Increased atrial fibrillation mortality: United States, 1980-1998

Cannabis, cocaine, methamphetamine, and opiates increase the risk of incident atrial fibrillation

AIMS

Atrial fibrillation (AF) is now regarded as a preventable disease, requiring a search for modifiable risk factors. With legalization of cannabis and more lenient laws regarding the use of other illicit substances, investigation into the potential effects of methamphetamine, cocaine, opiate, and cannabis exposure on incident AF is needed.

METHODS AND RESULTS

Using Office of Statewide Health Planning and Development databases, a longitudinal analysis was performed of adult Californians ≥18 years of age who received care in an emergency department, outpatient surgery facility, or hospital from 1 January 2005 to 31 December 2015. Associations between healthcare coding for the use of each substance and a new AF diagnosis were assessed. Among 23,561,884 patients, 98 271 used methamphetamine, 48 701 used cocaine, 10 032 used opiates, and 132 834 used cannabis. Of the total population, 998 747 patients (4.2%) developed incident AF during the study period. After adjusting for potential confounders and mediators, use of methamphetamines, cocaine, opiates, and cannabis was each associated with increased incidence of AF: hazard ratios 1.86 [95% confidence interval (CI) 1.81-1.92], 1.61 (95% CI 1.55-1.68), 1.74 (95% CI 1.62-1.87), and 1.35 (95% CI 1.30-1.40), respectively. Negative control analyses in the same cohort failed to reveal similarly consistent positive relationships.

CONCLUSION

Methamphetamine, cocaine, opiate, and cannabis uses were each associated with increased risk of developing incident AF. Efforts to mitigate the use of these substances may represent a novel approach to AF prevention.

Influence of pulsating intracardiac blood flow on radiofrequency catheter ablation outcomes in an anatomy-based atrium model

BACKGROUND

Highly consistent cardiac ablation outcomes through radiofrequency catheter ablation (RFCA) under pulsatile and constant flow profiles (PP&CP) of intracardiac blood were previously indicated by computer modeling, with simplified geometry and lossless receipt of inflow for ablation catheters. This study aimed to further investigate the effects of intracardiac blood pulsatility in an anatomy-based atrium model.

METHODS

Four pulmonary veins were blood inflows at 10 mm Hg. The mitral valve was the outflow, with PP based on pulsatile velocity curve from clinical measurements, and CP was obtained by averaging the velocity curve under PP over an ablation time of 30 s. A numerical comparison between ablation results under PP and CP, without experimental validation, was performed.

RESULTS

Temperature fluctuations persisted in mid-myocardium, and most clearly in blood and endocardium under PP. At a constant power of 20 W, marked differences in ablation outcome between PP and CP occurred in the middle of unilateral pulmonary veins and the posterior wall of the left atrium (LA) where the blood velocities were significantly decreased under CP. The mid-myocardial, blood and endocardial temperatures, as well as the effective lesion volume at the former position, were decreased by 4.1%, 15%, 13.6%, and 13.8%, respectively under PP. The extents for the latter position were 11%, 22%, 22.5%, and 55.6%, respectively.

CONCLUSION

Intracardiac flow pulsatility causes a greater reduction in blood and endocardial temperatures at ablation sites away from the main bloodstream, effective cooling of which is more likely to rely on blood velocities approaching peak PP values.

Sex-Differences in Atrial Fibrillation Patients: Bias or Proper Management?

Background

Studies analyze the degree to which gender-based differences are affected by age and comorbidities show mixed results.

Methods

Using a retrospective cohort study, we analyzed 327 consecutive patients who presented to the emergency department (ED) due to Atrial Fibrillation (AF) from 2014 to 2017 with follow-up at one year.

Results

Females with AF were older (p < 0.001), with higher Body Mass Indexes (BMI) (p < 0.001), and a higher rate of hypertension (p < 0.001), hyperlipidemia (p = 0.01), diabetes mellitus (p = 0.05), valvular heart disease (p = 0.05), and thyroid dysfunction (18.3% vs 1.8%, p < 0.001). AF males had higher rate of coronary artery disease (p < 0.001) and heart failure with reduced ejection fraction (p < 0.001). Females were managed with rate control medications more frequently than with antiarrhythmic (p < 0.001). After adjusting gender to age and comorbidities, females continued to have higher rates of heart failure hospitalization (Odds Ratio (OR) 2.73 95% Confidence Interval (CI) 1.04-5.89, P-value <0.001) and recurrent AF (OR 3.86, P-value=0.02). Thyroid dysfunction and the lack of antiarrhythmic treatments significantly increased the risk of AF (OR 5.95 95% CI 3.15-9.73, OR 3.42, respectively, P-value <0.001 for both) regardless of gender. The mortality rate differs only in a sub-group of females ≥75 years of age (OR 1.60, P < 0.001).

Conclusion

AF males and females differ significantly in baseline characteristics and tend to be treated unnecessarily differently for AF. Heart failure hospitalizations and recurrent AF continued to be associated with female AF patients, even after adjusting gender to age and comorbidities. Thyroid dysfunction and AF treatment may explain the higher rates of recurrent AF in female patients.

Healthcare resource utilization in patients with newly diagnosed atrial fibrillation in the United States

OBJECTIVES

To summarize healthcare resource utilization (HCRU) in patients with newly diagnosed (incident) paroxysmal or persistent atrial fibrillation (AF).

METHODS

This retrospective, observational cohort study assessed HCRU among patients with incident paroxysmal or persistent AF using data from 1 January 2015 to 30 September 2019 in the IBM MarketScan® Research Databases.

RESULTS

A total of 50,796 patients were identified in the overall incident AF cohort. Rates of all-cause inpatient hospital stays, all-cause emergency room visits, and all-cause outpatient visits in the overall incident cohort were 46.8, 114.7, and 2,752.7 events per 100 patient-years (PY), respectively. Rates of cardiovascular-related inpatient stays for the overall population were 11.3 events per 100 PY. During follow-up, 50.4% of the overall cohort filled prescriptions for direct-acting oral anticoagulants and 5.0% had catheter ablation.

CONCLUSIONS

Advances in anticoagulation and ablation have been realized since previously published HCRU analyses of patients with atrial fibrillation. This update suggests that HCRU among patients with incident AF in the US remains high with some subgroups of patients receiving more specialized care.

Effect of anisotropy in myocardial electrical conductivity on lesion characteristics during radiofrequency cardiac ablation: a numerical study

BACKGROUND

Traditional computer simulation studies of radiofrequency catheter ablation (RFCA) usually neglect the anisotropy in myocardial electrical conductivity (MEC), which is likely an essential factor in governing the ablation outcome. Here, a numerical study of lesion characteristics during RFCA based on an anatomy-based model incorporating fiber orientation was performed to investigate the anisotropy in MEC.

METHODS

A three-dimensional thorax model including atria, blood, connective tissue, muscle, fat, and skin was constructed. The myocardial fiber was established through a rule-based method (RBM) based on the anatomical structure of the heart. The anisotropic MEC were 0.40 and 0.28 S m^-1 in longitudinal and transverse directions, respectively. The ablation result was compared with the isotropic scenario where the isotropic MEC was the average of the anisotropic conductivities as 0.34 S m^-1.

RESULTS

The complexity of fiber architecture varied with that of the local anatomical structure. At RF power of 20 W for 30 s, the tissue temperature and lesion volume were reduced by 2.8 ± 0.1% and 6.9 ± 0.5%, respectively, under anisotropic MEC around the ostium of the pulmonary vein and left atrial appendage. Those for the posterior wall and roof of the left atrium, and the inside of the superior vena cava were 1.9 ± 0.3% and 5.6 ± 1.2%, respectively.

CONCLUSIONS

Anisotropy in MEC has a greater reduction effect on lesion volume than on tissue temperature during RFCA; this effect tends to be restrained at positions with more uniform fiber distributions and can be enhanced where significant variation in fiber architecture occurred.

Quality indicators for the care and outcomes of adults with atrial fibrillation

AIMS

To develop quality indicators (QIs) that may be used to evaluate the quality of care and outcomes for adults with atrial fibrillation (AF).

METHODS AND RESULTS

We followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of AF care for the diagnosis and management of AF (by a group of experts including members of the ESC Clinical Practice Guidelines Task Force for AF); (ii) the construction of candidate QIs (including a systematic review of the literature); and (iii) the selection of the final set of QIs (using a modified Delphi method). Six domains of care for the diagnosis and management of AF were identified: (i) Patient assessment (baseline and follow-up), (ii) Anticoagulation therapy, (iii) Rate control strategy, (iv) Rhythm control strategy, (v) Risk factor management, and (vi) Outcomes measures, including patient-reported outcome measures (PROMs). In total, 17 main and 17 secondary QIs, which covered all six domains of care for the diagnosis and management of AF, were selected. The outcome domain included measures on the consequences and treatment of AF, as well as PROMs.

CONCLUSION

This document defines six domains of AF care (patient assessment, anticoagulation, rate control, rhythm control, risk factor management, and outcomes), and provides 17 main and 17 secondary QIs for the diagnosis and management of AF. It is anticipated that implementation of these QIs will improve the quality of AF care.

Racial Disparities in In-Hospital Adverse Events Among Patients With Atrial Fibrillation Implanted With a Watchman Left Atrial Appendage Occlusion Device: A US National Perspective

[Figure: see text].

Hypertension in middle eastern arab and south asian patients with atrial fibrillation: From a 20-year hospital registry in Qatar (1990-2010)

Background:

The vast majority of literature on atrial fibrillation (AF) is based on studies from the developed world that mainly includes Caucasian patients. Data on AF in other ethnicities is very limited. The aim of this hospital-based study is to evaluate the effect of concomitant hypertension (HTN) on the characteristics and outcomes of Middle Eastern Arab and South Asian patients with AF in the state of Qatar.

Materials and Methods and Results:

During the 20-year period, 3850 AF patients were hospitalized; 1483 (38.5%) had HTN, and 2367 (61.5%) without HTN. Patients with HTN were 11 years older, compared to non-HTN patients, and had a significantly higher prevalence of diabetes mellitus, chronic kidney disease, and dyslipidemia, compared to non-HTN patients. Furthermore, underlying coronary artery disease and heart failure were significantly more common but not valvular and rheumatic heart diseases which were more common in those without HTN. The rates of in-hospital mortality and stroke were significantly higher in the presence of HTN (5.3% versus 3.5%, and 0.7% versus 0.2% respectively, P = 0.001), compared to non-HTN patients.

Conclusions:

HTN is significantly associated with more comorbidities and worse clinical outcomes when it coexists with AF in hospitalized Middle Eastern Arab and South Asian patients.

Does Serum Uric Acid Status Influence the Association Between Left Atrium Diameter and Atrial Fibrillation in Hypertension Patients?

Objective: Both serum uric acid (SUA) levels and left atrium diameter (LAD) associate with AF. However, the influence of SUA status for the associated risk of AF related to LAD in hypertension patients is currently unknown.

Methods: We retrospectively analyzed a hospital-based sample of 9,618 hypertension patients. Standard electrocardiograms were performed on all patients and were interpreted by expert electro-physiologists.

Results: Overall 1,028 (10.69%) patients had AF out of 9,618 patients. In men >65 years of age, the prevalence of AF in the1st, 2nd, and 3rd tertiles of SUA among those grouped in the third tertile of LAD were 9, 12.3, and 21.7%, respectively. In the hyperuricemia group, the OR (95% CI) of AF for the highest tertile of LAD in men ≤ 65 years of age was 3.150 (1.756, 5.651; P < 0.001). Similarly, the hyperuricemic men in the 3rd LAD tertile had a higher likelihood of AF than those belonging to the 1st tertile. The ORs and (95% CIs) were 3.150 (1.756, 5.651; P < 0.001) and 5.522 (2.932, 10.400; P ≤ 0.001) for patients ≤ 65 and >65 years of age. An increase in SUA values was significantly associated with an increased likelihood of AF among women at the top tertiles of LAD, with the OR (95% CI) = 4.593 (1.857, 11.358; P = 0.001). Also, men> 65 years of age with large LAD, present at the third tertile of SUA, had a higher likelihood of AF, with the OR (95% CI) = 2.427 (1.039, 5.667; P < 0.05).

Conclusion: SUA levels and LAD are associated with AF in patients with hypertension and the risk of AF associated with LAD increases among those with hyperuricemia.

Healthcare costs of NVAF patients treated with rivaroxaban and apixaban in the US

OBJECTIVES

To provide the most current assessment of real-world healthcare resource utilization (HRU) and costs among patients with non-valvular atrial fibrillation (NVAF) who newly initiated rivaroxaban and apixaban using a large US database.

MATERIAL AND METHODS

A retrospective weighted cohort design was used with healthcare insurance claims from the Optum Clinformatics Data Mart databases (January 2012-December 2018). The index date was defined as the first dispensing of rivaroxaban or apixaban. Adult NVAF patients with an index date on or after 1 January 2016, ≥ 12 months of continuous eligibility before the index date and ≥ 1 month after, and without prior use of oral anticoagulant were included. The observation period spanned from the index date to the earliest of the end of data availability, end of insurance coverage, or death. Inverse probability of treatment weighting (IPTW) was used to adjust for differences in baseline characteristics between cohorts. All-cause healthcare resource utilization (HRU), including hospitalization, emergency room, and outpatient visits, and healthcare costs, including medical and pharmacy costs, were evaluated from the payer's perspective during the observation period up to 18 and 24 months, separately.

RESULTS

In total, 23,822 rivaroxaban and 53,666 apixaban users were included. After weighting, all baseline characteristics were well balanced between cohorts (mean age: 73.8 years, female: 46.6% in both cohorts). Up to 18 months of follow-up, rivaroxaban users incurred significantly lower total healthcare costs compared to apixaban users (cost difference = -$1,121; p = 0.020), driven by significantly lower rates of outpatient hospital visits and associated costs (cost difference = -$1,579; p < 0.001). Similar results were found in the analysis conducted for up to 24 months of follow-up (total cost difference = ‒$1,111; p = 0.020).

CONCLUSIONS

In this large retrospective analysis, patients with NVAF initiated on rivaroxaban incurred significantly lower healthcare costs compared to those initiated on apixaban, which were primarily driven by significantly lower outpatient visits and costs during the 18- and 24-month follow-up periods.

Pulmonary Vein Activity Organization to Determine Atrial Fibrillation Recurrence: Preliminary Data from a Pilot Study

Ablation of pulmonary veins has emerged as a key procedure for normal rhythm restoration in atrial fibrillation patients. However, up to half of ablated Atrial fibrillation (AF) patients suffer recurrences during the first year. In this article, simultaneous intra-atrial recordings registered at pulmonary veins previous to the ablation procedure were analyzed. Spatial cross-correlation and transfer entropy were computed in order to estimate spatial organization. Results showed that, in patients with arrhythmia recurrence, pulmonary vein electrical activity was less correlated than in patients that maintained sinus rhythm. Moreover, correlation function between dipoles showed higher delays in patients with AF recurrence. Results with transfer entropy were consistent with spatial cross-correlation measurements. These results show that arrhythmia drivers located at the pulmonary veins are associated with a higher organization of the electrical activations after the ablation of these sites.

Impact of adding a video to patient education on quality of life among adults with atrial fibrillation: a randomized controlled trial

OBJECTIVE

To assess whether adding a video on atrial fibrillation (AF) to a face-to-face educational session improves quality of life (QoL), knowledge, and health resource utilization (HRU) among AF patients.

METHODS

In this parallel clinical trial, adults with AF received a face-to-face educational session on AF and were randomly allocated to watch an educational video or not. Self-reported questionnaires measured QoL (primary outcome; score 0-100), AF knowledge (score 0-25), and HRU. Data were collected before and after interventions. Within- and between-group changes were estimated by mixed models.

RESULTS

Sixty participants (age: 56 ± 13 years; men: n = 41) were allocated to watch the video after education (n = 30) or to receive education only (n = 30). Within groups over time, QoL and knowledge significantly improved. Knowledge increased by 2.3 units (95% confidence interval: 0.5-4.1) more in participants who watched the video than in others (P = 0.014). Changes in QoL and HRU were not different between groups.

CONCLUSION

Complementing education with a video on AF did not result in additional positive impacts on QoL and HRU among AF adults but led to greater improvements in AF knowledge.

PRACTICE IMPLICATIONS

The video on AF could be used as part of educational sessions to increase AF knowledge in AF patients.

Management of Atrial Fibrillation in Patients with Heart Failure: Time to Implement Ablation Control

PURPOSE OF THE REVIEW

Atrial fibrillation (AF) in patients with heart failure and reduced systolic ejection fraction (HFrEF) is common and associated with increased morbidity and mortality, and managing AF in this population has been particularly challenging with sparse data regarding the optimal treatment strategy.

RECENT FINDINGS

Recent data suggests that rhythm control with catheter ablation can be of particular benefit to patients with coexisting AF and HFrEF. Recent randomized control trials actually suggest that catheter ablation could potentially improve mortality in this particular patient population. This is in stark contrast to the current practice recommendations that reserve catheter ablation for symptomatic AF in the general population. In this paper, we will review the most current randomized controlled studies using catheter ablation in HFrEF patients with the hope to increase awareness of the potential mortality benefits the need for prioritization of catheter ablation in HFrEF patients in the next AF management guidelines.

Mortality and causes of death in patients with atrial fibrillation: A nationwide population-based study

Background

Patients with atrial fibrillation are known to have a high risk of mortality. There is a paucity of population-based studies about the impact of atrial fibrillation on the mortality risk stratified by age, sex, and detailed causes of death.

Methods

A total of 15,411 patients with atrial fibrillation from the Korean National Health Insurance Service-National Sample Cohort were enrolled, and causes of death were identified according to codes of the 10th revision of the International Classification of Diseases.

Results

From 2002 to 2013, a total of 4,479 (29%) deaths were confirmed, and the crude mortality rate for all-cause death was 63.3 per 1,000 patient-years. Patients with atrial fibrillation had a 3.7-fold increased risk of all-cause death compared with the general population. The standardized mortality ratio for all-cause death was the highest in young patients and decreased with increasing age (standardized mortality ratio 21.93, 95% confidence interval 7.60–26.26 in patients aged <20 years; standardized mortality ratio 2.77, 95% confidence interval 2.63–2.91 in patients aged ≥80 years). Women with atrial fibrillation exhibited a greater excess mortality risk than men (standardized mortality ratio 3.81, 95% confidence interval 3.65–3.98 in women; standardized mortality ratio 3.35, 95% confidence interval 3.21–3.48 in men). Cardiovascular disease was the leading cause of death (38.5%), and cerebral infarction was the most common specific disease. Patients with atrial fibrillation had an about 5 times increased risk of death due to cardiovascular disease compared with the general population.

Conclusions

Patients with atrial fibrillation had a 4 times increased risk of mortality compared with the general population. However, the impact of atrial fibrillation on mortality decreased with age and in men. Cerebral infarction was the most common cause of death, and more attention should be paid to reducing the risk of stroke.

Clinical importance of atrial cardiomyopathy

Atrial fibrillation (AF) is the most common cause of thromboembolic complications. The risk of suffering a thromboembolic complication correlates with the CHA2DS2-VASc score identifying patients at increased risk. It is based on patient age, prior thromboembolic events, and clinical comorbidities, but not based on pathophysiological changes in different types of atrial cardiomyopathy (ACM) as classified in the expert consensus on ACM published in 2016. The impact of different types of ACM has also been acknowledged in the expert consensus statement on catheter ablation of atrial fibrillation. The aim of this review is to review data on clinical importance of ACMs.

Atrial fibrillation independently linked with depression in community-dwelling older population. Results from the nationwide PolSenior project

BACKGROUND

Depression is a frequently observed comorbid condition in patients with cardiovascular diseases. In contrast to coronary heart disease and heart failure there is a limited amount of published data concerning the increased prevalence of depression among patients with atrial fibrillation (AF). Therefore, we decided to assess the prevalence of depression in Polish community-dwelling older patients with a history of AF.

METHODS

The data were collected as part of the nationwide PolSenior project (2007-2012). Out of 4979 individuals (age range 65-104 years), data on self-reported history of AF were available for 4677 (93.9%). Finally, 4049 participants without suspected moderate or severe dementia in Mini Mental State Examination test were assessed with the 15-item Geriatric Depression Scale (GDS), and a score of 6 points and more was regarded as suspected depression.

RESULTS

Mean age (±SD) of the study population was 78.1 (±8.3) years; 52% were males. The history of AF was reported by 788 (19.5%) subjects. In the univariate analysis a self-reported AF history was associated with 42% increase of suspected depression (41% vs 29%; P < 0.001). In multivariate logistic regression AF remained an independent predictor of depression (OR = 1.69; 95%CI: 1.43-2.00), stronger than heart failure, diabetes or coronary heart disease.

CONCLUSIONS

In community-dwelling geriatric Polish population AF is associated with higher prevalence of depression. This association is independent from the demographic factors, disabilities and comorbidities (including history of stroke).

Relation of Body Mass Index to Symptom Burden in Patients withAtrial Fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with significant morbidity and increased mortality. As body mass index (BMI) is increasingly recognized as an important risk factor for the development of AF, we tested the hypothesis that BMI modulates symptomatic AF burden. Cross-sectional data collected from 1,382 patients in the Vanderbilt AF Registry were analyzed. AF severity was assessed using the Toronto atrial fibrillation severity scale (AFSS). BMI was categorized according to World Health Organization guidelines and patients were grouped according to their present AF treatment regimen: no treatment (n = 185), rate control therapy with atrioventricular nodal blocking agents (n = 351), rhythm control with antiarrhythmic drugs (n = 636), and previous AF ablation (n = 210). Patients with BMI >35 kg/m2 had higher AFSS scores than those with BMI <30 kg/m2 in the rate control (43.57 vs 38.21: p = 0.0057), rhythm control (46.61 vs 41.08: p = 1.6 × 10-4), and ablation (44.01 vs 39.02: p = 0.047) groups. Inunivariate linear models, BMI was associated with an increase in the AFSS score in the rate control (0.27, 95% confidence interval [CI] 0.05 to 0.5, p = 0.02), rhythm control (0.38, 95% CI 0.21 to 0.56, p = 2.49 × 10-5), and ablation (0.38, 95% CI 0.03 to 0.73, p = 0.03) groups. The association remained significant in the rhythm control groups after adjusting for age, gender, race, and comorbidities (0.29, 95% CI 0.11 to 0.49, p = 0.002). In conclusion, increasing BMI was directly associated with patient reported measures of AF symptom severity, burden, and quality of life. This was most significant in patients treated with rhythm-control strategies.

Assessment of the clinical efficacy of the heart spectrum blood pressure monitor for diagnosis of atrial fibrillation: An unblinded clinical trial

Atrial fibrillation (AF) is the most common arrhythmia. The most common diagnostic method, 12-lead electrocardiogram (ECG), can record episodes of arrhythmia from which the type and severity can be determined. The Heart Spectrum Blood Pressure Monitor (P2; OSTAR Meditech Corp., New Taipei City, Taiwan) is used to measure cardiovascular pressure change with fast Fourier transform (FFT) analysis to obtain heart rate frequency variability and accurate blood pressure data. We compared the diagnostic efficacy of the Heart Spectrum Blood Pressure Monitor to a 12-lead ECG (gold standard) for patients with AF. Three measurement methods were used in this study to analyze the heart index and compare the results with simultaneous 12-lead ECG: blood pressure; mean arterial pressure, which was calculated from individual blood pressure as a constant pressure; and a constant pressure of 60 mmHg. The physician used a 12-lead ECG and the Heart Spectrum Blood Pressure Monitor simultaneously. The Heart Spectrum Blood Pressure Monitor used FFT analysis to diagnose AF, and the findings were compared to the 12-lead ECG readings. This unblinded clinical trial was conducted in the emergency department of Taipei Medical University Hospital. Twenty-nine subjects with AF and 33 without AF aged 25 to 97 y (mean, 63.5 y) were included. Subjects who were exposed to high-frequency surgical equipment during testing, those with cardiac pacemakers or implantable defibrillators, and pregnant women were excluded. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 97%, 97%, 97%, and 97%, respectively, for method 1; 90%, 100%, 100%, and 91%, respectively, for method 2; and 100%, 94%, 94%, and 100%, respectively, for method 3. The sensitivity, specificity, PPV, and NPV for both methods ranged between 90% and 100%, indicating that the Heart Spectrum Blood Pressure Monitor can be effectively applied for AF detection.

Low testosterone levels are predictive for incident atrial fibrillation and ischaemic stroke in men, but protective in women - results from the FINRISK study

Background Atrial fibrillation is the most common serious abnormal heart rhythm, and a frequent cause of ischaemic stroke. Recent experimental studies, mainly in orchiectomised rats, report a relationship between sex hormones and atrial electrophysiology and electroanatomy. We aimed to evaluate whether low testosterone levels are predictive for atrial fibrillation and/or ischaemic stroke in men and women. Design and methods The serum total testosterone levels were measured at baseline in a population cohort of 7892 subjects (3876 male, 4016 female), aged 25-74 years, using a commercially available immunoassay. The main outcome measure was atrial fibrillation or ischaemic stroke, whichever came first. Results During a median follow-up of 13.8 years, a total of 629 subjects (8.0%) suffered from incident atrial fibrillation ( n = 426) and/or ischemic stroke ( n = 276). Cox regression analyses, adjusted for age (used as time-scale), geographical region, total cholesterol (log), high-density lipoprotein-cholesterol (log), hypertension medication, known diabetes, smoking status, waist-hip-ratio, and time of blood drawn, documented differential predictive value of low sex-specific testosterone levels for atrial fibrillation and/or ischaemic stroke, in men and in women: Increasing levels were associated with lower risk in men (hazard ratio per one nmol/l increase 0.98 (95% confidence interval 0.93-1.00); p = 0.049). On the other hand, increasing testosterone levels were associated with higher risk in women (hazard ratio per one nmol/l increase 1.17 (95% confidence interval 1.02-1.36); p = 0.031). Conclusion Our study indicates that low testosterone levels are associated with increased risk of future atrial fibrillation and/or ischaemic stroke in men, while they are protective in women.

Racial and ethnic differences in the prevalence, management, and outcomes in patients with atrial fibrillation: A systematic review

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States and is associated with increased morbidity, mortality, and health care expenditures. In this review, our aim was to assess the racial and ethnic differences in the epidemiology, management, and outcomes of patients with AF. A search of relevant studies from January 1, 2007, to December 30, 2017, was conducted in PubMed, EMBASE, and Web of Science and supplemented by manual searches of the bibliographies of retrieved articles. We identified 152 studies of which 64 were subsequently included. We found that underrepresented racial and ethnic groups have a higher prevalence of established risk factors associated with the development of AF but an overall lower incidence and prevalence of AF as compared with non-Hispanic whites. Moreover, racial and ethnic differences exist in detection, awareness, and AF-associated symptoms. Nonwhite populations also experience decreased use of rhythm control modalities and anticoagulation for stroke prevention. Lastly, among those with AF, underrepresented racial and ethnic groups had increased morbidity and mortality relative to white groups. Racial and ethnic differences exist in the prevalence, quality of life, management, and outcomes of individuals with AF; however, the mechanisms for these differences have yet to be fully elucidated. Racial and ethnic differences in AF warrant further analysis to understand the factors contributing to the differences in prevalence and management to ensure the delivery of high quality care that prevents stroke, reduces deaths, and decreases expenses associated with caring for underrepresented populations with AF.

Treatment of Atrial Fibrillation in Patients with Co-existing Heart Failure and Reduced Ejection Fraction: Time to Revisit the Management Guidelines?

AF in patients with heart failure and reduced ejection fraction (HFrEF) is common and is associated with an increased risk of stroke, heart failure hospitalisation and all-cause mortality. Rhythm control of AF in this population has been traditionally limited to the use of antiarrhythmic drugs. Clinical trials assessing superiority of pharmacological rhythm control over rate control have been largely disappointing. Catheter ablation has emerged as a viable alternative to pharmacological rhythm control in symptomatic AF and has enjoyed significant technological advancements over the past decade. Recent clinical trials have suggested that catheter ablation is superior to pharmacological interventions in patients with co-existing AF and HFrEF. In this article, we will review the therapeutic options for AF in patients with HFrEF in the context of the latest clinical trials beyond the current established guidelines.

The Role of Implantable Cardiac Monitors in Atrial Fibrillation Management

Continuous heart rhythm monitoring using implantable cardiac monitors (ICMs) for atrial fibrillation (AF) management is steadily increasing in current clinical practice, even in the absence of an established indication provided by international guidelines. The increasing use of such devices is mainly associated with recent technological improvements including miniaturization, easier implant procedures, and remote monitoring, all of which make this strategy continuously more appealing and promising. For these and other reasons, ICMs have been proven to be a safe and highly effective tool for detecting AF episodes. However, ICMs are not the best option for every patient, as limitations exist. Therefore, it is imperative to weigh the possible benefits against the potential limitations of using these devices when deciding individualized patient care.

Short- and long-term clinical predictors of pharmacological cardioversion of persistent atrial fibrillation by dofetilide: A retrospective cohort study of 160 patients

INTRODUCTION

Dofetilide is a class III antiarrhythmic prescribed to cardiovert persistent atrial fibrillation (AF) to sinus rhythm (SR).

HYPOTHESIS

To determine the clinical predictors of cardioversion and readmission in persistent AF patients on dofetilide.

METHODS

We analyzed 160 patients with persistent AF who were started on dofetilide and followed for 1 year. We examined age, sex, race, hypertension, diabetes, smoking, dyslipidemia, CAD, left ventricular ejection fraction (LVEF), creatinine, BMI and concomitant use of calcium channel blockers (CCB), β-blockers in a multivariable logistic regression model. We also examined the same predictors in Cox regression model for AF-related readmission within 1 year of follow-up.

RESULTS

13.5% individuals did not convert to SR on dofetilide. 55.6% converted on the first dose and 83.1% converted by the fourth dose. In multivariable logistic models, dyslipidemia (OR: 2.4, CI: 1.12-5.16) and LVEF (OR: 3.83,CI: 1.37-10.8) were associated with failure to convert with the first dose. Female sex and LVEF also were associated with increased risk of failure to convert at all. Concomitant use of CCB associated with decreased risk of failure to convert to SR. In Cox proportional model, female sex, age <63 years and CAD were associated with increased AF readmission within 1 year.

CONCLUSIONS

Dyslipidemia and LVEF <40% were associated with failure to cardiovert after first dose, and female sex and LVEF 40% were related to failure to convert at all on dofetilide in persistent AF patients. After 1-year follow-up, female sex, known CAD, and age <63 years were associated with increased AF readmissions.

Relationship between lesion formation and electrophysiological responses using catheters equipped with mini-electrodes in chronic atrial fibrillation

BACKGROUND

The study focuses on the electrophysiological changes associated with lesion formation using 4.5-mm irrigated and 8-mm standard catheters equipped with mini-electrodes (MEs) positioned circumferentially on the tip.

OBJECTIVE

The aim of the study was to test the relationship between the maximal electrogram (EGM) reduction, frequency spectrum shift, and their impact on atrial lesion formation in the atrial fibrillation (AF) model. Furthermore, we hypothesize that the high fidelity recording from the MEs allows improved discrimination of ablated tissues from nonablated tissues.

METHODS

Under fluoroscopic and NavX guidance, atrial ablation lesions were placed in 4 canines in chronic AF (>12 months in AF) to achieve intercaval, cavotricuspid isthmus, and left atrial contiguous lesions. Lesion times were titrated to the maximal loss of EGM amplitude as recorded from the MEs. Radiofrequency (RF) lesions were sequentially connected on the basis of the ME recordings of tissue viability.

RESULTS

In lesions formed using a 4.5-mm irrigated catheter (172 lesions) and in those formed using an 8-mm catheter (155 lesions), the time to nadir of the EGM reduction was 22 ± 12 and 22 ± 9 seconds (NS:p>0.05). Contiguous transmural lesions were successfully placed and guided by the ME EGMs and confirmed by frequency spectra.

CONCLUSION

In the chronic AF model, EGM reduction and frequency spectrum shift recorded from the MEs are twice the reduction recorded using the 4.5mm and 8mm tip to ring electrodes. RF titration based on the maximal EGM diminution is an effective approach to monitor lesion formation and may improve safety by preventing unnecessarily prolonged RF application. The ME EGM recording greatly facilitates placement of contiguous transmural linear lesions.

Termination of atrial spiral waves by traction into peripheral non 1:1 conducting regions - A numerical study

Atrial ablation has been recently utilized to treat atrial fibrillation (AF) by isolation or destruction of arrhythmia drivers. In chronic or persistent AF patients these drivers often consist of one or few rotors at unknown locations, and several ablations are commonly conducted before arrhythmia is terminated. However, the irreversible damage done to the tissue may lead to AF recurrence. We propose an alternative strategy to terminate rotor activity by its attraction into a non 1:1 conducting region. The feasibility of the method was numerically tested in 2D models of chronic AF human atrial tissue. Left-to-right gradients of either acetylcholine (ACh) or potassium conductance were employed to generate regions of 1:1 and non 1:1 conduction, characterized by their dominant frequency (DF) ratios. Spiral waves were established in the 1:1 conducting region and raster scanning was employed using a stimulating probe to attract the spiral wave tip. The probe was then linearly moved towards the boundary between the two regions. Successful attraction of spiral waves to the probe was demonstrated when the probe was <8mm from the spiral wave tip. Maximal traction velocity without loss of anchoring increased in a non-linear way with increasing values of ACh. Success rate of spiral wave termination was over 90% for regional DF ratios of as low as 1:1.2. Given that normally much higher ratios are measured in physiological atrial tissues, we envision this technique to provide a feasible, safer alternative to ablation procedures performed in persistent AF patients.

Contemporary Burden of Atrial Fibrillation and Associated Mortality in Northeastern Italy

Based on different estimation methods, mortality attributable to atrial fibrillation (AF) has been demonstrated to increase over time in developed countries, reaching a share ranging from 1% to 5% of overall deaths. To assess the whole burden of AF-associated mortality, all diseases mentioned in death certificates of subjects aged ≥45 years resident in the Veneto Region (Northeastern Italy) were analyzed for the 2008 to 2013 period. The prevalence of common chronic co-morbidities was compared between deaths with mention of AF and a sample of age-matched deaths without reported AF. The disease was mentioned among conditions contributing to death in 25,834 subjects, corresponding to 9.8% of all regional deaths. Rates of AF-associated mortality were higher in men and increased steeply with age, being above 1 per 100 among residents aged ≥85 years. Compared with non-AF-associated deaths, the strongest associations were observed between AF and hypertensive diseases (prevalence ratio 1.62, 95% CI 1.57 to 1.67), cardiac valve disorders (2.43, 2.25 to 2.61), cardiomyopathies (1.93, 1.70 to 2.19), cerebrovascular diseases (1.55, 1.50 to 1.60), and chronic obstructive pulmonary disease (1.49, 1.42 to 1.57). AF-associated mortality resulted higher than previously reported, probably due to aging of the population with multiple predisposing diseases, an increased recognition of AF among the elderly, and a raised awareness of certifying physicians about the importance of AF. Analyses of all diseases mentioned in death certificates underscored the interaction of AF with several other circulatory and respiratory disorders in pathologic networks leading to an increased risk of death.

Investigation of selection bias in the association of race with prevalent atrial fibrillation in a national cohort study: REasons for Geographic And Racial Differences in Stroke (REGARDS)

PURPOSE

Atrial fibrillation (AF) is diagnosed more commonly in whites than blacks in the United States. In epidemiologic studies, selection bias could induce a noncausal positive association of white race with prevalent AF if voluntary enrollment was influenced by both race and AF status. We investigated whether nonrandom enrollment biased the association of race with prevalent self-reported AF in the US-based REasons for Geographic And Racial Differences in Stroke Study (REGARDS).

METHODS

REGARDS had a two-stage enrollment process, allowing us to compare 30,183 fully enrolled REGARDS participants with 12,828 people who completed the first-stage telephone survey but did not complete the second-stage in-home visit to finalize their REGARDS enrollment (telephone-only participants).

RESULTS

REGARDS enrollment was higher among whites (77.1%) than among blacks (62.3%) but did not differ by self-reported AF status. The prevalence of AF was 8.45% in whites and 5.86% in blacks adjusted for age, sex, income, education, and perceived general health. The adjusted white/black prevalence ratio of self-reported AF was 1.43 (95% CI, 1.32-1.56) among REGARDS participants and 1.38 (1.22-1.55) among telephone-only participants.

CONCLUSIONS

These findings suggest that selection bias is not a viable explanation for the higher prevalence of self-reported AF among whites in population studies such as REGARDS.

Atrial Fibrillation and Risk of ESRD in Adults with CKD

BACKGROUND AND OBJECTIVES

Atrial fibrillation frequently complicates CKD and is associated with adverse outcomes. Progression to ESRD is a major complication of CKD, but the link with atrial fibrillation has not been fully delineated. In this study, we examined the association of incident atrial fibrillation with the risk of ESRD in patients with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We studied participants in the prospective Chronic Renal Insufficiency Cohort Study without atrial fibrillation at entry. Incident atrial fibrillation was identified by study visit ECGs, self-report, and hospital discharge diagnostic codes, with confirmation by physician adjudication. ESRD through 2012 was ascertained by participant self-report, medical records, and linkage to the US Renal Data System. Data on potential confounders were obtained from self-report, study visits, and laboratory tests. Marginal structural models were used to study the potential association of incident atrial fibrillation with risk of ESRD after adjustment for time-dependent confounding.

RESULTS

Among 3091 participants, 172 (5.6%) developed incident atrial fibrillation during follow-up. During mean follow-up of 5.9 years, 43 patients had ESRD that occurred after development of incident atrial fibrillation (11.8/100 person-years) compared with 581 patients without incident atrial fibrillation (3.4/100 person-years). In marginal structural models with inverse probability weighting, incident atrial fibrillation was associated with a substantially higher rate of ESRD (hazard ratio, 3.2; 95% confidence interval, 1.9 to 5.2). This association was consistent across important subgroups by age, sex, race, diabetes status, and baseline eGFR.

CONCLUSIONS

Incident atrial fibrillation was associated with higher risk of developing ESRD in CKD. Additional study is needed to identify potentially modifiable pathways through which atrial fibrillation was associated with a higher risk of progression to ESRD. More aggressive monitoring and treatment of patients with CKD and atrial fibrillation may improve outcomes in this high-risk population.

Is there an association between the prevalence of atrial fibrillation and severity and control of hypertension? The REasons for Geographic And Racial Differences in Stroke study

The association of atrial fibrillation (AF) with the severity and control of hypertension (HTN) remains unclear. We analyzed data from the national biracial cohort of REasons for Geographic And Racial Differences in Stroke study. The AF prevalence ratios were estimated and full multivariable adjustment included demographics, risk factors, medication adherence, HTN duration, and antihypertensive medication classes. Of the 30,018 study participants (8.6% with AF), 4386 had normotension (4.3% with AF), 5916 had prehypertension (4.3 with AF%), 12,294 had controlled HTN (11.2% with AF), 5587 had uncontrolled HTN (8.1% with AF), 547 had controlled apparent treatment-resistant hypertension (aTRH) (19.2% with AF), and 1288 had uncontrolled aTRH (15.5% with AF). Compared with normotension, the AF prevalence ratios for prehypertension, controlled HTN, uncontrolled HTN, controlled aTRH, and uncontrolled aTRH groups in fully adjusted model were 1.01 (95% confidence interval: 0.84, 1.21), 1.42 (1.18, 1.71), 1.37 (1.14, 1.65), 1.17 (0.86, 1.58), and 1.42 (1.10, 1.84), respectively (P < .001). The prevalence of AF was similar among persons with HTN regardless of blood pressure level and antihypertensive treatment resistance.

50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study

BACKGROUND

Comprehensive long-term data on atrial fibrillation trends in men and women are scant. We aimed to provide such data through analysis of the Framingham cohort over 50 years.

METHODS

We investigated trends in incidence, prevalence, and risk factors for atrial fibrillation and its association with stroke and mortality after onset in 9511 participants enrolled in the Framingham Heart Study between 1958 and 2007. We analysed trends within 10 year groups (1958-67, 1968-77, 1978-87, 1988-97, and 1998-2007), stratified by sex.

FINDINGS

During 50 years of observation (202,417 person-years), 1544 cases of new-onset atrial fibrillation occurred (of whom 723 [47%] were women). Between 1958-67 and 1998-2007, age-adjusted prevalence of atrial fibrillation quadrupled from 20·4 to 96·2 cases per 1000 person-years in men and from 13·7 to 49·4 cases per 1000 person-years in women; age-adjusted incidence increased from 3·7 to 13·4 new cases per 1000 person-years in men and from 2·5 to 8·6 new cases per 1000 person-years in women (ptrend<0·0001 for all comparisons). For atrial fibrillation diagnosed by electrocardiograph (ECG) during routine Framingham examinations, age-adjusted prevalence per 1000 person-years increased (12·6 in 1958-67 to 25·7 in 1998-2007 in men, ptrend=0·0007; 8·1 to 11·8 in women, ptrend=0·009). However, age-adjusted incidence of atrial fibrillation by Framingham Heart Study ECGs did not change significantly with time. Although the prevalence of most risk factors changed over time, their associated hazards for atrial fibrillation changed little. Multivariable-adjusted proportional hazards models revealed a 74% (95% CI 50-86%) decrease in stroke (hazards ratio [HR] 3·77, 95% CI 1·98-7·20 in 1958-1967 compared with 1998-2007; ptrend=0·0001) and a 25% (95% CI -3-46%) decrease in mortality (HR 1·34, 95% CI 0·97-1·86 in 1958-1967 compared with 1998-2007; ptrend=0·003) in 20 years following atrial fibrillation onset.

INTERPRETATION

Trends of increased incidence and prevalence of atrial fibrillation in the community were probably partly due to enhanced surveillance. Measures are needed to enhance early detection of atrial fibrillation, through increased awareness coupled with targeted screening programmes and risk factor-specific prevention.

FUNDING

NIH, NHLBI, NINDS, Deutsche Forschungsgemeinschaft.

European Primary Care Cardiovascular Society (EPCCS) consensus guidance on stroke prevention in atrial fibrillation (SPAF) in primary care

Background

Atrial fibrillation affects 1–2% of the general population and 10% of those over 75, and is responsible for around a quarter of all strokes. These strokes are largely preventable by the use of anticoagulation therapy, although many eligible patients are not treated. Recent large clinical trials have added to the evidence base on stroke prevention and international clinical guidelines have been updated.

Design

Consensus practical recommendations from primary care physicians with an interest in vascular disease and vascular specialists.

Methods

A focussed all-day meeting, with presentation of summary evidence under each section of this guidance and review of European guidelines on stroke prevention in atrial fibrillation, was used to generate a draft document, which then underwent three cycles of revision and debate before all panel members agreed with the consensus statements.

Results

Six areas were identified that included how to identify patients with atrial fibrillation, how to determine their stroke risk and whether to recommend modification of this risk, and what management options are available, with practical recommendations on maximising benefit and minimising risk if anticoagulation is recommended and the reasons why antiplatelet therapy is no longer recommended. The summary evidence is presented for each area and simple summary recommendations are highlighted, with areas of remaining uncertainty listed.

Conclusions

Atrial fibrillation-related stroke is a major public health priority for most health systems. This practical guidance can assist generalist community physicians to translate the large evidence base for this cause of preventable stroke and implement this at a local level.

Incidence, mortality, and sex differences of non-valvular atrial fibrillation: a population-based study

Background

It is unclear whether the incidence of non‐valvular atrial fibrillation (NVAF) has been increasing over time. We aimed to provide contemporary estimates of the incidence and case‐fatality of NVAF in a well‐defined population.

Methods and Results

We used the computerized databases of the Régie de l'assurance maladie du Québec (RAMQ), responsible for administering the universal health care services for all its residents, to identify a population‐based cohort of 243 800 patients with an incident diagnosis of NVAF during 2000–2009. The incidence rate of NVAF, age‐ and sex‐standardized to the 2004 population of Québec, was 32.4 (95% confidence interval, 32.3 to 32.5) per 10 000 per year. There was no evidence of an increasing incidence of NVAF during the 10‐year study period. The incidence rate was higher in men compared with women (age‐adjusted incidence rate ratio 1.51; 95% CI 1.50 to 1.52). The 30‐day case‐fatality was 9.2% (95% CI 9.0 to 9.3), higher for men (10.0%; 95% CI 9.8 to 10.1) than women (8.5; 95% CI 8.3 to 8.6), and increasing with age, ranging from around 1% for cases aged <40 years to around 16% for cases aged ≥80.

Conclusion

Current incidence estimates illustrate the significant burden of NVAF. Mortality remains particularly high around the time of diagnosis, and case‐fatality increases with age, being systematically higher in men than women.

Co-prevalence of carotid stenosis and coronary artery disease in Chinese patients with paroxysmal atrial fibrillation

OBJECTIVES

To investigate the co-prevalence of coronary artery disease (CAD) and carotid stenosis and to determine predictors related to CAD in Chinese patients with paroxysmal atrial fibrillation (PAF), presenting without previously diagnosed or excluded CAD.

METHODS

Consecutive patients with PAF were recruited. CAD was evaluated using multislice computed tomography. Intima-media thickness (IMT) of the carotid artery was evaluated via ultrasonography.

RESULTS

A total of 62/192 (32.3%) patients had CAD. Carotid stenosis was observed in 26/192 (13.5%) patients. The co-prevalence of carotid stenosis and CAD was 7.8% (15/192). The prevalence of carotid stenosis was 8.5%, 16.7%, 25.0%, and 41.7% in patients with zero-, one-, two-, and three-vessel CAD, respectively. Diabetes mellitus, maximal IMT and hyperhomocysteinaemia were independently related to the presence of CAD.

CONCLUSIONS

The prevalence of CAD was 32.3% in Chinese patients with PAF. Carotid stenosis and CAD co-occurred in 7.8% of patients, and the prevalence of carotid stenosis correlated with the severity of CAD. Screening of carotid stenosis is recommended, especially in patients with PAF and multivessel CAD.

Detection of abnormal cardiac activity using principal component analysis--a theoretical study

Electrogram-guided ablation has been recently developed for allowing better detection and localization of abnormal atrial activity that may be the source of arrhythmogeneity. Nevertheless, no clear indication for the benefit of using electrograms guided ablation over empirical ablation was established thus far, and there is a clear need of improving the localization of cardiac arrhythmogenic targets for ablation. In this paper, we propose a new approach for detection and localization of irregular cardiac activity during ablation procedures that is based on dimension reduction algorithms and principal component analysis (PCA). Using an 8×8 electrode array, our method produces manifolds that allow easy visualization and detection of possible arrhythmogenic ablation targets characterized by irregular conduction. We employ mathematical modeling and computer simulations to demonstrate the feasibility of the new approach for two well established arrhythmogenic sources for irregular conduction--spiral waves and patchy fibrosis. Our results show that the PCA method can differentiate between focal ectopic activity and spiral wave activity, as these two types of activity produce substantially different manifold shapes. Moreover, the technique allows the detection of spiral wave cores and their general meandering and drifting pattern. Fibrotic patches larger than 2 mm(2) could also be visualized using the PCA method, both for quiescent atrial tissue and for tissue exhibiting spiral wave activity. We envision that this method, contingent to further numerical and experimental validation studies in more complex, realistic geometrical configurations and with clinical data, can improve existing atrial ablation mapping capabilities, thus increasing success rates and optimizing arrhythmia management.

Atrial fibrillation: an observational study with outpatients

BACKGROUND

Atrial fibrillation (AF) is the most common sustained arrhythmia with serious clinical consequences in the absence of treatment. However, there are limited data on the treatment of these patients in Argentina. The objective was to describe the therapeutic management of patients with nonacute AF by Argentinean cardiologists and to determine the incidence of clinical events after 12 months follow-up.

METHODS

The Atrial Fibrillation study in Argentina (FARAON) was an observational, descriptive, prospective, national, and multicentric study that included outpatients with AF, followed for 12 months. The study included 38 sites in Argentina. Each researcher included the first 10 patients who met the inclusion criteria of being over 21 and also being an AF carrier documented by electrocardiogram or Holter within 12 months prior to or at the time of enrollment.

RESULTS

A total of 373 patients were included, mean age 70 ± 11.5 years, 40% women; 65% had AF rhythm at the time of inclusion, 57% had permanent AF, and 56% were asymptomatic. At the time of enrollment, 40% of physicians opted for rhythm control strategy. β-blockers and amiodarone were the most used drugs. Patients with rhythm control drugs had higher success rate than those with frequency control drug therapy (80% vs 57%).

CONCLUSION

Cardiologists in Argentina receive patients with AF that are mostly permanent AF. More than half of the patients are asymptomatic. They opt primarily by controlling the pace. When choosing antiarrhythmic drugs, nearly half of them indicated amiodarone.

Saudi Atrial Fibrillation Survey

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The Saudi Atrial Fibrillation Survey registry was designed to provide epidemiological and clinical data on patients with AF. The registry included 400 consecutive patients who met the eligibility criteria. Control of AF at the time of the initial visit was achieved by 211 (52.75%) patients. Cardiovascular risk profile of the patients with AF was smoking 92 (23.5%), hypertension 253 (63.25%), diabetes 192 (48%), and dyslipidemia 173 (44%). Rate control was the most frequent management strategy (in 265 patients, 66.2%) whereas rhythm control was chosen in 48 (12%) patients. Both strategies were attempted in 5 (1.2%) patients. This is the first nationwide registry of patients with AF in Saudi Arabia. Compared to developed countries, our patients with AF are relatively young and have higher rates of diabetes and rheumatic heart disease. Rate control is the main strategy currently used for managing AF.

Atrial fibrillation as a cause of death increased steeply in England between 1995 and 2010

AIMS

To report trends in mortality rates for atrial fibrillation/flutter (AF), using all the certified causes of death mentioned on death certificates (conventionally known as 'mentions') as well as the underlying cause of death, in the national population of England (1995-2010) and in a regional population with longer coverage of all-mentions mortality (1979-2010).

METHODS AND RESULTS

Analysis of death registration data in England and in the Oxford record linkage study. In England between 1995 and 2010, AF was mentioned as a cause of death (either as an underlying cause or as a contributory cause) in 192 770 registered deaths in people aged 45 years of age and over (representing 0.254% of all registered deaths in this age group). Atrial fibrillation was given as the underlying cause of death in 21.4% of all deaths in which it was mentioned (41 298 of 192 770). In England, age-standardized death rates for mentions of AF increased almost three-fold between 1995 and 2010, from 202.5 deaths per million (1995) to 554.1 deaths per million (2010), with an average annual percentage change of 6.6% (95% confidence interval: 6.3, 7.0). Mortality rates for AF did not increase substantially until the mid-1990s: rates in Oxford were 145.4 deaths per million in 1979, 178.1 in 1995, and 505.1 in 2010.

CONCLUSION

Atrial fibrillation has become much more common as a certified cause of death. The reasons for this are likely to be multifactorial, with changes in demographics, lifestyle, advances in therapeutics, and altered perception of the importance of the condition by certifying doctors all likely to be contributing factors.