed the possibility of predicting new-onset AF using ECG findings and simple information.

Follow-up from the A041202 study shows continued efficacy of ibrutinib regimens for older adults with CLL

ABSTRACT

A041202 (NCT01886872) is a phase 3 study comparing bendamustine plus rituximab (BR) with ibrutinib and the combination of ibrutinib plus rituximab (IR) in previously untreated older patients with chronic lymphocytic leukemia (CLL). The initial results showed that ibrutinib-containing regimens had superior progression-free survival (PFS) and rituximab did not add additional benefits. Here we present an updated analysis. With a median follow-up of 55 months, the median PFS was 44 months (95% confidence interval [CI], 38-54) for BR and not yet reached in either ibrutinib-containing arm. The 48-month PFS estimates were 47%, 76%, and 76% for BR, ibrutinib, and IR, respectively. The benefit of ibrutinib regimens over chemoimmunotherapy was consistent across subgroups of patients defined by TP53 abnormalities, del(11q), complex karyotype, and immunoglobulin heavy chain variable region (IGHV). No significant interaction effects were observed between the treatment arm and del(11q), the complex karyotype, or IGHV. However, a greater difference in PFS was observed among the patients with TP53 abnormalities. There was no difference in the overall survival. Notable adverse events with ibrutinib included atrial fibrillation (afib) and hypertension. Afib was observed in 11 patients (pts) on BR (3%) and 67 pts on ibrutinib (18%). All-grade hypertension was observed in 95 pts on BR (27%) and 263 pts on ibrutinib (55%). These data show that ibrutinib regimens prolong PFS compared with BR for older patients with treatment-naïve CLL. These benefits were observed across subgroups, including high-risk groups. Strikingly, within the ibrutinib arms, there was no inferior PFS for patients with abnormalities in TP53, the highest risk feature observed in CLL. These data continue to demonstrate the efficacy of ibrutinib in treatment-naïve CLL.

Atrial fibrillation: age at diagnosis, incident cardiovascular events, and mortality

BACKGROUND AND AIMS

Patients with atrial fibrillation (AF) are at increased risks of cardiovascular diseases and mortality, but risks according to age at diagnosis have not been reported. This study investigated age-specific risks of outcomes among patients with AF and the background population.

METHODS

This nationwide population-based cohort study included patients with AF and controls without outcomes by the application of exposure density matching on the basis of sex, year of birth, and index date. The absolute risks and hazard rates were stratified by age groups and assessed using competing risk survival analyses and Cox regression models, respectively. The expected differences in residual life years among participants were estimated.

RESULTS

The study included 216 579 AF patients from year 2000 to 2020 and 866 316 controls. The mean follow-up time was 7.9 years. Comparing AF patients with matched controls, the hazard ratios among individuals ≤50 years was 8.90 [95% confidence interval (CI), 7.17-11.0] for cardiomyopathy, 8.64 (95% CI, 7.74-9.64) for heart failure, 2.18 (95% CI, 1.89-2.52) for ischaemic stroke, and 2.74 (95% CI, 2.53-2.96) for mortality. The expected average loss of life years among individuals ≤50 years was 9.2 years (95% CI, 9.0-9.3) years. The estimates decreased with older age.

CONCLUSIONS

The findings show that earlier diagnosis of AF is associated with a higher hazard ratio of subsequent myocardial disease and shorter life expectancy. Further studies are needed to determine causality and whether AF could be used as a risk marker among particularly younger patients.

Oxidized high-density lipoprotein associates with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common heart arrhythmia and considered to be a progressive chronic disease associated with increased morbidity and mortality. Recent data suggest a link between inflammation, oxidative stress, and AF, although the underlying mechanisms are not fully understood. Because oxidized lipoproteins cause structural damage and electrophysiologic changes in cardiomyocytes, it is feasible that the transformation of atheroprotective high-density lipoprotein (HDL) into dysfunctional HDL contributes to the development of AF.

OBJECTIVE

The purpose of this study was to determine whether a reduced antioxidant function of HDL is associated with the presence of AF.

METHODS

In this multicenter cross-sectional cohort study, we assessed HDL function in sera of 1206 participants. Patients were divided into groups according to the presence of AF (n = 233) or no AF (n = 973). A validated cell-free biochemical assay was used to determine reduced HDL antioxidant function as assessed by increased normalized HDL lipid peroxide content (nHDLox).

RESULTS

Participants with AF had a 9% higher mean relative nHDLox compared to persons without AF (P = .025). nHDLox was strongly associated with AF in all models of logistic regression, including the analysis adjusted for age, sex, and risk factors for AF (all P ≤.01).

CONCLUSION

Reduced antioxidant HDL function is associated with the presence of AF, which supports growing evidence that impaired lipoprotein function is linked to electrophysiological changes in cardiomyocytes. nHDLox is one of several contributors to the initiation and perpetuation of AF.

Identifying CLL patients at high risk of atrial fibrillation on treatment using machine learning

An increased risk of developing atrial fibrillation (AF) has been observed in patients with chronic lymphocytic leukemia (CLL) who were treated with ibrutinib and other BTK inhibitors. Previous studies have explored the prevalence of AF in CLL and the risk of developing AF at time of diagnosis. However, the interaction between treatment type with other risk factors on risk of developing atrial fibrillation at the time of treatment initiation has not been investigated. This becomes particularly crucial in CLL, as there is often a substantial time gap between diagnosis and treatment, unlike many other cancers. We propose a treatment-aware approach using predictive modeling to identify the risk factors associated with AF at time of treatment initiation. Moreover, the model provides treatment-dependent risk factors by including the interaction between the treatment types and other risk factors. The results demonstrated that the treatment-aware modeling including interactions outperformed currentrisk scores.

Impact of maintaining serum potassium concentration ≥ 3.6mEq/L versus ≥ 4.5mEq/L for 120 hours after isolated coronary artery bypass graft surgery on incidence of new onset atrial fibrillation: Protocol for a randomized non-inferiority trial

BACKGROUND

Atrial Fibrillation After Cardiac Surgery (AFACS) occurs in about one in three patients following Coronary Artery Bypass Grafting (CABG). It is associated with increased short- and long-term morbidity, mortality and costs. To reduce AFACS incidence, efforts are often made to maintain serum potassium in the high-normal range (≥ 4.5mEq/L). However, there is no evidence that this strategy is efficacious. Furthermore, the approach is costly, often unpleasant for patients, and risks causing harm. We describe the protocol of a planned randomized non-inferiority trial to investigate the impact of intervening to maintain serum potassium ≥ 3.6 mEq/L vs ≥ 4.5 mEq/L on incidence of new-onset AFACS after isolated elective CABG.

METHODS

Patients undergoing isolated CABG at sites in the UK and Germany will be recruited, randomized 1:1 and stratified by site to protocols maintaining serum potassium at either ≥ 3.6 mEq/L or ≥ 4.5 mEq/L. Participants will not be blind to treatment allocation. The primary endpoint is AFACS, defined as an episode of atrial fibrillation, flutter or tachycardia lasting ≥ 30 seconds until hour 120 after surgery, which is both clinically detected and electrocardiographically confirmed. Assuming a 35% incidence of AFACS in the 'tight control group', and allowing for a 10% loss to follow-up, 1684 participants are required to provide 90% certainty that the upper limit of a one-sided 97.5% confidence interval (CI) will exclude a > 10% difference in favour of tight potassium control. Secondary endpoints include mortality, use of hospital resources and incidence of dysrhythmias not meeting the primary endpoint (detected using continuous heart rhythm monitoring).

DISCUSSION

The Tight K Trial will assess whether a protocol to maintain serum potassium ≥ 3.6 mEq/L is non inferior to maintaining serum potassium ≥ 4.5 mEq/L in preventing new-onset AFACS after isolated CABG.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04053816. Registered on 13 August 2019. Last update 7 January 2021.

Incidental Arrhythmias During Atrial Fibrillation Screening With Repeat 7-Day Holter ECGs in a Hospital-Based Patient Population

BACKGROUND

Screening for atrial fibrillation (AF) may reveal incidental arrhythmias of relevance. The aim of this study was to describe incidental arrhythmias detected during screening for AF in the STAR-FIB (Predicting SilenT AtRial FIBrillation in Patients at High Thrombembolic Risk) cohort study.

METHODS AND RESULTS

In the STAR-FIB cohort study, we screened hospitalized patients for AF with 3 repeat 7-day Holter ECGs. We analyzed all Holter ECGs for the presence of the following incidental arrhythmias: (1) sinus node dysfunction, defined as sinus pause of ≥3 seconds' duration; (2) second-degree (including Wenckebach) or higher-degree atrioventricular block (AVB); (3) sustained supraventricular tachycardia of ≥30 seconds' duration; and (4) sustained ventricular tachycardia of ≥30 seconds' duration. We furthermore report treatment decisions because of incidental arrhythmias. A total of 2077 Holter ECGs were performed in 794 patients (mean age, 74.7 years; 49% women), resulting in a mean cumulative duration of analyzable ECG signal of 414±136 hours/patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were sinus node dysfunction in 14 patients (1.8%), AVB in 41 (5.2%), supraventricular tachycardia in 42 (5.3%), and ventricular tachycardia in 2 (0.3%). Second-degree AVB was found in 23 patients (2.9%), 2:1 AVB in 10 (1.3%), and complete AVB in 8 (1%). Subsequently, 8 patients underwent pacemaker implantation, 1 for sinus node dysfunction (post-AF conversion pause of 9 seconds) and 7 for advanced AVB. One patient had an implantable cardioverter-defibrillator implanted for syncopal ventricular tachycardia.

CONCLUSIONS

Incidental arrhythmias were frequently detected during screening for AF in the STAR-FIB study and resulted in device therapy in 1.1% of our cohort patients.

Associations of Dietary and Lifestyle Components with Atrial Fibrillation

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia that still remains a significant health concern, especially due to its consequences, including stroke and heart failure. This review explores the intricate interplay between AF, lifestyle choices, and dietary habits. It is particularly focused on findings from diverse studies about non-pharmacological methods of managing AF. Moreover, its purpose is to elucidate the implementation of lifestyle changes such as physical activity or proper diet choices in the integrated treatment strategy of patients with AF.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Incident Atrial Fibrillation and Survival Outcomes in Esophageal Cancer following Radiotherapy

PURPOSE

Radiation therapy (RT) associates with long-term cardiotoxicity. In preclinical models, RT exposure induces early cardiotoxic arrhythmias including atrial fibrillation (AF). Yet, whether this occurs in patients is unknown.

METHODS AND MATERIALS

Leveraging a large cohort of consecutive patients with esophageal cancer treated with thoracic RT from 2007 to 2019, we assessed incidence and outcomes of incident AF. Secondary outcomes included major adverse cardiovascular events (MACE), defined as AF, heart failure, ventricular arrhythmias, and sudden death, by cardiac RT dose. We also assessed the relationship between AF development and progression-free and overall survival. Observed incident AF rates were compared with Framingham predicted rates, and absolute excess risks were estimated. Multivariate regression was used to define the relationship between clinical and RT measures, and outcomes. Differences in outcomes, by AF status, were also evaluated via 30-day landmark analysis. Furthermore, we assessed the effect of cardiac substructure RT dose (eg, left atrium, LA) on the risk of post RT-related outcomes.

RESULTS

Overall, from 238 RT treated patients with esophageal cancer, 21.4% developed incident AF, and 33% developed MACE with the majority (84%) of events occurring ≤2 years of RT initiation (median time to AF, 4.1 months). Cumulative incidence of AF and MACE at 1 year was 19.5%, and 25.7%, respectively; translating into an observed incident AF rate of 824 per 10,000 person-years, compared with the Framingham predicted rate of 92 (relative risk, 8.96; P < .001, absolute excess risk 732). Increasing LA dose strongly associated with incident AF (P = .001); and those with AF saw worse disease progression (hazard ratio, 1.54; P = .03). In multivariate models, outside of traditional cancer-related factors, increasing RT dose to the LA remained associated with worse overall survival.

CONCLUSIONS

Among patients with esophageal cancer, radiation therapy increases AF risk, and associates with worse long-term outcomes.

Higher Cumulative Blood Pressure in Midlife Predicts an Increased Risk of Atrial Fibrillation: Evidence From the Atherosclerosis Risk in Communities Study

BACKGROUND

Elevated blood pressure (BP) is reportedly associated with an increased risk of atrial fibrillation (AF). However, the association between cumulative BP exposure in midlife and incident AF in mid-to-late life remains unclear.

METHODS AND RESULTS

Participants enrolled in the ARIC (Atherosclerosis Risk in Communities) study with 4 consecutive BP measurements and no prevalent AF at baseline were included. Cumulative BP was calculated as the area under the curve from visit 1 to visit 4. Incident AF was identified by study visit ECGs, hospital discharge codes, or death certificates. A total of 9892 participants were included (44.6% men and mean age 62.9±5.7 years at visit 4) with 1550 (15.7%) individuals who developed new-onset AF during an average follow-up of 15.4 years. The incidence rates of AF per 1000 person-years across the 4 quartiles of cumulative systolic BP were 7.9, 9.2, 12.5, and 16.9, respectively. After multivariable adjustment, the hazard ratios for incident AF among participants in the highest quartile of cumulative systolic BP, pulse pressure, and mean arterial pressure were 1.48 (95% CI, 1.27-1.72), 1.81 (95% CI, 1.53-2.13), and 1.22 (95% CI, 1.05-1.41), respectively, compared with those in the lowest quartile. The addition of cumulative systolic BP or pulse pressure slightly improved the ability to predict new-onset AF.

CONCLUSIONS

Higher exposure to cumulative systolic BP, pulse pressure, and mean arterial pressure was significantly associated with increased risk of incident AF.

Machine Learning for Predicting Postoperative Atrial Fibrillation After Cardiac Surgery: A Scoping Review of Current Literature

Postoperative atrial fibrillation (POAF) occurs in up to 20% to 55% of patients who underwent cardiac surgery. Machine learning (ML) has been increasingly employed in monitoring, screening, and identifying different cardiovascular clinical conditions. It was proposed that ML may be a useful tool for predicting POAF after cardiac surgery. An electronic database search was conducted on Medline, EMBASE, Cochrane, Google Scholar, and ClinicalTrials.gov to identify primary studies that investigated the role of ML in predicting POAF after cardiac surgery. A total of 5,955 citations were subjected to title and abstract screening, and ultimately 5 studies were included. The reported incidence of POAF ranged from 21.5% to 37.1%. The studied ML models included: deep learning, decision trees, logistic regression, support vector machines, gradient boosting decision tree, gradient-boosted machine, K-nearest neighbors, neural network, and random forest models. The sensitivity of the reported ML models ranged from 0.22 to 0.91, the specificity from 0.64 to 0.84, and the area under the receiver operating characteristic curve from 0.67 to 0.94. Age, gender, left atrial diameter, glomerular filtration rate, and duration of mechanical ventilation were significant clinical risk factors for POAF. Limited evidence suggest that machine learning models may play a role in predicting atrial fibrillation after cardiac surgery because of their ability to detect different patterns of correlations and the incorporation of several demographic and clinical variables. However, the heterogeneity of the included studies and the lack of external validation are the most important limitations against the routine incorporation of these models in routine practice. Artificial intelligence, cardiac surgery, decision tree, deep learning, gradient-boosted machine, gradient boosting decision tree, k-nearest neighbors, logistic regression, machine learning, neural network, postoperative atrial fibrillation, postoperative complications, random forest, risk scores, scoping review, support vector machine.

Paroxysmal Atrial Fibrillation (PFA) Detection With Cardiac Monitoring Devices Implanted by Neurologists in Patients With Embolic Strokes of Undetermined Source (ESUS)

Introduction Ischemic stroke is among the leading causes of death and disability. Approximately 50% of cryptogenic strokes are embolic strokes of undetermined source (ESUS). The most common cause of ESUS is atrial fibrillation. Therefore, the detection of atrial fibrillation with long-term implantable devices is needed. Neurologists are directly involved with acute and post-acute stroke care and have direct access to the management of stroke patients. Therefore, there is a need for neurologists to recommend, implant, and monitor cardiac implantable devices in patients with ESUS. Methods From November 2022 to October 2023, our group implanted 32 ESUS patients with Confirm Rx™ insertable cardiac monitors (Abbott, USA). Atrial fibrillation detection was supervised and monitored daily. Results In 24 months, atrial fibrillation was detected in 12.5% of patients (four patients), sinus bradycardia in 6.25% of patients (two patients), paroxysmal supraventricular tachycardia in 9.4% of patients (three patients), and asystole in one patient. Conclusion Our study shows that neurologists involved in the treatment of stroke care can safely implant, monitor, and detect atrial fibrillation accurately. Our rate of detection of atrial fibrillation in patients with ESUS was 12.8%, which is consistent with prior studies.

Atrial fibrillation in young hospitalized patients: Clinical characteristics, predictors of new onset, and outcomes

BACKGROUND

Atrial fibrillation (AF) in young adults is an uncommon and not well studied entity.

METHODS

Consecutive patients aged 18-45 years admitted to internal or cardiology services in a large tertiary medical center (January 1, 2009 through December 31, 2019) were included. Clinical, electrocardiographic, and echocardiographic data were compared between patients with and without AF at baseline. Predictors of new-onset AF in the young were identified using multivariate Cox regression model among patients free of baseline AF.

RESULTS

Final cohort included 16,432 patients with median age of 34 (IQR 26-41) years of whom 8914 (56 %) were men. Patients with AF at baseline (N = 366; 2 %) were older, more likely to be men, and had higher proportion of comorbidities and electrocardiographic conduction disorders. Male sex, increased age, obesity, heart failure, congenital heart disease (CHD) and the presence of left or right bundle branch block were all independently associated with baseline AF in a multivariate model (p < 0.001 for all). Sub-analysis of 10,691 (98 %) patients free of baseline AF identified 85 cases of new-onset AF during a median follow up of 3.5 (IQR 1.5-6.5) years. Multivariate model identified increased age, heart failure, and CHD as independent predictors of new-onset AF. Finally, the CHARGE-AF risk score outperformed the CHA2DS2-VASc score in AF prediction [AUC of ROC 0.75 (0.7-0.8) vs. 0.56 (0.48-0.65)].

CONCLUSIONS

AF among hospitalized young adults is not rare. Screening for new-onset AF in young post hospitalization patients may be guided by specific clinical predictors and the CHARGE-AF risk score.

A Discussion of the Contemporary Prediction Models for Atrial Fibrillation

Atrial Fibrillation is a complex disease state with many environmental and genetic risk factors. While there are environmental factors that have been shown to increase an individual's risk of atrial fibrillation, it has become clear that atrial fibrillation has a genetic component that influences why some patients are at a higher risk of developing atrial fibrillation compared to others. This review will first discuss the clinical diagnosis of atrial fibrillation and the corresponding rhythm atrial flutter. We will then discuss how a patients' risk of stroke can be assessed by using other clinical co-morbidities. We will then review the clinical risk factors that can be used to help predict an individual patient's risk of atrial fibrillation. Many of the clinical risk factors have been used to create several different risk scoring methods that will be reviewed. We will then discuss how genetics can be used to identify individuals who are at higher risk for developing atrial fibrillation. We will discuss genome-wide association studies and other sequencing high-throughput sequencing studies. Finally, we will touch on how genetic variants derived from a genome-wide association studies can be used to calculate an individual's polygenic risk score for atrial fibrillation. An atrial fibrillation polygenic risk score can be used to identify patients at higher risk of developing atrial fibrillation and may allow for a reduction in some of the complications associated with atrial fibrillation such as cerebrovascular accidents and the development of heart failure. Finally, there is a brief discussion of how artificial intelligence models can be used to predict which patients will develop atrial fibrillation.

New-onset atrial fibrillation prediction: the HARMS2-AF risk score

AIMS

Lifestyle risk factors are a modifiable target in atrial fibrillation (AF) management. The relative contribution of individual lifestyle risk factors to AF development has not been described. Development and validation of an AF lifestyle risk score to identify individuals at risk of AF in the general population are the aims of the study.

METHODS AND RESULTS

The UK Biobank (UKB) and Framingham Heart Study (FHS) are large prospective cohorts with outcomes measured >10 years. Incident AF was based on International Classification of Diseases version 10 coding. Prior AF was excluded. Cox proportional hazards regression identified independent AF predictors, which were evaluated in a multivariable model. A weighted score was developed in the UKB and externally validated in the FHS. Kaplan-Meier estimates ascertained the risk of AF development. Among 314 280 UKB participants, AF incidence was 5.7%, with median time to AF 7.6 years (interquartile range 4.5-10.2). Hypertension, age, body mass index, male sex, sleep apnoea, smoking, and alcohol were predictive variables (all P < 0.001); physical inactivity [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.96-1.05, P = 0.80] and diabetes (HR 1.03, 95% CI 0.97-1.09, P = 0·38) were not significant. The HARMS2-AF score had similar predictive performance [area under the curve (AUC) 0.782] to the unweighted model (AUC 0.802) in the UKB. External validation in the FHS (AF incidence 6.0% of 7171 participants) demonstrated an AUC of 0.757 (95% CI 0.735-0.779). A higher HARMS2-AF score (≥5 points) was associated with a heightened AF risk (score 5-9: HR 12.79; score 10-14: HR 38.70). The HARMS2-AF risk model outperformed the Framingham-AF (AUC 0.568) and ARIC (AUC 0.713) risk models (both P < 0.001) and was comparable to the CHARGE-AF risk score (AUC 0.754, P = 0.73).

CONCLUSION

The HARMS2-AF score is a novel lifestyle risk score which may help identify individuals at risk of AF in the general community and assist population screening.

Association Between Onset of Type 2 Diabetes and Risk of Atrial Fibrillation in New Zealanders With Impaired Glucose Tolerance Over 25 Years

Background The association between the onset of type 2 diabetes (T2D) and atrial fibrillation (AF) risk in individuals with impaired glucose tolerance (IGT) remains unclear. This study aimed to investigate the relationship between the incident onset of T2D and 5- and 10-year (after the landmark period) risks of AF in people with IGT identified in South and West Auckland primary care settings between 1994 and 2019. Methods and Results We compared AF risk in patients with IGT with and without newly diagnosed T2D within a 1- to 5-year exposure window. Tapered matching and landmark analysis (to address immortal bias) were used to control for confounding variables. The cohorts incorporated 785 patients who had T2D newly diagnosed within 5 years from enrollment (landmark date) and 15 079 patients without a T2D diagnosis. Patients progressing to T2D exhibited significantly higher 5-year (after the landmark period) AF risk (hazard ratio [HR], 1.34 [95% CI, 1.10-1.63]) and 10-year (after the landmark period) AF risk (HR, 1.28 [95% CI, 1.02-1.62]) compared with those without incident T2D. The association was more pronounced among men, older patients, socioeconomically deprived individuals, current smokers, those with higher metabolic measures, and lower renal function. New Zealand European ethnicity was associated with a lower 5- and 10-year risk of AF. Conclusions This study found a mediating effect of T2D on the risk of AF in a population with IGT in New Zealand. The development of risk scores and future replication studies can help identify and guide management of individuals with IGT at the highest risk of AF following incident T2D.

Direct oral anti-Xa anticoagulants versus warfarin in newly diagnosed atrial fibrillation and CKD: the Korean National Health Insurance Data

Introduction

Despite the benefits of direct oral anti-Xa anticoagulants (DOACs), the risk-benefit profile of DOAC therapy compared to warfarin therapy in patients with non-valvular atrial fibrillation (AF) and chronic kidney disease (CKD), including end-stage renal disease (ESRD), is uncertain.

Methods

We conducted a retrospective study using the Korea National Health Insurance Database from 2013 to 2018. We evaluated patients with incident non-valvular AF and CKD. The primary and secondary effectiveness outcomes were ischemic stroke and all-cause mortality. The primary safety outcomes included intracranial hemorrhage, gastrointestinal bleeding, and extracranial or unclassified major bleeding.

Results

Among the 1,885 patients evaluated, 970 (51.5%) initiated warfarin therapy, and 915 (48.5%) initiated DOAC therapy. During a mean follow-up period of 23.8 months, there were 293 and 214 cases of ischemic stroke and all-cause death, respectively. Kaplan-Meier survival analysis showed significantly lower all-cause mortality in DOAC users than in warfarin users. In multivariate Cox regression analyses, DOAC therapy had a hazard ratio for all-cause mortality of 0.41 (95% CI, 0.30-0.56; p < 0.001) compared to warfarin therapy. Additionally, DOAC therapy significantly reduced intracranial hemorrhage and gastrointestinal bleeding.

Discussion

Our study demonstrates that DOAC therapy has a better risk-benefit profile than warfarin therapy in patients with AF and CKD. Further well-designed clinical trials are needed to clarify the benefits of DOACs in this patient population.

Determinants of Atrial Fibrillation Progression and Its Influence on Overall Mortality in a Cohort of Patients From South India

BACKGROUND

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with increased morbidity and mortality. However, factors influencing AF progression and their impact on all-cause mortality in South Indian patients remain poorly understood.

METHODS

We conducted a retrospective cohort study involving 500 individuals diagnosed with AF. Patient characteristics, including age, sex, and comorbidities, were collected. Left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) were measured via echocardiography. Participants were followed for a median of three years. Cox proportional hazard regression was used to analyze factors associated with AF progression and all-cause mortality.

RESULTS

Of the participants, 60% exhibited persistent or permanent AF, and 40% had paroxysmal AF. The mean age was 63.5 ± 10.8 years, with 60% males and 40% females. Common comorbidities included hypertension (80%), diabetes (50%), and coronary artery disease (35%). The mean LAD was 42.3 ± 5.6 mm and the mean LVEF was 52.7 ± 6.8%; left atrial appendage thrombus (LAAT) was present in 15% of patients. Over the follow-up, 24% experienced all-cause mortality. Multivariate analysis revealed age, hypertension, diabetes, LAD, and LVEF as significant predictors of AF progression (p<0.05). Patients with persistent or permanent AF exhibited a higher risk of progression than those with paroxysmal AF (hazard ratio=1.74, 95% CI, 1.23-2.45). Age, hypertension, heart failure, and AF progression were independent predictors of all-cause mortality (p<0.05).

CONCLUSION

Our study identified age, hypertension, diabetes, LAD, and LVEF as independent predictors of AF progression. Additionally, age, hypertension, heart failure, and AF progression independently predicted all-cause mortality. These findings underscore the need for early detection and management of AF progression and comorbidities to improve outcomes in South Indian AF patients. Prospective studies with larger cohorts are warranted to confirm these findings and explore interventions to prevent AF progression and enhance patient outcomes.

Sex-specific risks for cardiovascular disease across the glycaemic spectrum: a population-based cohort study using the UK Biobank

Background

We sought to examine sex-specific risks for incident cardiovascular disease (CVD) across the full glycaemic spectrum.

Methods

Using data from UK Biobank, we categorised participants' glycated haemoglobin (HbA1c) at baseline as low-normal (<35 mmol/mol), normal (35-41 mmol/mol), pre-diabetes (42-47 mmol/mol), undiagnosed diabetes (≥48 mmol/mol), or diagnosed diabetes. Our outcomes were coronary artery disease (CAD), atrial fibrillation, deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, heart failure, and a composite outcome of any CVD. Cox regression estimated sex-specific associations between HbA1c and each outcome, sequentially adjusting for socio-demographic, lifestyle, and clinical characteristics.

Findings

Among 427,435 people, CVD rates were 16.9 and 9.1 events/1000 person-years for men and women, respectively. Both men and women with pre-diabetes, undiagnosed diabetes, and, more markedly, diagnosed diabetes were at higher risks of CVD than those with normal HbA1c, with relative increases more pronounced in women than men. Age-adjusted HRs for pre-diabetes and undiagnosed diabetes ranged from 1.30 to 1.47; HRs for diagnosed diabetes were 1.55 (1.49-1.61) in men and 2.00 (1.89-2.12) in women (p-interaction <0.0001). Excess risks attenuated and were more similar between men and women after adjusting for clinical and lifestyle factors particularly obesity and antihypertensive or statin use (fully adjusted HRs for diagnosed diabetes: 1.06 [1.02-1.11] and 1.17 [1.10-1.24], respectively).

Interpretation

Excess risks in men and women were largely explained by modifiable factors, and could be ameliorated by attention to weight reduction strategies and greater use of antihypertensive and statin medications. Addressing these risk factors could reduce sex disparities in risk of CVD among people with and without diabetes.

Funding

Diabetes UK (#15/0005250) and British Heart Foundation (SP/16/6/32726).

Brady- and tachyarrhythmias detected by continuous rhythm monitoring in paroxysmal atrial fibrillation

OBJECTIVE

Atrial fibrillation (AF) is associated with adverse events including conduction disturbances, ventricular arrhythmias and sudden death. The aim of this study was to examine brady- and tachyarrhythmias using continuous rhythm monitoring in patients with paroxysmal self-terminating AF (PAF).

METHODS

In this multicentre observational substudy to the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling and Vascular destabilisation in the progression of AF (RACE V), we included 392 patients with PAF and at least 2 years of continuous rhythm monitoring. All patients received an implantable loop recorder, and all detected episodes of tachycardia ≥182 beats per minute (BPM), bradycardia ≤30 BPM or pauses ≥5 s were adjudicated by three physicians.

RESULTS

Over 1272 patient-years of continuous rhythm monitoring, we adjudicated 1940 episodes in 175 patients (45%): 106 (27%) patients experienced rapid AF or atrial flutter (AFL), pauses ≥5 s or bradycardias ≤30 BPM occurred in 47 (12%) patients and in 22 (6%) patients, we observed both episode types. No sustained ventricular tachycardias occurred. In the multivariable analysis, age >70 years (HR 2.3, 95% CI 1.4 to 3.9), longer PR interval (HR 1.9, 1.1-3.1), CHA2DS2-VASc score ≥2 (HR 2.2, 1.1-4.5) and treatment with verapamil or diltiazem (HR 0.4, 0.2-1.0) were significantly associated with bradyarrhythmia episodes. Age >70 years was associated with lower rates of tachyarrhythmias.

CONCLUSIONS

In a cohort exclusive to patients with PAF, almost half experienced severe bradyarrhythmias or AF/AFL with rapid ventricular rates. Our data highlight a higher than anticipated bradyarrhythmia risk in PAF.

TRIAL REGISTRATION NUMBER

NCT02726698.

The association between lipoprotein(a) and atrial fibrillation: A systemic review and meta-analysis

Lipoprotein(a) (Lp[a]) is a particle consisting of a low-density lipoprotein (LDL)-like core connected to an apolipoprotein(a) chain, which is an established risk factor for cardiovascular disease. However, studies addressing the relationship between atrial fibrillation (AF) and Lp(a) demonstrated conflicted results. Thus, we sought to evaluate this relationship by conducting this systemic review and meta-analysis. We performed a comprehensive systematic search of health science databases, including PubMed, Embase, Cochrane Library, Web of Science, MEDLINE, and ScienceDirect, to identify all relevant literature from their inception to March 1, 2023. We identified nine related articles, which were eventually included in this study. Our study showed no association between Lp(a) with new-onset AF (HR = 1.45, 95% confidence interval [CI]: 0.57-3.67, p = .432). In addition, genetically elevated Lp(a) was not associated with the risk of atrial fibrillation (OR = 1.00, 95% CI: 1.00-1.00, p = .461). Different stratification of Lp(a) levels may have different outcomes. Also, higher Lp(a) levels may be inversely associated with the risk of developing AF compared to those with lower levels. Lp(a) levels were not associated with incident AF. Further research is needed to identify the mechanism underlying these results and better understand Lp(a) stratification for AF and the possible inverse association between Lp(a) and AF.

A randomized clinical trial of omega-3 fatty acid and vitamin D supplementation on electrocardiographic risk profiles

Beneficial and adverse associations with arrhythmias have been reported for omega-3 fatty acids (omega-3 FA) and Vitamin D. The 12 lead electrocardiogram (ECG) contains quantitative measures reflecting diverse aspects of electrophysiology that might provide insights into mechanisms underlying these associations. In a pre-specified ancillary study of the VITaminD and omegA-3 (VITAL) trial, we examined the effect of 1 g of marine omega-3 FA per day, comprised of 460 mg eicosapentanoic acid and 380 mg of docosahexaenoic acid, and 2000 IU VitaminD3 per day on ECG characteristics associated with atrial and ventricular arrhythmias among individuals age 50 years or greater. A total of 911 study participants underwent ECGs at baseline and again at 2 years after the randomization. Individuals randomized to active omega-3 FA demonstrated significant net increase in PR-interval duration (p = 0.005) and P-wave duration (p = 0.03) as well significant net decrease in P-wave amplitude (p = 0.037) as compared to placebo. RMSSD increased to a greater extent in the omega-3 FA arm compared to placebo (p = 0.040). For Vitamin D3, the Cornell voltage increased to a lesser extent in the participants assigned to active treatment as compared to placebo (p = 0.044). There were no other significant differences in QRS, QTc, Cornell voltage or heart rate. Thus, randomized treatment with omega-3 FA supplements resulted in changes on the ECG that are potentially reflective of heightened vagal tone and/or slowing of intraatrial and AV conduction. Vitamin D3 supplementation resulted in modest reductions in progressive LV voltage suggestive of a potential antihypertrophic effect.Trial registration ClinicalTrials.gov Identifiers: NCT01169259, NCT02178410 (06/26/2010 and 06/30/2014).

Clinical Application of the HCM-AF Risk Score in the Prediction of Clinical Outcomes of Polish Patients with Hypertrophic Cardiomyopathy

The recently introduced HCM-AF Risk Calculator allows the prognosis of atrial fibrillation (AF) occurrence in hypertrophic cardiomyopathy (HCM) patients. The aim of this study was to assess the clinical application of the HCM-AF Risk Score in the prediction of the clinical outcomes of Polish patients. The study included 92 patients (50.0% female, median age 55 years), with a baseline sinus rhythm diagnosed between 2013 and 2018. The analysis involved the incidence of clinical characteristics and outcomes, total mortality, rehospitalisation, and the course of heart failure (HF). According to the HCM-AF Risk Score, the HCM population was stratified into three subgroups, with a low (13/14.2%), intermediate (30/32.6%), and high risk of AF (49/53.2%). Subgroups differed significantly: the high-risk subgroup was older, had a higher body mass index (BMI), and more advanced signs of left ventricular (LV) hypertrophy and left atrium (LA) dilatation. The registered AF incidence was 31.5% and 43.5% in the 2- and 5-year follow-ups, and it was significantly higher than in the HCM-AF Risk Score population, which had 4.6% in the 2-year follow-up, and 10.7% in the 5-year follow-up. In the whole population, the AF incidence in both the 2- and 5-year follow-ups revealed a strong correlation with the HCM-AF Risk Score (r = 0.442, p < 0.001; r = 0.346, p < 0.001, respectively). The clinical outcomes differed among the subgroups: the total mortality was 15.4% vs. 20.0% vs. 42.9% (p < 0.05); rehospitalisation was 23.1% vs. 53.3% vs. 71.4% (p < 0.05). The highest HF progression was in the high-risk subgroup (36.7%). Regardless of the high results of the HCM-Risk Score in Polish patients, the score underestimates the real-life high level of AF incidence. The HCM-AF Risk Score seems to be useful in the prediction of the general clinical outcomes in HCM patients.

Association Between Electrocardiographic Age and Cardiovascular Events in Community Settings: The Framingham Heart Study

BACKGROUND

Deep neural networks have been used to estimate age from ECGs, the electrocardiographic age (ECG-age), which predicts adverse outcomes. However, this prediction ability has been restricted to clinical settings or relatively short periods. We hypothesized that ECG-age is associated with death and cardiovascular outcomes in the long-standing community-based FHS (Framingham Heart Study).

METHODS

We tested the association of ECG-age with chronological age in the FHS cohorts in ECGs from 1986 to 2021. We calculated the gap between chronological and ECG-age (Δage) and classified individuals as having normal, accelerated, or decelerated aging, if Δage was within, higher, or lower than the mean absolute error of the model, respectively. We assessed the associations of Δage, accelerated and decelerated aging with death or cardiovascular outcomes (atrial fibrillation, myocardial infarction, and heart failure) using Cox proportional hazards models adjusted for age, sex, and clinical factors.

RESULTS

The study population included 9877 FHS participants (mean age, 55±13 years; 54.9% women) with 34 948 ECGs. ECG-age was correlated to chronological age (r=0.81; mean absolute error, 9±7 years). After 17±8 years of follow-up, every 10-year increase of Δage was associated with 18% increase in all-cause mortality (hazard ratio [HR], 1.18 [95% CI, 1.12-1.23]), 23% increase in atrial fibrillation risk (HR, 1.23 [95% CI, 1.17-1.29]), 14% increase in myocardial infarction risk (HR, 1.14 [95% CI, 1.05-1.23]), and 40% increase in heart failure risk (HR, 1.40 [95% CI, 1.30-1.52]), in multivariable models. In addition, accelerated aging was associated with a 28% increase in all-cause mortality (HR, 1.28 [95% CI, 1.14-1.45]), whereas decelerated aging was associated with a 16% decrease (HR, 0.84 [95% CI, 0.74-0.95]).

CONCLUSIONS

ECG-age was highly correlated with chronological age in FHS. The difference between ECG-age and chronological age was associated with death, myocardial infarction, atrial fibrillation, and heart failure. Given the wide availability and low cost of ECG, ECG-age could be a scalable biomarker of cardiovascular risk.

Risk Factors and Prognostic Implications of New-Onset Paroxysmal Atrial Fibrillation in Patients Hospitalized with Intracerebral Hemorrhage

Objective

We aimed to assess the prevalence and risk factors of new-onset paroxysmal atrial fibrillation (PAF) in patients hospitalized with ICH and determine whether the new-onset PAF had influenced functional outcomes.

Methods

We analyzed a database of all consecutive patients with ICH from October 2013 to May 2022. Univariate and multivariable regression analyses were performed to identify risk factors for new-onset PAF in patients with ICH. Multivariate models were also constructed to assess whether the new-onset PAF was an independent predictor of poor functional outcome, as measured using the modified Rankin scale.

Results

This study included 650 patients with ICH, among whom 24 patients had new-onset PAF. In the multivariable model, older age (OR per 10-y increase, 2.26 [95% CI, 1.52-3.35]; P<0.001), hematoma volume (OR per 10-mL increase, 1.80 [95% CI, 1.26-2.57]; P=0.001), and heart failure (OR, 21.77 [95% CI, 5.52-85.91]; P<0.001) were independent risk factors for new-onset PAF. In a sensitivity analysis restricted to 428 patients with N-terminal pro-B-type natriuretic peptide (NT-proBNP), older age, larger hematoma volume, heart failure, and increased NT-proBNP were associated with new-onset PAF. After adjusting for baseline variables, new-onset PAF was an independent predictor of poor functional outcome (OR, 10.35 [95% CI, 1.08-98.80]; P=0.042).

Conclusion

Older age, larger hematoma volume, and heart failure were independent risk factors for new-onset PAF after ICH. Increased NT-proBNP is correlated with higher risks for new-onset PAF when their information is available at admission. Furthermore, new-onset PAF is a significant predictor of poor functional outcome.

U-shaped association between the triglyceride-glucose index and atrial fibrillation incidence in a general population without known cardiovascular disease

OBJECTIVE

The triglyceride-glucose (TyG) index has been shown to be a new alternative measure for insulin resistance. However, no study has attempted to investigate the association of the TyG index with incident atrial fibrillation (AF) in the general population without known cardiovascular diseases.

METHODS

Individuals without known cardiovascular diseases (heart failure, coronary heart disease, or stroke) from the Atherosclerosis Risk in Communities (ARIC) cohort were recruited. The baseline TyG index was calculated as the Ln [fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The association between the baseline TyG index and incident AF was examined using Cox regression.

RESULTS

Of 11,851 participants, the mean age was 54.0 years; 6586 (55.6%) were female. During a median follow-up of 24.26 years, 1925 incidents of AF cases (0.78/per 100 person-years) occurred. An increased AF incidence with a graded TyG index was found by Kaplan‒Meier curves (P < 0.001). In multivariable-adjusted analysis, both < 8.80 (adjusted hazard ratio [aHR] = 1.15, 95% confidence interval [CI] 1.02, 1.29) and > 9.20 levels (aHR 1.18, 95% CI 1.03, 1.37) of the TyG index were associated with an increased risk of AF compared with the middle TyG index category (8.80-9.20). The exposure-effect analysis confirmed the U-shaped association between the TyG index and AF incidence (P = 0.041). Further sex-specific analysis showed that a U-shaped association between the TyG index and incident AF still existed in females but not in males.

CONCLUSIONS

A U-shaped association between the TyG index and AF incidence is observed in Americans without known cardiovascular diseases. Female sex may be a modifier in the association between the TyG index and AF incidence.

Artificial intelligence in cardiovascular prevention: new ways will open new doors

Prevention and effective treatment of cardiovascular disease are progressive issues that grow in tandem with the average age of the world population. Over recent decades, the potential role of artificial intelligence in cardiovascular medicine has been increasingly recognized because of the incredible amount of real-world data (RWD) regarding patient health status and healthcare delivery that can be collated from a variety of sources wherein patient information is routinely collected, including patient registries, clinical case reports, reimbursement claims and billing reports, medical devices, and electronic health records. Like any other (health) data, RWD can be analysed in accordance with high-quality research methods, and its analysis can deliver valuable patient-centric insights complementing the information obtained from conventional clinical trials. Artificial intelligence application on RWD has the potential to detect a patient's health trajectory leading to personalized medicine and tailored treatment. This article reviews the benefits of artificial intelligence in cardiovascular prevention and management, focusing on diagnostic and therapeutic improvements without neglecting the limitations of this new scientific approach.

Development of a clinical score to estimate pancreatitis-related hospital admissions in patients with a new diagnosis of chronic pancreatitis: the trinity score

BACKGROUND

The clinical course of chronic pancreatitis is unpredictable and there is no globally accepted score to predict the disease course. We developed a clinical score to estimate pancreatitis-related hospitalisation in patients with newly diagnosed chronic pancreatitis.

METHODS

We conducted a retrospective cohort study using two clinical chronic pancreatitis databases held in tertiary referral centres in Dublin, Ireland, and in Tarragona, Spain. Individuals diagnosed with chronic pancreatitis between 2007 and 2014 were eligible for inclusion. Candidate predictors included aetiology, body mass index, exocrine dysfunction, smoking and alcohol history. We used multivariable logistic regression to develop the model.

RESULTS

We analysed data from 154 patients with newly diagnosed chronic pancreatitis. Of these, 105 patients (68%) had at least one hospital admission for pancreatitis-related reasons in the 6 years following diagnosis. Aetiology of chronic pancreatitis, body mass index, use of pain medications and gender were found to be predictive of more pancreatic-related hospital admissions. These predictors were used to develop a clinical score which showed acceptable discrimination (area under the ROC curve = 0.70).

DISCUSSION

We developed a clinical score based on easily accessible clinical parameters to predict pancreatitis-related hospitalisation in patients with newly diagnosed chronic pancreatitis.

Artificial Intelligence for the Detection and Treatment of Atrial Fibrillation

AF is the most common clinically relevant cardiac arrhythmia associated with multiple comorbidities, cardiovascular complications (e.g. stroke) and increased mortality. As artificial intelligence (AI) continues to transform the practice of medicine, this review article highlights specific applications of AI for the screening, diagnosis and treatment of AF. Routinely used digital devices and diagnostic technology have been significantly enhanced by these AI algorithms, increasing the potential for large-scale population-based screening and improved diagnostic assessments. These technologies have similarly impacted the treatment pathway of AF, identifying patients who may benefit from specific therapeutic interventions. While the application of AI to the diagnostic and therapeutic pathway of AF has been tremendously successful, the pitfalls and limitations of these algorithms must be thoroughly considered. Overall, the multifaceted applications of AI for AF are a hallmark of this emerging era of medicine.

Direct Oral Anticoagulants: An Updated Systematic Review of Their Clinical Pharmacology and Clinical Effectiveness and Safety in Patients With Nonvalvular Atrial Fibrillation

Direct oral anticoagulants have been an increasingly used class of drugs in the setting of nonvalvular atrial fibrillation, defying vitamin K antagonists' monopoly when it comes to anticoagulation due to its several limitations. Direct oral anticoagulants (DOACs) have entered the market as a noninferior and safer option in comparison with vitamin K antagonists, as their respective phase III clinical trials proved. The aim of this article was to update and summarize data on their clinical pharmacology and to review real-world data to know their comparative effectiveness and safety. We performed a systematic review using PubMed, Google Scholar, Embase, and Web of Science as search engines. Regarding pharmacodynamics, there were no substantial changes reported from their original profile. There were many advances in the knowledge about clinical pharmacokinetics of DOACs that have had a direct impact on their clinical use, mainly related to drug-drug interactions. In a real-world setting, DOACs have shown to be noninferior in preventing thromboembolic events compared to vitamin K antagonists. In regards to safety, DOACs have shown a lower bleeding risk relative to warfarin. Comparison between DOACs has demonstrated rivaroxaban to have the highest bleeding risk. Overall, the evidence gathered showed few changes from the original data presented in phase III clinical trials, concluding that their real-world use coincides greatly with them.

Heart failure with reduced ejection fraction and atrial fibrillation: a Sub-Saharan African perspective

Cardiovascular diseases are a well-established cause of death in high-income countries. In the last 20 years, Sub-Saharan Africa (SSA) has seen one of the sharpest increases in cardiovascular disease-related mortality, superseding that of infectious diseases, including HIV/AIDS, in South Africa. This increase is evidenced by a growing burden of heart failure and atrial fibrillation (AF) risk factors. AF is a common comorbidity of heart failure with reduced ejection fraction (HFrEF), which predisposes to an increased risk of stroke, rehospitalizations, and mortality compared with patients in sinus rhythm. AF had the largest relative increase in cardiovascular disease burden between 1990 and 2010 in SSA and the second highest (106.4%) increase in disability-adjusted life-years (DALY) between 1990 and 2017. Over the last decade, significant advancements in the management of both HFrEF and AF have emerged. However, managing HFrEF/AF remains a clinical challenge for physicians, compounded by the suboptimal efficacy of guideline-mandated pharmacotherapy in this group of patients. There may be an essential role for racial differences and genetic influence on therapeutic outcomes of HFrEF/AF patients, further complicating our overall understanding of the disease and its pathophysiology. In SSA, the lack of accurate and up-to-date epidemiological data on this subgroup of patients presents a challenge in our quest to prevent and reduce adverse outcomes. This narrative review provides a contemporary overview of the epidemiology of HFrEF/AF in SSA. We highlight important differences in the demographic and aetiological profile and the management of this subpopulation, emphasizing what is currently known and, more importantly, what is still unknown about HFrEF/AF in SSA.

Variations in documentation of atrial fibrillation predicted by population and service level characteristics in primary health care in England

BACKGROUND

Identifying features associated with atrial fibrillation (AF) documentation could inform screening. This study used published data to describe differences in documented and estimated AF prevalence in general practices, and explored predictors of variations in AF prevalence.

METHODS

Cross-sectional study of 7318 general practices in England. Descriptive and inferential statistics were undertaken. Multiple linear regression was used to model the difference between estimated AF and documented AF, adjusted for population, practice and practice performance variables.

RESULTS

Documented AF prevalence was lower than estimated (- 0.55% 95% confidence intervals, -1.89, 2.99). The proportion of variability accounted for in the final regression model was 0.25. Factors positively associated with AF documentation (increase in difference between estimated and documented), were patients 65-74 years, 75 years +, Black or South Asian ethnicity, diabetes mellitus and practices in East and Midlands of England. Eight variables (female patients, deprivation score, heart failure and peripheral artery disease, total patients per practice, full-time GPs and nurses; and location in South of England) were negatively associated with AF documentation (reduction in difference).

CONCLUSION

Variations in AF documentation were predicted by several practice and population characteristics. Screening could target these sources of variation to decrease variation and improve AF documentation.

Associations of risk factor burden and genetic predisposition with the 10-year risk of atrial fibrillation: observations from a large prospective study of 348,904 participants

BACKGROUND

Understanding the effects of risk factor burden and genetic predisposition on the long-term risk of atrial fibrillation (AF) is important to improve public health initiatives. However, the 10-year risk of AF considering risk factor burden and genetic predisposition is unknown.

METHODS

A total of 348,904 genetically unrelated participants without AF at baseline from the UK were categorized into three groups: index ages 45 years (n = 84,206), 55 years (n=117,520), and 65 years (n=147,178). Optimal, borderline, or elevated risk factor burden was determined by body mass index, blood pressure, diabetes mellitus, alcohol consumption, smoking status, and history of myocardial infarction or heart failure. Genetic predisposition was estimated using the polygenic risk score (PRS), constructed using 165 predefined genetic risk variants. The combined effects of risk factor burden and PRS on the risk of incident AF in 10 years were estimated for each index age. Fine and Gray models were developed to predict the 10-year risk of AF.

RESULTS

The overall 10-year risk of AF was 0.67% (95% CI: 0.61-0.73%) for index age 45 years, 2.05% (95% CI: 1.96-2.13%) for index age 55 years, and 6.34% (95% CI: 6.21-6.46%) for index age 65 years, respectively. An optimal risk factor burden was associated with later AF onset regardless of genetic predisposition and sex (P < 0.001). Significant synergistic interactions were observed for risk factor burden with PRS at each index age (P < 0.05). Participants with an elevated risk factor burden and high PRS had the highest 10-year risk of AF in reference to those who had both an optimal risk factor burden and a low PRS. At younger ages, optimal risk burden and high PRS might also lead to later onset of AF, compared to the joint effect of elevated risk burden and low/intermediate PRS.

CONCLUSIONS

Risk factor burden together with a genetic predisposition is associated with the 10-year risk of AF. Our results may be helpful in selecting high-risk individuals for primary prevention of AF and facilitating subsequent health interventions.

Prevalence and prognosis of atrial fibrillation in a hypertensive population: A prospective cohort study

Identifying risk factors for atrial fibrillation (AF) and evaluating their impact are essential to avoid the occurrence of adverse events. However, few studies to date have explored the prevalence, risk factors, and prognosis of AF in hypertensive patients. The objective of this study was to investigate the epidemiology of AF in a hypertensive population and determine the relationship between AF and all-cause mortality. At baseline, a total of 8541 Chinese patients with hypertension were enrolled from the Northeast Rural Cardiovascular Health Study. A logistic regression model was established to assess the relationship between blood pressure and AF, and Kaplan-Meier survival curve analysis and multivariate Cox regression were used to explore the relationship between AF and all-cause mortality. Meanwhile, subgroup analyses illustrated the robustness of results. This study found that the overall prevalence rate of AF was 1.4% in its Chinese hypertensive population. After adjusting for the confounding factors, every standard deviation increase in diastolic blood pressure (DBP) was associated with a 37% increase in the prevalence of AF (95% confidence interval: 1.152-1.627, p < .001). Compared to hypertensive patients without AF, those with AF had an increased risk of all-cause mortality (hazard ratio = 1.866, 95% confidence interval: 1.117-3.115, p = .017) in the adjusted model. The results show that the burden of AF is quite large in rural-dwelling Chinese hypertensive patients. Focusing on the control of DBP to prevent the occurrence of AF can be helpful. Meanwhile, AF increases risk of all-cause mortality in hypertensive patients. Our results indicated a huge burden of AF. Considering that most of the risk factors of AF were unmodifiable in hypertensive individuals and given their high risk of mortality, long-term interventions, including AF education, timely screening, and widespread use of anticoagulant drugs, should be emphasized in hypertensive populations.

Current Evidence on Prevention of Atrial Fibrillation: Modifiable Risk Factors and the Effects of Risk Factor Intervention

Atrial fibrillation (AF) is one of the most encountered arrhythmias in clinical practice. It is also estimated that the absolute AF burden may increase by greater than 60% by 2050. It is inevitable that AF will become one of the largest epidemics in the world and may pose a major health problem for countries. Although AF rarely causes mortality in the acute period, it causes a significant increase in mortality and morbidity, including a fivefold increase in the risk of stroke, a twofold increase in dementia, and a twofold increase in myocardial infarction in the chronic period. Despite all the advances in the treatment of AF, it is better understood day by day that preventing AF may play a key role in reducing AF and its related complications. Modification of the main modifiable factors such as quitting smoking, abstaining from alcohol, changing eating habits, and exercise seems to be the first step in preventing AF. The strict adherence to the treatment process of secondary causes predisposing to AF such as DM, hypertension, obesity, and sleep apnea is another step in the prevention of AF. Both an individual approach and global public health campaigns can be highly beneficial to reduce the risk of AF. In this review, we aimed to summarize the current evidence on the relationship between modifiable risk factors and AF, and the impact of possible interventions on these factors in preventing or reducing the AF burden in the light of recently published guidelines and studies.

Association Between rs2200733 Polymorphism of PITX2 Gene and the Risk of Atrial Fibrillation

BACKGROUND

As observed in recent genetic studies, PITX2 is one of the most popular genes with atrial fibrillation; single nucleotide polymorphism (rs2200733) at chromosome 4q25 (near PITX2) is found to be strongly associated with atrial fibrillation, but it has a difference among Chinese Han population. The basic aim of conducting this study is to find the correlation between PITX2 gene polymorphism and the risk of atrial fibrillation and to identify the possibility for early diagnosis of silent atrial fibrillation and high-risk atrial fibrillation.

METHODS

The study included 98 cases of atrial fibrillation patients and 88 non-atrial fibrillation patients in Affiliated Hospital of Yangzhou University were enrolled in a case-control study. The single nucleotide polymorphism of rs2200733 at 4q25 near PITX2 was genotyped by polymerase chain reaction-restriction fragment length polymorphism analysis.

RESULTS

A total of 98 patients with atrial fibrillation were genotyped, and the following frequencies were included in genotype percentages (44.9%, 50%, and 5.1%) while distribution of significant single nucleotide polymorphism rs2200733 consisted (29.55%, 53.41%, and 17.05%) which showed (χ2 = 9.159, P =.01). There was no significant difference in TC genotype frequency (P =.642), frequency of T allele (χ2 = 7.447, P =.006), and T allele was 1.806 times that of the control group (odds ratio = 1.806, 95% CI = 1.179-2.766, P =.006). According to logistic regression analysis, following results were concluded for TC genotype (odds ratio = 3.128, 95% CI = 1.053-9.287, P =.04), or TT genotype (odds ratio = 5.077, 95% CI = 1.653-15.595, P =.005) increased the risk of atrial fibrillation.

CONCLUSIONS

The genotype and allele frequency distribution of rs2200733 (T/C) near PITX2 is different in the atrial fibrillation group and the control group. The T allele is a risk factor for atrial fibrillation. Compared with the CC genotype, the TT genotype increased the risk of atrial fibrillation.

Evaluation of Huawei smart wearables for detection of atrial fibrillation in patients following ischemic stroke: The Liverpool-Huawei stroke study

BACKGROUND

Atrial fibrillation (AF) often remains undetected following stroke. Documenting AF is critical to initiate oral anticoagulation, which has proven benefit in reducing recurrent stroke and mortality in patients with AF. The accuracy and acceptability of using smart wearables to detect AF in patients following stroke is unknown.

METHODS

The aims of the Liverpool-Huawei Stroke Study are to determine the effectiveness, cost-effectiveness and patient and staff acceptability of using Huawei smart wearables to detect AF following ischemic stroke. The study plans to recruit 1,000 adults aged ≥18 years following ischemic stroke from participating hospitals over 12 months. All participants will be asked to wear a Huawei smart band for 4 weeks postdischarge. If participants do not have access to a compatible smartphone required for the study, they will be provided with a smartphone for the 4-week AF monitoring period.

RESULTS

Participants with suspected AF detected by the smart wearables, without previous known AF, will be referred for further evaluation. To determine the effectiveness of the Huawei smart wearables to detect AF, the positive predictive value will be determined. Patient acceptability of using this technology will also be examined. Additional follow-up assessments will be conducted at 6 and 12 months, and clinical outcomes recorded in relation to prevalent and incident AF post-stroke. The study opened for recruitment on May 30, 2022, and is currently open at 4 participating hospitals; the first 106 participants have been recruited. One further hospital is preparing to open for recruitment.

CONCLUSIONS

This prospective study will examine the effectiveness and acceptability of the use of smart wearables in patients following ischemic stroke. This could have important implications for detection of AF and therefore, earlier prophylaxis for recurrent stroke. The study is registered on https://www.isrctn.com/ (Identifier ISRCTN30693819).

Associations of high-normal blood pressure and impaired fasting glucose with atrial fibrillation

OBJECTIVE

To investigate the association of high-normal blood pressure (BP) and impaired fasting glucose (IFG) with the risk of atrial fibrillation (AF) in two cohorts.

METHODS

The Korean National Health Insurance Service-Health Screening (K-NHIS-HealS, 2002-2003, follow-up until 2013) Study and the UK Biobank (2007-2010, follow-up until 2021) were evaluated. We used Cox proportional hazards regression models to evaluate the associations of high-normal BP and IFG with incident AF.

RESULTS

In the K-NHIS-HealS and the UK Biobank, 2346 and 5314 incident AF events were recorded during the mean follow-up of 7.4 and 11.8 years. The adjusted HRs (95% CIs) for AF in the Korean and UK cohorts were 1.11 (1.02 to 1.21) and 1.07 (1.01 to 1.13) in individuals with high-normal BP; and 1.14 (1.04 to 1.25) and 1.10 (1.01 to 1.20) in individuals with IFG, respectively. The AF risk showed a dose-response relationship with BP and fasting blood glucose level. The risk of incident AF was increased by the combination of high-normal BP and IFG.

CONCLUSIONS

In healthy individuals, high-normal BP and IFG were important risk factors for AF. When high-normal BP and IFG were combined, the risk of new-onset AF was significantly increased. These findings may suggest that lifestyle interventions for high-normal BP and IFG should be considered to reduce the risk of AF.

Value of baseline characteristics in the risk prediction of atrial fibrillation

Introduction

Atrial fibrillation (AF) is prone to heart failure and stroke. Early management can effectively reduce the stroke rate and mortality. Current clinical guidelines screen high-risk individuals based solely on age, while this study aims to explore the possibility of other AF risk predictors.

Methods

A total of 18,738 elderly people (aged over 60 years old) in Chinese communities were enrolled in this study. The baseline characteristics were mainly based on the diagnosis results of electrocardiogram (ECG) machine during follow up, accompanied by some auxiliary physical examination basic data. After the analysis of both independent and combined baseline characteristics, AF risk predictors were obtained and prioritized according to the results. Independent characteristics were studied from three aspects: Chi-square test, Mann-Whitney U test and Cox univariate regression analysis. Combined characteristics were studied from two aspects: machine learning models and Cox multivariate regression analysis, and the former was combined with recursive feature elimination method and voting decision.

Results

The resulted optimal combination of risk predictors included age, atrial premature beats, atrial flutter, left ventricular hypertrophy, hypertension and heart disease.

Conclusion

Patients diagnosed by short-time ECG machines with the occurrence of the above events had a higher probability of AF episodes, who are suggested to be included in the focus of long-term ECG monitoring or increased screening density. The incidence of risk predictors in different age ranges of AF patients suggests differences in age-specific patient management. This can help improve the detection rate of AF, standardize the management of patients, and slow down the progression of AF.

Risk factor structure of heart failure in patients with cancer after treatment with anticancer agents' assessment by big data from a Japanese electronic health record

As the prognosis of cancer patients has been improved, comorbidity of heart failure (HF) in cancer survivors is a serious concern, especially in the aged population. This study aimed to examine the risk factors of HF development after treatment by anticancer agents, using a machine learning-based analysis of a massive dataset obtained from the electronic health record (EHR) in Japan. This retrospective, cohort study, using a dataset from 2008 to 2017 in the Diagnosis Procedure Combination (DPC) database in Japan, enrolled 140,327 patients. The structure of risk factors was determined using multivariable analysis and classification and regression tree (CART) algorithm for time-to-event data. The mean follow-up period was 1.55 years. The prevalence of HF after anticancer agent administration were 4.0%. HF was more prevalent in the older than the younger. As the presence of cardiovascular diseases and various risk factors predicted HF, CART analysis of the risk factors revealed that the risk factor structures complicatedly differed among different age groups. The highest risk combination was hypertension, diabetes mellitus, and atrial fibrillation in the group aged  ≤ 64 years, and the presence of ischemic heart disease was a key in both groups aged 65-74 years and 75 ≤ years. The machine learning-based approach was able to develop complicated HF risk structures in cancer patients after anticancer agents in different age population, of which knowledge would be essential for realizing precision medicine to improve the prognosis of cancer patients.

Development and validation of prediction models for incident atrial fibrillation in heart failure

OBJECTIVES

Accurate prediction of heart failure (HF) patients at high risk of atrial fibrillation (AF) represents a potentially valuable tool to inform shared decision making. No validated prediction model for AF in HF is currently available. The objective was to develop clinical prediction models for 1-year risk of AF.

METHODS

Using the Danish Heart Failure Registry, we conducted a nationwide registry-based cohort study of all incident HF patients diagnosed from 2008 to 2018 and without history of AF. Administrative data sources provided the predictors. We used a cause-specific Cox regression model framework to predict 1-year risk of AF. Internal validity was examined using temporal validation.

RESULTS

The population included 27 947 HF patients (mean age 69 years; 34% female). Clinical experts preselected sex, age at HF, NewYork Heart Association (NYHA) class, hypertension, diabetes mellitus, chronic kidney disease, obstructive sleep apnoea, chronic obstructive pulmonary disease and myocardial infarction. Among patients aged 70 years at HF, the predicted 1-year risk was 9.3% (95% CI 7.1% to 11.8%) for males and 6.4% (95% CI 4.9% to 8.3%) for females given all risk factors and NYHA III/IV, and 7.5% (95% CI 6.7% to 8.4%) and 5.1% (95% CI 4.5% to 5.8%), respectively, given absence of risk factors and NYHA class I. The area under the curve was 65.7% (95% CI 63.9% to 67.5%) and Brier score 7.0% (95% CI 5.2% to 8.9%).

CONCLUSION

We developed a prediction model for the 1-year risk of AF. Application of the model in routine clinical settings is necessary to determine the possibility of predicting AF risk among patients with HF more accurately and if so, to quantify the clinical effects of implementing the model in practice.