Role of NT-proBNP for Atrial Fibrillation Detection After Ischemic Stroke: A Time-Dependent Relationship

BACKGROUND

Atrial fibrillation detected after stroke (AFDAS) affects secondary stroke prevention, yet identification can be challenging. Easily accessible cardiac blood biomarkers such as NT-proBNP (N-terminal pro-B-type natriuretic peptide) could guide diagnostic workup, but optimal cutoff values and the time-dependent relationship between NT-proBNP and AFDAS are unclear. We aimed (1) to externally validate earlier presented NT-proBNP cutoffs for atrial fibrillation prediction and (2) to assess the time-dependent relationship of NT-proBNP and early in-hospital AFDAS versus AFDAS after discharge.

METHODS

We conducted a pooled data analysis of patients with ischemic stroke from the prospective international multicenter BIOSIGNAL (Biomarker Signature of Stroke Aetiology) cohort study (European Stroke Centers from October 2014 to October 2017) and the prospective single-center Graz stroke pathway study (Austria from May 2018 to August 2020). AFDAS was defined as ≥30-s atrial fibrillation/flutter diagnosed within 1 year post-admission and categorized in in-hospital versus after discharge. NT-proBNP was assessed ≤24 hours of symptom onset. The association between NT-proBNP and AFDAS was evaluated by a multivariable logistic regression analysis.

RESULTS

AFDAS was diagnosed in 374 (16%) of 2292 patients with ischemic stroke (median age, 74 years; 42% female), 268 (72%) during hospitalization, and 106 (28%) after discharge (median duration of hospitalization, 15 days). NT-proBNP levels at admission had a good predictive capacity for in-hospital AFDAS (area under the receiver operating characteristic curve, 0.83 [95% CI, 0.81-0.86]). For patients diagnosed with AFDAS after discharge, the predictive capacity of NT-proBNP was poor (area under the receiver operating characteristic curve, 0.65 [95% CI, 0.60-0.70]), and 20% had normal NT-proBNP values <125 pg/mL at admission. The NT-proBNP cutoff of 505 pg/mL exhibited high sensitivity (82%) and specificity (71%) for in-hospital AFDAS, with a negative predictive value of 96%.

CONCLUSIONS

In patients with ischemic stroke, the admission NT-proBNP cutoff of 505 pg/mL seems to be a reliable predictor for in-hospital AFDAS, while the predictive capacity of NT-proBNP for AFDAS after discharge is limited. Our results might influence the designs of future secondary stroke prevention trials.

Catheter Ablation for Atrial Fibrillation in Octogenarians-Outcome and Impact for Future Same Day Discharge Strategies

BACKGROUND

Catheter ablation (CA) for atrial fibrillation (AF) in the elderly poses a growing challenge. Outcome data regarding CA in these patients are scarce.

METHODS

Octogenarians with AF or consecutive atrial tachycardia undergoing index or re-ablation (pulmonary vein isolation [PVI] and ablation beyond PVI with different energy sources) in a single center, were analyzed. Study endpoints were efficacy as well as procedural safety. Secondary endpoints included periprocedural complications and predictors for prolonged hospital stay.

RESULTS

In total, 301 patients (82.1 ± 1.9 years, paroxysmal AF n = 94 [31.2%], CHA2DS2-VASc-Score 4.2 ± 1.2) undergoing index ablation (n = 172/301, 57.1% [PVI only n = 156/172, radiofrequency n = 92, cryoballoon n = 59, pulsed-field ablation n = 5]) and re-ablation (n = 129/301 [42.9%]) were included. Arrhythmia-free survival at 1 year was 72.6%. Complication rates were low (groin site n = 2/301 [0.7%], tamponade n = 2/301 [0.7%] and stroke n = 1/301 [0.3%]). However concomitant infections (pneumonia n = 5/301 [1.7%], urinary-tract-infections n = 4/301, [1.3%]) and pacemaker-implantation n = 6/301 (2%) occurred more commonly. Hospital stay after CA was 2.3 ± 2 nights. Predictors for prolonged hospitalization were complications (odds ratio: 3.1), infections (odds ratio: 2.1), female sex (odds ratio: 1.15) and frailty assessed by Barthel index (odds ratio: 1.02).

CONCLUSIONS

CA for AF in octogenarians shows low procedural complications and reasonable efficacy. However, concomitant infections and pacemaker implantations occur in this cohort. Due to prolonged hospitalization after CA, especially in female and frail octogenarians, same-day discharge may not be suitable for this specific patient cohort.

Efficacy, safety, and bleeding risk factor analysis of oral anticoagulants in AF patients ≥ 65 years of age: a multicenter retrospective cohort study

BACKGROUND

Stroke prevention in elderly patients with atrial fibrillation (AF) is challenging and requires a balance between thromboembolic prevention and bleeding. The comparison of novel oral anticoagulants (NOACs) and warfarin in clinical practice in elderly Asian patients has not been well studied. The purpose of this study was to evaluate the efficacy and safety of NOACs versus warfarin in elderly patients with AF in conjunction with data from real-world observational studies.

METHODS

This was a retrospective multicenter cohort study conducted in 4 centers in China, where patient information and clinical events were collected through an average of 15 months of follow-up and case queries. Clinical outcomes included major bleeding, minor bleeding, total bleeding, thrombosis, and all-cause mortality.

RESULTS

A total of 3450 elderly patients with AF were enrolled. 2656 patients were treated with at least 1 NOAC (dabigatran, rivaroxaban, apixaban, or edoxaban), and 794 patients were treated with warfarin. After correcting for confounders, NOACs significantly reduced the risk of minor bleeding [OR 0.70 (95% CL, 0.49-1.01),P = 0.049] and all-cause mortality [OR 0.57( 95% CI, 0.44-0.75),P < 0.001] compared with warfarin, however, major bleeding events [OR 1.51 (95% CL, 0.98-2.42),P = 0.075] and thrombotic events [OR 0.79 (95% CL, 0.57-1.13),P = 0.187] were not significantly different. There was no heterogeneity between clinical outcomes of NOACs and warfarin in subgroup analyses of age (65-74, 75-84, ≥ 85 years), sex (male, female), BMI (≥ 25, < 25), comorbidities (including hypertension, diabetes and no hypertension, no diabetes), except in female subgroup, where NOACs significantly reduced the risk of minor bleeding [OR 0.56 (95% CL, 0.34-0.91),P = 0.018] and increased the risk of major bleeding [OR 2.28 (95% CL, 1.12-5.14),P = 0.032] compared with warfarin.

CONCLUSION

Compared with warfarin, NOACs significantly reduced the risk of minor bleeding, all-cause mortality, and there were no statistically significant differences in major bleeding or thrombotic events. NOACs were not more effective than warfarin in thrombotic and bleeding events, regardless of the subgroup analyses on age, male, BMI and comorbid hypertension and diabetes.

Qualitative study of patients' and clinicians' experiences of an educational intervention for warfarin therapy control in atrial fibrillation in Thailand

OBJECTIVES

We aimed to understand the (1) perspectives of patients with atrial fibrilation (AF) regarding their experience and implementation of The SAMe-TT2R2 score-guided approach in anticoagulant-nave Thai patients with atrial fibrillation (TREATS-AF) educational intervention for warfarin therapy control, including views on cultural transferability to the Thai context, and (2) healthcare professionals' (HCPs) experience of implementing the intervention.

DESIGN

Qualitative research study.

SETTING

Three university hospitals and four tertiary care hospitals in Thailand.

PARTICIPANTS

13 newly diagnosed patients with AF and 13 HCPs delivering the TREATS-AF intervention, an intensive structured educational programme.

METHODS

Semistructured interviews. Patient participants were interviewed at two time points: 4 weeks and 6 months after intervention delivery. HCPs were interviewed when they had at least 6 months experience of intervention delivery. A thematic analysis of content was informed by the framework analytical approach.

RESULTS

13 patients and 13 HCPs were interviewed; most were female (73.3% of patients and all HCPs). Mean age was 70 (68-76) and 40 (38-42.5) years for patients and HCPs, respectively. There were four categories related to the experience of the TREATS-AF intervention: (1) key experiences of the educational sessions, (2) core perceptions of the educational materials provided, (3) suggestions for improving the educational materials and session, and (4) behavioural change and self-management influenced by the TREATS-AF intervention.

CONCLUSIONS

The TREATS-AF intervention assisted interviewees who were newly diagnosed with AF in preparing themselves with the necessary knowledge and skills to manage their condition. They stated that it increased their confidence in self-management.For implementation, regionalised Thai-related food and beverages, patients' literacy and family support should be considered, and infrastructure support for widespread use in healthcare settings would be required.

TRIAL REGISTERATION NUMBER

TCTR20180711003.

The Genetic Mechanisms and Pathology of Atrial Fibrillation: A Narrative Review

Atrial fibrillation (AF), the most prevalent tachyarrhythmia worldwide, is a complex condition influenced by genetic, structural, and environmental factors. While AF in the elderly is often associated with underlying cardiac disease, early-onset or "lone" AF (LAF) exhibits a stronger genetic predisposition. Studies have identified both monogenic and polygenic contributors to AF risk. Monogenic mutations, inherited in Mendelian patterns, often affect ion channels and regulatory proteins, while polygenic variants modulate susceptibility and interact with environmental factors. Genome-wide association studies (GWAS) and exosome-wide association studies (ExWAS) have expanded our understanding of AF genetics, identifying numerous susceptibility loci, though challenges remain in linking these variants to specific molecular mechanisms. Pathophysiologically, AF results from a balance of triggers, drivers, and substrates. Triggers, such as ectopic foci in the pulmonary veins, initiate AF episodes, while structural and electrical remodeling perpetuates the arrhythmia. Fibrosis, atrial dilation, and tachycardia-induced remodeling promote reentry circuits and irregular conduction, increasing AF vulnerability. The interplay between genetic predisposition and remodeling processes underscores the complexity of AF maintenance, particularly in persistent AF forms. Emerging insights into AF genetics and pathophysiology highlight the need for personalized approaches to its prevention and management. Understanding genetic risk, combined with targeted therapies addressing structural and electrical remodeling, holds promise for improved patient outcomes. Future research into AF's molecular and genetic mechanisms will be key to advancing precision medicine in this field.

Effectiveness of the AF-EduCare and AF-EduApp approach to improve atrial fibrillation knowledge and risk factor awareness in patients with atrial fibrillation: a randomized controlled trial

AIMS

Developing an integrated care pathway for atrial fibrillation (AF) patients is of pivotal importance, given the different treatment strategies. Moreover, knowledge about the condition is an important factor in engaging patients in their care. Patient education formed the core of the integrated AF-EduCare/AF-EduApp approach. The main aim of this manuscript is to report the impact of this approach on AF and risk factor (RF)-related knowledge and self-care awareness.

METHODS AND RESULTS

Atrial fibrillation patients (n = 1232) were randomized to standard care (SC) or three educational interventions: in-person, online, or app-based education. Patients in the intervention groups received targeted education based on their responses to the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) and a Self-Care Questionnaire (SCQ) presented at different time points. Patients who received educational follow-up reached a significantly higher knowledge score (in-person: 86.5 ± 13.2%; online: 82.5 ± 19.3%; app: 80.1 ± 15.0%) than the SC group (65.3 ± 16.6%) after 12/18 months (P < 0.001). The knowledge rapidly improved with the first sessions (i.e. 3 months) and remained sustained in all education groups. Patients with RF at baseline showed a slight but significant increase in awareness about their RF through education [e.g. no knowledge of last measured systolic blood pressure compared between education vs. SC: odds ratio of 0.45 (P = 0.012)], a change that was not seen in SC patients. Nevertheless, patients keep under-estimating the presence of their own RFs compared with objective documentation in their medical record (e.g. hypertension).

CONCLUSION

The JAKQ and SCQ are good instruments to provide targeted education to AF patients in daily clinical care. Knowledge level increases clinically significantly, but the impact on awareness about personal risk factors remains unsatisfactory.

REGISTRATION

ClinicalTrials/gov: NCT03707873NCT03788044.

Left Atrial Appendage Closure: What Do We Know?

Atrial fibrillation (AF) is the most common arrhythmia in the United States and the most common cause of embolic cerebrovascular events, with the majority of these thrombi originating in the left atrial appendage. The left atrial appendage (LAA) has separate developmental, ultrastructural, and physiological characteristics from the left atrium. Although LAA anatomy is highly variable, it can be categorized into 4 types: cactus, cauliflower, chicken wing, and windsock. The cauliflower type is associated with higher stroke risk in patients with nonvalvular AF. Although the cornerstone of therapy to prevent embolic strokes from AF has been anticoagulation with thrombin inhibitors, a large group of patients are unable to tolerate anticoagulation due to bleeding. This has led to the development and advancement of multiple surgical and percutaneous LAA closure devices to prevent embolic cerebrovascular accidents without the need for anticoagulation. In this article, we discuss the outcomes of major studies that utilized surgical LAA occlusion and its effectiveness. Furthermore, we summarize nonsurgical methods of LAA closure and future directions regarding LAA closure.

The importance of intensive follow-up and achieving optimal chronic antithrombotic treatment in hospitalized medical patients with anemia: A prospective cohort study

BACKGROUND

Anemia is a global health concern, particularly among the elderly on chronic antithrombotic treatment. Close monitoring of hemoglobin (Hb) levels and achievement of an optimized treatment significantly enhance patients' quality of life. This study aimed to examine the impact of antithrombotic treatment on Hb levels and readmissions in hospitalized patients with anemia.

METHODS

This is a prospective cohort study of patients admitted to the Department of Internal Medicine of the University Hospital of Heraklion, Greece, from November 2021 to October 2022 with the diagnosis of anemia while receiving antithrombotic treatment. Data regarding demographics, past medical history, and laboratory and endoscopy findings were recorded. For those receiving inappropriate therapy according to international guidelines, antithrombotic treatment was optimized. Subsequent follow-ups occurred at one and six months post-discharge. Six- and twelve-month anemia-caused readmissions, as well as annual mortality, were evaluated.

RESULTS

In total, 104 patients were assessed. Among them, 34.6% were on antiplatelets, 56.7% were on anticoagulants, and 8.7% were on combination treatment. The mean age was 80 ± 8.2 years, and 54.8% were males. On admission, mean Hb levels were 6.86 ± 1.23 g/dL, while 56 (53.8%) patients had severe anemia. Gastroscopy and colonoscopy were performed in 75.0% and 41.4% of patients, respectively, confirming gastrointestinal bleeding in most of the cases. Treatment optimization was carried out for 56 patients. Follow-up revealed elevated Hb levels after one and six months post-discharge, while anemia-related readmissions stayed below 10%.

CONCLUSIONS

Most hospitalized anemic patients on antithrombotic treatment had endoscopic findings favoring gastrointestinal bleeding. Half received inappropriate antithrombotic therapy. Treatment optimization and regular follow-up improved Hb levels and reduced readmissions.

National Trends in Mortality Due to Ischemic Stroke Among Older Adults With Atrial Fibrillation in the USA, 1999-2020

BACKGROUND

Atrial fibrillation (AF) is a significant contributor to ischemic stroke risk and mortality, particularly in aging populations. This study examines mortality trends from ischemic stroke secondary to AF in the U.S. from 1999 to 2020, focusing on demographic and regional disparities.

METHODS

Using data from the CDC WONDER database, this cross-sectional analysis included individuals aged ≥ 65 years with death certificates indicating ischemic stroke (ICD I63) and AF (ICD I48) as contributing causes. Age-adjusted mortality rates (AAMR) were calculated, and temporal trends were analyzed using join-point regression to estimate annual percentage changes (APC). Data were stratified by age, sex, race/ethnicity, urbanization, and geographic regions.

RESULTS

From 1999 to 2020, ischemic stroke with AF caused 62,443 deaths (AAMR: 6.75/100,000; 95% CI: 6.70-6.80). Mortality rates increased significantly after 2010, peaking between 2014 and 2017 (APC: 31.3 for females, 28.1 for males). Older adults (≥ 85 years) exhibited the highest AAMR (43.2/100,000; 95% CI: 41.6-44.8). Nonmetropolitan areas consistently showed higher mortality compared to metropolitan regions. Demographic disparities were evident, with higher AAMRs in females, Whites, and the Western U.S., though Hispanics had the sharpest APC increase during 2014-2017.

CONCLUSION

Mortality rates from ischemic stroke with AF are rising in older adults, with significant demographic and regional disparities. The findings underscore the need for targeted public health strategies to mitigate AF-related stroke risks and improve healthcare equity.

The Association of New Onset Postoperative Atrial Fibrillation and Abnormal P-Terminal Force in Lead V1 After On-Pump Cardiac Surgery

Introduction: Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with higher morbidity and mortality. This paper presents several studies that conclude the presence of an aberrant p-terminal force vector in lead V1 (PTFV1) has been identified as a significant predictor of atrial fibrillation in the non-surgical population. It is uncertain whether or not there is an association of PTFV1 and new-onset POAF in patients after cardiac surgery. Methods: In this secondary analysis, adult patients undergoing on-pump cardiac surgery for aortocoronary bypasses, valve surgery, combined bypass, and valve surgery were analyzed from 12/2018 to 08/2020. Patients who had a previous occurrence of atrial fibrillation or atrial flutter, patients with pacemakers and/or Implantable Cardioverter-Defibrillators (ICDs), and those who did not have an electrocardiogram (ECG) performed within the 3 months before surgery were excluded. In addition, ECGs that were considered to be of low quality were also removed. Preoperative 12-lead ECGs were examined and the PTFV1 was measured. Secondarily, we examined the P-wave length in lead II, the area under the P-wave in lead II, PR interval, and QRS duration in lead V1 and II. The occurrence of POAF was extracted from the hospital record. Results: Out of a total of 252 patients, 62 patients (24.6%) developed new onset POAF during their hospital stay. POAF occurred primarily in older patients, with poor renal function, and exhibited larger left atria. Analysis of ORs (odds ratios) revealed that age, creatinine clearance, valve surgery, and left atrial volume index (LAVI) were associated with POAF. In the context of the multivariable analysis, it was demonstrated that only age presented a significant correlation with postoperative atrial fibrillation (POAF). There was no observed relationship between any of the parameters based on ECG and the occurrence of POAF. Conclusion: No association was found between PTFV1 or other ECG-based measurements and new onset POAF in cardiac surgery patients. Age was the only independent predictor of POAF.

Vitamin K Antagonist Anticoagulation in Antiphospholipid Syndrome: Time in Therapeutic Range and Clinical Outcomes

BACKGROUND

Thrombosis in antiphospholipid syndrome is still frequently treated with vitamin K antagonists, with a target international normalized ratio of 2-3. Time in therapeutic range of international normalized ratio of ≥ 70% is considered optimal. Time in therapeutic range among antiphospholipid syndrome patients is not well documented and the clinical consequences of poor international normalized ratio control are uncertain. This study aimed to determine the proportion of vitamin K antagonist-treated antiphospholipid syndrome patients achieving time in therapeutic range ≥ 70%, to define the features associated with poor control and to determine its association with thrombotic and bleeding events.

METHODS

This medical records review included antiphospholipid syndrome patients treated with vitamin K antagonists, between 2012-2023. The proportion of patients achieving a time in therapeutic range ≥ 70% was determined, and thrombotic and bleeding events were compared between patients with time in therapeutic range ​​≥ 70% vs < 70%.

RESULTS

Sixty seven antiphospholipid syndrome patients were studied. It was observed that 29.9% achieved time in therapeutic range ≥ 70% and 9.1% of patients with 3 or more comorbidities achieved time in therapeutic range values ≥ 70% compared with 40% of patients with less than 3 comorbidities. Fewer recurrent arterial and overall thrombotic events occurred with time in therapeutic range ​​≥ 70%.

CONCLUSIONS

A minority of antiphospholipid syndrome patients treated with vitamin K antagonists achieve optimal anticoagulation and are at risk for recurrent thrombotic events, particularly arterial. Presence of multiple comorbidities is associated with poor international normalized ratio control. Careful monitoring of this patient population is warranted.

Atrial Fibrillation Prediction Model Following Aortic Valve Replacement Surgery

(1) Background: Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery. It leads to increased perioperative morbidity and costs. Our study aimed to determine the incidence of new-onset POAF in patients undergoing isolated aortic valve replacement (AVR) and develop a multivariate model to identify its predictors. (2) Methods: We conducted a retrospective study including all consecutive patients who underwent isolated AVR at our institution between January 2010 and December 2022. Patients younger than 18, with a history of atrial fibrillation, previous cardiac surgery, or those who underwent concomitant procedures were excluded. Patients were dichotomized into POAF and No POAF groups. Multivariate logistic regression with backward elimination was utilized for predictive modeling. (3) Results: This study included 1108 patients, of which 297 (27%) developed POAF. The final multivariate model identified age, larger valve size, cardiopulmonary bypass time, delayed sternal closure, ventilation time, and intensive care unit stay as predictors of POAF. The model exhibited fair predictive ability (AUC = 0.678, p < 0.001), with the Hosmer-Lemeshow test confirming good model fit (p = 0.655). The overall correct classification percentage was 65.6%. (4) Conclusions: A POAF prediction model offers personalized risk estimates, allowing for tailored management strategies with the potential to enhance patient outcomes and optimize healthcare costs.

Direct Oral Anticoagulants in Patients With ESRD and Kidney Transplantation

Direct oral anticoagulant (DOAC) use has significantly increased because major medical organizations endorse their role for conditions in which anticoagulation is indicated. Owing to important pharmacokinetic properties, the use of apixaban and rivaroxaban requires careful consideration in at-risk populations such as those with kidney disease. Both apixaban and rivaroxaban undergo some degree of renal elimination, and thus total drug exposure is increased in patients with renal insufficiency and/or those undergoing renal replacement therapy (RRT). The available clinical trial and real-world data in this population suggests that apixaban is likely at least comparably effective as warfarin at preventing thromboembolic events and is likely safer when evaluating bleeding risk. Rivaroxaban data is more limited, and the reported results are more discordant. Both apixaban and rivaroxaban have been used successfully in patients with end-stage renal disease (ESRD) undergoing kidney transplant listing as well as in the posttransplant setting. Prospective clinical trials evaluating the safety and efficacy of apixaban and rivaroxaban in various conditions where anticoagulation is indicated should include patients with ESRD and kidney transplant recipients to help further define the role that these important novel agents should play in these complex patient populations.

Steerable Delivery Sheath for Optimized LAA Closure: First Experience and Procedural Outcomes

BACKGROUND

The new Amplatzer Steerable Delivery Sheath is a delivery system designed to improve ease-of-use and procedural results of left atrial appendage closure (LAAC). We aimed to compare procedural results after switching our LAAC program at a tertiary care center with the Amulet device to the Steerable Delivery Sheath, with a control group of LAAC employing the standard sheath.

METHODS

The first n = 32 consecutively treated patients at our site using the Amulet device with the Steerable Delivery Sheath were included in this retrospective analysis. As a control-group, n = 39 consecutive patients treated with the Amulet device before the switch to the new sheath were used.

RESULTS

LAAC was successful in all patients in both groups (100%). Contrast use and fluoroscopy time were numerically higher in the steerable sheath group (steerable sheath vs. control group: contrast use 70 ± 23 vs. 55 ± 50 mL, p = 0.09, fluoroscopy time 12.7 ± 4.6 vs. 10.2 ± 6.6 min, p = 0.3). Fluoroscopy time and dose decreased after 3 months while contrast use remained unchanged. Complete sealing rate was high in both groups (steerable sheath vs. control group 97% vs. 95%, p > 0.9) and periprocedural complication rate was low, without any periprocedural stroke, vascular complications, or death in both cohorts.

CONCLUSIONS

LAAC with the Amplatzer Amulet steerable delivery sheath is feasible and safe. Fluoroscopy time and dose suggest a learning curve with the new sheath.

Effect of Postoperative Atrial Fibrillation After Cardiac Surgery: A Meta-Analysis

BACKGROUND

A meta-analysis study was conducted to determine how to predict the effect of postoperative atrial fibrillation after cardiac surgery.

HYPOTHESIS

Long-term mortality and cardiovascular morbidity are linked to postoperative atrial fibrillation.

METHOD

Until August 2024, a comprehensive literature study was completed, and 3486 connected studies were revised. The 38 selected studies included 241 299 cardiac surgery participants at the beginning of the study. The odds ratio (OR) and 95% confidence intervals (CIs) were used to look at the effect of atrial fibrillation after heart surgery using two-sided methods and either a fixed or random model.

RESULTS

Individuals with cardiac surgery with postoperative atrial fibrillation had significantly higher mortality at 1 year (OR, 1.39; 95% CI, 1.12-1.72, p < 0.001), mortality at 5 years (OR, 1.61; 95% CI, 1.33-1.94, p < 0.001), mortality at 10 years (OR, 1.61; 95% CI, 1.39-1.87, p < 0.001), and overall stroke (OR, 1.61; 95% CI, 1.34-1.94, p < 0.001) compared to without postoperative atrial fibrillation.

CONCLUSIONS

Individuals with cardiac surgery with postoperative atrial fibrillation had significantly higher mortality at 1 year, mortality at 5 years, mortality at 10 years, and overall stroke compared to those without postoperative atrial fibrillation. To validate this discovery, more research and caution must be implemented when interacting with its values.

Effects of different exercise methods and intensities on the incidence and prognosis of atrial fibrillation

Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, exhibits a higher risk of cardiovascular adverse events. Exercise plays a crucial role in AF prevention, but the effects of different exercise types and doses are inconclusive. This review aims to comprehensively explore the most recent evidence and possible mechanisms of diverse exercise modalities concerning AF incidence and therapeutic outcomes. Multiple studies underscore the efficacy of moderate-intensity continuous training (MICT) in reducing AF incidence and symptom burden, rendering it the currently favored exercise therapy for AF patients. High-intensity interval training (HIIT) shows promise, potentially surpassing MICT, especially in reducing age-related AF susceptibility and improving symptoms and exercise capacity. Conversely, prolonged high-intensity endurance exercise exacerbates AF risk due to excessive exercise volume, with potential mechanisms encompassing irreversible atrial remodeling, heightened inflammation, and increased vagal tone. In summation, MICT is a secure strategy for populations in mitigating the risk associated with AF incidence and secondary cardiovascular events and should be encouraged. Also, it is recommended to initiate large-scale clinical intervention trials encompassing a variety of exercise types to delineate the optimal exercise prescription for cardiovascular patients, including those afflicted with AF.

Impact of direct oral anticoagulants on ROTEM® variables; a sample size-calculated experimental study

Direct oral anticoagulants (DOAC) are increasingly common, with bleeding events associated with elevated plasma concentrations. Rotational thromboelastometry (ROTEM), a point-of-care tool for assessing secondary hemostasis, has demonstrated a correlation with increasing concentrations of DOAC. However, previous studies have only partially explored this relationship. The primary aim in the current study was to investigate the impact of increasing rivaroxaban concentrations on clotting time (CT) in the EXTEM assay. The secondary aims were to investigate the impact of increasing rivaroxaban concentrations on clot formation time (CFT) and α-angle (AA) and to investigate the impact of increasing concentrations of dabigatran and apixaban on CT, CFT and AA. Blood from 12 healthy volunteers was spiked to anticipated concentrations of rivaroxaban, dabigatran and apixaban at 0, 50, 100, 200, 500 and 1000 µg/L each. Blood with these varying concentrations was analyzed in four different ROTEM assays and CT, CFT and AA were extracted. CT increased linearly with increasing concentrations of all three DOACs. Rivaroxaban and dabigatran spiked blood showed an increase in CT-EXTEM for the 200-1000µg/L concentrations, compared to baseline, and apixaban for the 500-1000 µg/L concentrations. CFT and AA were affected only in supratherapeutic concentrations for all tested DOACs and primarily in the INTEM assay. Among the tested DOACs, apixaban demonstrated the least impact on CT across all assays. In conclusion, ROTEM-derived CT measurements can serve as surrogate markers for DOAC concentrations.

Synergistic effects of rivaroxaban and hypothermia or acidosis on coagulation initiation measured with ROTEM®: a prospective observational study

BACKGROUND

Hypothermia and acidosis individually inhibit haemostasis. We designed this study with the aim to investigate whether rivaroxaban combined with hypothermia or acidosis exhibit synergistic inhibitory effects on haemostasis using ROTEM®.

METHODS

Patients with a clinical indication to start rivaroxaban treatment were prospectively included. Blood samples were collected before initiation of treatment and the day after. All blood samples were in vitro modified with respect to temperature (incubated and analysed at 28, 33, 37 and 40 degrees Celsius (°C)) and pH (6.8, 7.0, 7.2 and 7.4). The temperature and acidosis effects on the ROTEM EXTEM variables clotting time (CT), clot formation time (CFT) and alpha-angle (AA) were measured along with the individual effect of rivaroxaban on the same variables. The additive effect was calculated. The observed (potential synergistic) effects for the temperature and pH modified rivaroxaban samples on the same ROTEM variables, were registered. Differences between the additive and observed (potential synergistic) effects were analysed using matched non-parametric hypothesis testing.

RESULTS

In total, 13 patients were included. Hypothermia and rivaroxaban exhibited a synergistic effect on CT at 28 °C (p = 0.0002) and at 33 °C (p = 0.0007). The same applied for acidosis at pH 6.8 (p = 0.003) and pH 7.0 (p = 0.003). There were no signs of synergistic effects of rivaroxaban and temperature or acidosis on CFT. In AA there were signs of synergism at 28 °C (p = 0,001), but not at other tested temperatures or pH levels.

CONCLUSIONS

The combination rivaroxaban together with hypothermia or acidosis demonstrated inhibitory synergistic effects on haemostasis.

TRIAL REGISTRATION

The study was retrospectively registered 2023-03-01 at ClinTrials.gov with NCT05669313.

Implementing a remote self-screening programme for atrial fibrillation using digital health technology among community-dwellers aged 75 years and older: a qualitative evaluation

OBJECTIVE

To examine the feasibility of implementing remote atrial fibrillation (AF) self-screening among older people supported by a remote central monitoring system.

DESIGN

Process evaluation of the Mass AF randomised clinical trial (ACTRN12621000184875) with one-to-one semistructured interviews using interview guides underpinned by the Critical Realism approach and coded using the UK Medical Research Council Guidance of Process Evaluation Framework.

SETTING AND PARTICIPANTS

Community-dwelling people aged ≥75 years from both genders (ratio 1:1) and urban/rural (ratio 2:1) in Australia.

INTERVENTIONS

Participants were provided handheld single-lead electrocardiogram (ECG) devices and trained to self-record ECGs once daily on weekdays for at least 6 months. A remote central team notified participants and general practitioners (GPs) of AF.

PRIMARY FEASIBILITY OUTCOMES

The strengths, weaknesses, opportunities and threats (SWOT) analysis examined enablers (ie, strengths and opportunities) and barriers (ie, weaknesses and threats).

RESULTS

Overall, 200 participants; 98.5% completed the 6-month programme, 96% reported being satisfied with screening and 48 were interviewed: mean age 79 years, 54% male and 71% urban. 11 GPs were interviewed: 55% female and 64% urban. Programme participants trusted the remote monitoring system that supported the screening programme and provided follow-up pathways where required. GPs saw opportunities to introduce this self-screening programme to at-risk patients and improve patients' risk profiles. Programme participants reported that after being trained to use the device, they felt empowered to do self-screening and found it convenient. GPs saw empowerment could enhance the doctor-patient relationship. Participants and GPs valued screening in diagnosing AF that would otherwise be missed in usual care, but the uncertainty of effective screening duration could be a barrier.

CONCLUSIONS

This screening programme was feasible with the reinforcement of the underpinning enablers. Several implementation strategies were identified using SWOT analysis, including leveraging the opportunity for GPs to introduce this screening programme to at-risk patients.

TRIAL REGISTRATION NUMBER

ACTRN12621000184875.

The incidence and risk factors of atrial high-rate episodes in patients with a dual-chamber pacemaker

Background and Objectives

Cardiovascular implantable electronic devices can detect atrial high-rate episodes (AHREs). However, the predictors of clinically relevant AHREs have not been well identified.

Methods

This prospective study included 145 patients (median age 64.5 ± 16.4 years, 53.1% females) without atrial fibrillation (AF) from December 2020 to January 2022. AHREs were defined as a programmed atrial detection rate >190 beats per minute. Cox regression analysis was used to identify the risk factors of AHREs.

Results

During 6 months of follow-up, AHREs occurred in 30.3% of patients. Multivariable Cox regression analysis showed factors related to development of AHREs including using anti-arrhythmic drugs (AAD) before implantation (Hazard ratio (HR) 7.71; 95% confidence interval [95% CI], 2.58-23.02, p < .001), history of paroxysmal supraventricular tachycardia (PSVT; HR 2.45; [95% CI], 1.18-5.09, p = .016), the percentage of premature atrial contraction (PAC) on 24-h Holter electrocardiogram (ECG) monitoring (HR 1.008; [95% CI], 1.003-1.014, p = .003), and left ventricular global longitudinal strain (GLS-LV; HR 0.92;[95% CI], 0.84-0.99, p = .049).

Conclusions

This study showed that a history of PSVT and using AAD, the percentage of PAC on 24-h Holter ECG monitoring, and GLS-LV were the independent predictors of new-onset AHREs.

Comparison of Apixaban, Rivaroxaban, Dabigatran, and Vitamin K Antagonists in Patients With Atrial Fibrillation and Liver Disease: A Network Meta-Analysis

Atrial fibrillation (AF) patients with liver disease present unique challenges in anticoagulation management due to increased risks of both thromboembolism and bleeding. This network meta-analysis aimed to compare the efficacy and safety of direct oral anticoagulants (DOACs), apixaban, rivaroxaban, and dabigatran, with vitamin K antagonists (VKAs) in this specific patient population. We conducted a comprehensive literature search across multiple databases, identifying seven studies (six observational and one randomized controlled trial) that met our inclusion criteria. The primary outcomes were the risk of stroke or systemic embolism (SE) and bleeding events. Our analysis revealed that all three DOACs demonstrated superior efficacy and safety profiles compared to VKAs. Apixaban showed the most favorable outcomes, with the highest probability of being the most effective in preventing both stroke/SE (RR: 0.51, 95% CI: 0.38-0.67) and bleeding events (RR: 0.54, 95% CI: 0.43-0.69). Rivaroxaban and dabigatran also significantly reduced the risk of these outcomes compared to VKAs but to a lesser extent than apixaban. Notably, rivaroxaban was associated with a slightly increased bleeding risk compared to apixaban (RR: 0.76, 95% CI: 0.58-0.99). The consistency of our network model was confirmed through both global and local tests. While these findings provide valuable guidance for clinicians, the study's limitations, including the predominance of observational data, highlight the need for large-scale randomized controlled trials. Future research should focus on clearly defined anticoagulant dosing regimens and comprehensive assessments of cirrhosis status to further optimize anticoagulation strategies in AF patients with liver disease.

Early Initiation of Guideline-Directed Medical Therapy for Heart Failure After Cardiac Surgery

There is an evolving role for guideline-directed medical therapy (GDMT) in managing heart failure with reduced ejection fraction after cardiac surgery. GDMT is based on the use of pharmacologic agents from each of 4 distinct drug classes, also known as the 4 pillars of heart failure therapy: β-blockers, renin-angiotensin system inhibitors, often paired with neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Despite the demonstrated benefits of GDMT in reducing mortality and hospitalization rates in the nonsurgical literature, there is conspicuous underuse of GDMT after cardiac surgery. The lack of published literature and practical challenges surrounding the timing for initiation of GDMT in the immediate postoperative period has limited standardized implementation strategies. A multidisciplinary approach will be necessary to assist in initiating, titrating, and monitoring the response to these therapies in patients with heart failure with reduced ejection fraction after cardiac surgery.

Left Atrial Appendage Thrombus as a Marker of Disease Severity in 500 Patients with Atrial Fibrillation on Oral Anticoagulation: A 13-Year Follow-Up Study

Background/Objective: Whether left atrial appendage thrombus (LAAT) in patients with atrial fibrillation (AF) on chronic anticoagulation significantly increases cardiovascular risk is unknown. This study aimed to assess LAAT prevalence and its predictive role in cardiovascular events among consecutive anticoagulated patients with AF admitted for electrical cardioversion. Methods: This prospective study included 500 patients. The primary outcome was LAAT on transesophageal echocardiography. Patients were followed up for a median of 1927.5 (interquartile range 1004-2643) days to assess cardiovascular events. Results: LAAT was detected in 65 (13%) patients. No significant differences in stroke, transient ischemic attack, systemic thromboembolic events, or myocardial infarction prevalence were observed between patients with AF with and without LAAT. Hospitalization for heart failure (HF) was more frequent in patients with LAAT than in those without LAAT; however, the effect of LAAT on HF hospitalization was not statistically significant. Patients with LAAT had a significantly higher risk of cardiovascular death than those without LAAT. LAAT and greater left atrial (LA) diameter were associated with higher rates of cardiovascular death. The independent HF hospitalization predictors were greater LA diameter, lower left ventricular ejection fraction (LVEF), and estimated glomerular filtration rate (eGFR). Conclusions: Patients with AF who received anticoagulation therapy showed a high prevalence of LAAT. LAAT and greater LA diameter were associated with significantly higher rates of cardiovascular death. LAAT, greater LA diameter, lower LVEF, and lower eGFR were associated with poor prognosis in anticoagulated patients with AF and were predictors of disease severity.

Adherence to oral anticoagulants in patients with non-valvular atrial fibrillation: the role of patients' characteristics and out-of-pocket payments

BACKGROUND

Recent practice guidelines favor direct oral anticoagulants (DOACs) over warfarin for primary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). However, challenges persist in Iraq's private pharmaceutical sector. DOACs have been sold at high and inconsistent retail prices and lack insurance coverage, leading to significant out-of-pocket (OOP) costs. The objective of this study is to investigate the impact of OOP costs on oral anticoagulants (OAC) adherence among NVAF patients.

RESEARCH DESIGN AND METHODS

This multicenter cross-sectional study interviewed 359 eligible patients attending three private cardiology clinics within Iraq's southern region from December 2022 to February 2023. The 8-item Morisky Adherence Scale evaluated patient adherence. Statistical analyses, including descriptive analysis, ANOVA, and chi-square. p < 0.05 was considered statistically significant.

RESULTS

The most frequently prescribed OAC were DOACs (62.8%). Patient adherence level to OAC was chiefly medium (54.6%) with no significant difference in adherence based on OAC type. Patient adherence was significantly associated with monthly income (p = 0.001), number of daily pills (p = 0.006), and OACs' average monthly cost (p = 0.011).

CONCLUSION

Addressing the issue of cost-related non-adherence to OACs requires multiple actions. These include ensuring comprehensive health insurance coverage for OACs, increasing the use of affordable generic alternatives, and establishing effective cost-related discussions between healthcare providers and patients.

Direct Oral Anticoagulants in Older and Frail Patients with Atrial Fibrillation: A Decade of Experience

INTRODUCTION

Both the prevalence of atrial fibrillation (AF) and its subsequent use of direct oral anticoagulants (DOACs) are rapidly increasing in patients of older age. In the absence of contra-indications, guidelines advocate anticoagulation based on the CHA2DS2-VASc score for all AF patients aged 75 and above. However, some practitioners are hesitant to prescribe anticoagulants to older and frail patients due to perceived elevated bleeding risks. This review delves into the comparative treatment outcomes of DOACs versus vitamin K antagonists (VKAs) in older patients with AF, particularly focusing on those of advanced age, frailty, increased risk of falling, chronic kidney disease (CKD), or with a history of major bleeding. Additionally, considerations on the use of off-label DOAC doses, the role of left atrial appendage (LAA) closure and future developments in factor XIa-inhibitors will be discussed.

RESULTS

While strong evidence supports the use of DOACs in the vital older patients with nonvalvular AF, it remains scant in frail patient groups. There is some evidence from non-randomized studies suggesting that the effect of DOACs compared with VKAs is consistent between frail and nonfrail patients. However, recent findings from a single randomized trial showed increased bleeding risks but comparable thromboembolic outcomes in frail individuals switching from VKAs to DOACs. In patients with an increased risk of falling, data suggest no relevant interaction of increased risk of falling on the effectiveness and safety of DOACs compared with warfarin. Resuming oral anticoagulants in patients with Af after major bleeding seems to be beneficial. Off-label low-dose DOAC is often prescribed to patients who were underrepresented in larger randomized trails because of an elevated risk of bleeding or overexposure to DOACs, but its effect on clinical outcomes remains uncertain.

CONCLUSIONS

DOACs are the recommended oral anticoagulant for vital older patients with AF. The scarcity of data backing DOAC use in frail individuals, those with renal impairments, or significant bleeding history underscores the necessity for further investigation. However, existing evidence suggests at least similar effectiveness and safety and potential benefits for DOACs in these patient subsets. Therefore, there is no reason to suggest these patients should be treated differently than the established guidelines regarding anticoagulation.

Associated Factors and Mortality of Arrhythmia in Emergency Department: A Narrative Review

Cardiac arrhythmias represent a major concern in the emergency department (ED), particularly given their association with significant morbidity and mortality. This narrative review examines the various factors influencing arrhythmias and their impact on patient outcomes in emergency settings. Managing complex supraventricular and ventricular arrhythmias (VAs) during acute myocardial infarction (AMI) and severe cardiovascular conditions remains challenging, despite advancements in diagnostic and therapeutic techniques. Ventricular arrhythmias frequently forecast worse outcomes during hospital stays and heighten the chances of sudden cardiac death and cardiac arrest, especially within the initial 30 days after a heart attack. The incidence of arrhythmias in ED is increasing due to demographic changes and higher rates of chronic illnesses such as diabetes, hypertension, and chronic kidney disease. These comorbidities, coupled with lifestyle factors such as smoking and alcohol consumption, complicate arrhythmia management, especially among older adults and males. Rapid and precise ECG interpretation in the ED is crucial for identifying specific arrhythmia types and initiating appropriate treatments. Atrial fibrillation (AF), the most prevalent form of rapid heart rhythm originating above the ventricles, notably impacts patient outcomes, particularly in cases of AMI and heart failure. In the ED, managing AF focuses on preventing strokes with thromboprophylaxis and employing risk assessment tools such as CHA2DS2-VASc and HAS-BLED scores. The analysis highlights how risk factors like hypertension, obesity, obstructive sleep apnea (OSA), and diabetes intricately influence the development and worsening of AF. Optimizing AF treatment outcomes requires a multidisciplinary approach involving cardiologists, emergency physicians, and critical care specialists. Future research should prioritize evaluating the effectiveness of preventive and therapeutic interventions for AF, integrating new risk factors and genetic insights to enhance prediction and management strategies. Understanding the factors contributing to arrhythmias and mortality in the ED underscores the importance of timely and accurate diagnostic and therapeutic measures to improve patient care and outcomes.

Trends in atrial fibrillation-related mortality in Europe, 2008-2019

AIMS

Update data regarding the atrial fibrillation (AF)-related mortality trend in Europe remain scant. We assess the age- and sex-specific trends in AF-related mortality in the European states between the years 2008 and 2019.

METHODS AND RESULTS

Data on cause-specific deaths and population numbers by sex for European countries were retrieved through the publicly available World Health Organization mortality dataset for the years 2008-2019. Atrial fibrillation-related deaths were ascertained when the International Classification of Diseases, 10th Revision code I48 was listed as the underlying cause of death in the medical death certificate. To calculate annual trends, we assessed the average annual % change (AAPC) with relative 95% confidence intervals (CIs) using Joinpoint regression. During the study period, 773 750 AF-related deaths (202 552 males and 571 198 females) occurred in Europe. The age-adjusted mortality rate (AAMR) linearly increased from 12.3 (95% CI: 11.2-12.9) per 100 000 population in 2008 to 15.3 (95% CI: 14.7-15.7) per 100 000 population in 2019 [AAPC: +2.0% (95% CI: 1.6-3.5), P < 0.001] with a more pronounced increase among men [AAPC: +2.7% (95% CI: 1.9-3.5), P < 0.001] compared with women [AAPC: +1.7% (95% CI: 1.1-2.3), P < 0.001] (P for parallelism 0.01). Higher AAMR increases were observed in some Eastern European countries such as Latvia, Lithuania, and Poland, while the lower increases were mainly clustered in Central Europe.

CONCLUSION

Over the last decade, the age-adjusted AF-related mortality has increased in Europe, especially among males. Disparities still exist between Western and Eastern European countries.

Impact of Defibrillator Electrode Placement on Outcome of Electrical Cardioversion of Atrial Fibrillation: A Pilot Observational Study

BACKGROUND

Anterior-posterior electrode placement is preferred in electrical cardioversion of atrial fibrillation. However, the optimal anterior-posterior electrode position in relation to the heart is not studied.

METHODS AND RESULTS

We performed a prospective observational study on patients presenting for cardioversion of atrial fibrillation. Electrodes were placed in the anterior-posterior position and shock was delivered in a step-up approach (100 J→200 J→360 J). Fluoroscopic images were obtained, and distances were measured from points A, midanterior electrode; and B, midposterior electrode, to midpoint of the cardiac silhouette. Patients requiring one 100 J shock for cardioversion success (group I) were compared with those requiring >1 shock/100 J (group II). Logistic regression was used to determine the impact of electrode distance on low energy (100 J) cardioversion success. Computed tomography scans from this cohort were analyzed for anatomic landmark correlation to the cardiac silhouette. Of the 87 patients included, 54 (62%) comprised group I and 33 (38%) group II. Group I had significantly lower distances from the mid-cardiac silhouette to points A (5.0±2.4 versus 7.4±3.3 cm; P<0.001) and B (7.3±3.0 versus 10.0±3.8 cm; P=0.002) compared with group II. On multivariate analysis, higher distances from the mid-cardiac silhouette to point A (odds ratio, 1.33 [95% CI, 1.07-1.70]; P=0.01) and B (odds rsatio, 1.24 [95% CI, 1.05-1.50]; P=0.01) were independent predictors of low energy (100 J) cardioversion failure. Based on review of computed tomography scans, we suggest that the xiphoid process may be an easy landmark to guide proximity to the myocardium.

CONCLUSIONS

In anterior-posterior electrode placement, closer proximity to the cardiac silhouette predicts successful 100 J cardioversion irrespective of clinical factors.

Assessing the impact of atrial fibrillation self-care interventions: A systematic review

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population.

[Overdosing of direct oral anticoagulants]

BACKGROUND

Direct oral anticoagulants (DOAC) are increasingly used for prophylaxis and treatment of thromboembolic events. Incorrectly dosed DOAC treatment is associated with excess mortality.

PURPOSE

This article aims at raising awareness of DOAC overdosing and its causes as well as presenting a diagnostic and therapeutic work-up.

MATERIAL AND METHODS

Based on a case presentation, a structured review of the current literature on DOAC overdosing was performed and treatment recommendations were extracted.

RESULTS

In addition to wittingly or unwittingly increased DOAC intake, common causes of overdose are inadequate dose adjustment for concomitant medication or comorbidities. Global coagulation testing should be supplemented with DOAC-specific testing. Severe bleeding and the need for invasive diagnostics or urgent surgery represent indications for treating DOAC overdoses. Based on the cause of an DOAC overdose, active charcoal, endoscopic pill rescue, antagonization with idarucizumab or andexanet alfa and the targeted substitution of coagulation factors represent treatment options.

CONCLUSION

The sensitization of clinicians is important to ensure a timely diagnosis and adequate treatment of DOAC overdosing. This report provides an overview of current knowledge on diagnostics and treatment; however, further studies are necessary to improve the existing algorithms.

Impact of frailty in patients with non-valvular atrial fibrillation undergoing catheter ablation

Background

The relationships between frailty and clinical outcomes in elderly Japanese patients with non-valvular atrial fibrillation (NVAF) after catheter ablation (CA) have not been established. We evaluated the frailty rate of patients undergoing CA for NVAF, examined whether CA for NVAF improves frailty, and analyzed the CA outcomes of patients with and without frailty.

Methods

Elderly Japanese patients (≥65 years; mean age: 72.8 years) who participated in the real-world ablation therapy with anti-coagulants in management of atrial fibrillation registry and who responded to the frailty screening index survey were included (n = 213). Frailty and AF recurrence were assessed preoperatively and at 3 and 6 months after CA.

Results

Twenty-six patients (12.8%) were frail, 109 (53.7%) were pre-frail, and 68 (33.5%) were robust. Cardiovascular (frailty: 0.5%/person-year; pre-frailty: 0.1%/person-year; robust: 0.1%/person-year) and cardiac (frailty: 0.5%/person-year; pre-frailty: 0.1%/person-year; robust: 0.1%/person-year) events, as well as major bleeding (frailty: 0.3%/person-year; pre-frailty: 0.1%/person-year; robust: 0.1%/person-year), were numerically more frequent in the frailty group. No deaths from cardiovascular or stroke/systemic thromboembolic events occurred. A large proportion of patients did not experience 3-month (frailty: 96.2%; pre-frailty: 96.3%; robust: 88.2%) or 6-month (frailty: 88.5%; pre-frailty: 91.7%; robust: 86.8%) AF recurrence after CA. Weight loss, walking speed, and fatigue improved in the frailty and pre-frailty groups after CA.

Conclusion

Japanese patients aged ≥65 years with frailty or pre-frailty had improved frailty screening index components, such as weight loss, walking speed and fatigue, after CA. Therefore, elderly patients with frailty or pre-frailty may benefit from CA for NVAF.

Sleep-Disordered Breathing, Advanced Age, and Diabetes Mellitus Are Associated with De Novo Atrial Fibrillation after Cardiac Surgery

Background: Postoperative de novo atrial fibrillation (POAF) is one of the most frequently encountered complications following cardiac surgery. Despite the identification of several risk factors, the link between sleep-disordered breathing (SDB) and POAF has barely been examined. The objective of this prospective observational study was to determine whether severe SDB is associated with POAF in patients after elective coronary artery bypass grafting (CABG) surgery. Study design and methods: The incidence and preoperative predictors of in-hospital POAF were assessed in 272 patients undergoing CABG surgery at the University Medical Center Regensburg (Germany). In-hospital POAF was detected by continuous telemetry-ECG monitoring and 12-lead resting ECGs within the first seven postoperative days. POAF that occurred after hospital discharge within 60 days post CABG surgery was classified as post-hospital POAF and was ascertained by standardized phone interviews together with the patients' medical files, including routinely performed Holter-ECG monitoring at 60 days post CABG surgery. The night before surgery, portable SDB monitoring was used to assess the presence and type of severe SDB, defined by an apnea-hypopnea index ≥ 30/h. Results: The incidence of in-hospital POAF was significantly higher in patients with severe SDB compared to those without severe SDB (30% vs. 15%, p = 0.009). Patients with severe SDB suffered significantly more often from POAF at 60 days post CABG surgery compared to patients without severe SDB (14% vs. 5%, p = 0.042). Multivariable logistic regression analysis showed that severe SDB (odds ratio, OR [95% confidence interval, CI]: 2.23 [1.08; 4.61], p = 0.030), age ≥ 65 years (2.17 [1.04; 4.53], p = 0.038), and diabetes mellitus (2.27 [1.15; 4.48], p = 0.018) were significantly associated with in-hospital POAF. After additional adjustment for heart failure, the association between sleep apnea and postoperative atrial fibrillation was attenuated (1.99 [0.92; 4.31], p = 0.081). Conclusions: Amongst established risk factors, severe SDB was significantly associated with in-hospital POAF in patients undergoing CABG surgery. Whether SDB contributes to POAF independently of heart failure and whether risk for POAF may be alleviated by proper treatment of SDB merits further investigation.

Predictive Value of Serum microRNA-29b-3p in Recurrence of Atrial Fibrillation After Radiofrequency Catheter Ablation

Objective

Atrial fibrillation (AF) is a common arrhythmia. This study explored serum miR-29b-3p expression in AF patients and its value in predicting AF recurrence after radiofrequency catheter ablation (RFCA).

Methods

Totally 100 AF patients who underwent RFCA were enrolled, with 100 individuals without AF as controls. Serum miR-29b-3p expression in participants was determined using RT-qPCR. The correlation between miR-29b-3p and atrial fibrosis markers (FGF-21/FGF-23) was assessed by Pearson analysis. The diagnostic efficacy of serum miR-29b-3p and FGF-21/FGF-23 in predicting AF recurrence after RFCA was analyzed by the receiver operating characteristic (ROC) curves. The Kaplan-Meier method was adopted to evaluate the effect of miR-29b-3p expression on the incidence of AF recurrence after RFCA. The independent risk factors for AF recurrence after RFCA were analyzed by logistic regression analysis.

Results

Serum miR-29b-3p was poorly expressed in AF patients. After RFCA, AF patients showed elevated serum miR-29b-3p expression. Serum miR-29b-3p expression in AF patients negatively correlated with serum FGF-21 and FGF-23 concentrations. The cut-off values of serum miR-29b-3p, FGF-21, and FGF-23 in identifying AF recurrence were 0.860 (sensitivity: 100.00%, specificity: 39.71%), 222.2 pg/mL (sensitivity: 96.88%, specificity: 32.35%) and 216.3 ng/mL (sensitivity: 53.13%, specificity: 70.59%), respectively. Patients with low miR-29b-3p expression had a significantly higher incidence of AF recurrence than patients with high miR-29b-3p expression. Serum miR-29b-3p expression was one of the independent risk factors for AF recurrence after RFCA.

Conclusion

Low miR-29b-3p expression in AF patients has certain predictive values and is one of the independent risk factors for AF recurrence after RFCA.

Obesity effect on newly diagnosed and recurrent post-ablation atrial fibrillation: a systematic review and meta-analysis

BACKGROUND AND AIMS

The role of overweight and obesity in the development of atrial fibrillation (AF) is well established; however, the differential effect on the occurrence and recurrence of AF remains uncertain. The aim of this review is to compare the effect of underweight and varying degrees of obesity on onset of AF and in recurrent post-ablation AF, and, when possible, in relation to sex.

METHODS

A systematic literature search was conducted in PubMed, Embase, and Cochrane Library from inception to January 31, 2023. Studies reporting frequency of newly-diagnosed AF and of recurrent post-ablation AF in different BMI categories, were included. 3400 records were screened and 50 met the inclusion criteria. Standardized data search and abstraction were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement. Data were extracted from the manuscripts and were analyzed using a random effect model. The outcome was the occurrence of AF in population studies and in patients undergoing ablation.

RESULTS

Data from 50 studies were collected, of which 27 for newly-diagnosed AF and 23 for recurrent post-ablation AF, for a total of 15,134,939 patients, of which 15,115,181 in studies on newly-diagnosed AF and 19,758 in studies on recurrent post-ablation AF. Compared to normal weight, the increase in AF was significant (p < 0.01) for overweight, obese, and morbidly obese patients for newly-diagnosed AF, and for obese and morbidly obese patients for recurrent post-ablation AF. Newly-diagnosed AF was more frequent in obese female than obese male patients.

CONCLUSION

The effect of increased BMI was greater on the onset of AF, and obese women were more affected than men.

A China-Based Cost-Effectiveness Analysis of Novel Oral Anticoagulants versus Warfarin in Patients with Left Ventricular Thrombosis

Purpose

This study aims to conduct a comprehensive cost-effectiveness comparison between novel oral anticoagulants (NOACs) and warfarin in Chinese patients with left ventricular thrombosis (LVT). By incorporating the impact of volume-based procurement (VBP) policy for pharmaceuticals in China, this analysis intends to provide crucial insights for informed healthcare decision-making.

Patients and Methods

A Markov model was employed to simulate the disease progression of LVT over a 54-week time horizon, using weekly cycles and six mutually exclusive health states. The model incorporated transition probabilities between health states calculated based on clinical trial data and literature sources. Various cost and utility parameters were also included. Additionally, a series of sensitivity analyses were conducted to address parameter variations and associated uncertainties.

Results

The study finding suggest that from the perspective of Chinese healthcare, the majority of brand-name drug (BND) NOACs generally lack cost-effectiveness when compared to warfarin. However, when considered the VBP policy, NOACs, particularly rivaroxaban, prove to be more cost-effective than warfarin. Rivaroxaban provided an additional 0.0304 quality-adjusted life years (QALYs) per patient and reduced overall medical costs by 9095.73 CNY, resulting in an incremental cost-effectiveness ratio (ICER) of -298,786.20 CNY/QALY. Sensitivity analysis indicated a 78.4% probability of any NOACs being more cost-effective compared to warfarin. However, specifically considering NOACs under the VBP policy, the likelihood of them being more cost-effective approached 90%.

Conclusion

Taking into account Chinese pharmaceutical procurement policies, the findings highlight the superior efficacy of NOACs, especially rivaroxaban, in enhancing both the quality of life and economic benefits for Chinese LVT patients. NOACs present a more cost-effective treatment option, improving patient quality of life and healthcare cost efficiency compared to warfarin.

Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis

BACKGROUND

New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation.

METHODS

MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates.

RESULTS

We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke.

CONCLUSION

These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for prevention and management of postoperative atrial fibrillation after cardiac surgery: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023

Background

Postoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery.

Methods

Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type.

Results

Preoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery.

Conclusions

Despite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.

A real-world multicenter study on left atrial appendage occlusion: The Italian multi-device experience

Background

Transcatheter left atrial appendage occlusion (LAAO) has emerged as an alternative treatment for stroke prevention in patients with atrial fibrillation (AF) at high risk of thromboembolism, who cannot tolerate long-term oral anticoagulation (OAC). Questions persist regarding effectiveness and safety of this treatment and the optimal post-interventional antithrombotic regimen after LAAO.

Methods

We retrospectively gathered data from 428 patients who underwent percutaneous LAAO in 6 Italian high-volume centres, aimed at describing the real-world utilization, safety, and effectiveness of LAAO procedures, also assessing the clinical outcomes associated with different antithrombotic strategies.

Results

Among the entire population, 20 (4.7 %) patients experienced a combination of pericardial effusion and periprocedural major bleeding: 8 (1.9 %) pericardial effusion, 1 (0.3 %) fatal bleeding, and 3 (0.7 %) non-fatal procedural major bleeding. Patients were discharged with different antithrombotic regimens: dual (DAPT) (27 %) or single (SAPT) (26 %) antiplatelet therapy, OAC (27 %), other antithrombotic regimens (14 %). Very few patients were not prescribed with antithrombotic drugs (6 %). At a medium 523 ± 58 days follow-up, 14 patients (3.3 %) experienced all-cause death, 6 patients (1.4 %) cardiovascular death, 3 patients (0.7 %) major bleeding, 10 patients (2.6 %) clinically relevant non-major bleeding, and 3 patients (0.7 %) ischemic stroke. At survival analysis, with DAPT as the reference group, OAC therapy was associated with better outcomes.

Conclusions

Our findings confirm that LAAO is a safe procedure. Different individualized post-discharge antithrombotic regimens are now adopted, likely driven by the perceived thrombotic and hemorrhagic risk. The incidence of both ischemic and bleeding events tends to be low.

Influence of the COVID-19 pandemic on patients receiving oral anticoagulants for the treatment of non-valvular atrial fibrillation

Background

Frequent monitoring of patients declined during the COVID-19 pandemic, harming patients with chronic diseases who critically needed correct monitoring. We evaluated the impact of the COVID-19 pandemic in patients with non-valvular atrial fibrillation (NVAF) receiving treatment with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) in clinical practice in Spain.

Methods

This observational, retrospective study analyzed prevalent patients treated with NOAC/VKA on 14/03/2019 (pre-COVID-19 period) and 14/03/2020 (COVID-19 period), who were followed up to 12 months. The study also considered incident patients who started treatment with NOAC/VKA between 15/03/2019 and 13/03/2020 (pre-COVID-19 period) and from 15/03/2020 to 13/03/2021 (COVID-19 period). Demographic characteristics, comorbidities, effectiveness, treatment patterns, and healthcare resource utilization were considered.

Results

Prevalent patients amounted to 12,336 and 13,342 patients, whereas 1,612 and 1,602 incident patients were included in the pre-COVID-19 and COVID-19 periods, respectively. Prevalent patients treated with VKA had more strokes, thromboembolism, and major bleeding compared to those receiving NOAC, particularly during the COVID-19 period. NOAC patients had a 12 % lower risk of death than those on treatment with VKA (Hazard ratio = 0.88 [95 % CI: 0.81 - 0.95], p = 0.033). In addition, VKA patients were less persistent after 12 months than NOAC patients (pre-COVID-19 period: 52.1 % vs. 78.9 %, p < 0.001; COVID-19 period: 49.2 % vs. 80.3 %, p < 0.001), and required more healthcare visits and hospitalizations than those on treatment with NOAC.

Conclusion

Compared to VKA, NOAC seems to have reduced the incidence of severe events and the use of healthcare resources for NVAF, particularly during the pandemic.

Establishment and evaluation of a nomogram for in-hospital new-onset atrial fibrillation after percutaneous coronary intervention for acute myocardial infarction

Background

New-onset atrial fibrillation (NOAF) is prognostic in acute myocardial infarction (AMI). The timely identification of high-risk patients is essential for clinicians to improve patient prognosis.

Methods

A total of 333 AMI patients were collected who underwent percutaneous coronary intervention (PCI) at Zhejiang Provincial People's Hospital between October 2019 and October 2020. Least absolute shrinkage and selection operator regression (Lasso) and multivariate logistic regression analysis were applied to pick out independent risk factors. Secondly, the variables identified were utilized to establish a predicted model and then internally validated by 10-fold cross-validation. The discrimination, calibration, and clinical usefulness of the prediction model were evaluated using the receiver operating characteristic (ROC) curve, calibration curve, Hosmer-Lemeshow test decision curve analyses, and clinical impact curve.

Result

Overall, 47 patients (14.1%) developed NOAF. Four variables, including left atrial dimension, body mass index (BMI), CHA2DS2-VASc score, and prognostic nutritional index, were selected to construct a nomogram. Its area under the curve is 0.829, and internal validation by 10-fold cross-folding indicated a mean area under the curve is 0.818. The model demonstrated good calibration according to the Hosmer-Lemeshow test (P = 0.199) and the calibration curve. It showed satisfactory clinical practicability in the decision curve analyses and clinical impact curve.

Conclusion

This study established a simple and efficient nomogram prediction model to assess the risk of NOAF in patients with AMI who underwent PCI. This model could assist clinicians in promptly identifying high-risk patients and making better clinical decisions based on risk stratification.

Intracardiac Echocardiography-guided Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) is a suitable alternative to oral anticoagulant therapy to prevent stroke in patients with AF. Most procedures are performed under transoesophageal echocardiography (TOE) guidance, which facilitates transseptal puncture, reduces the risk of procedurerelated complications and provides an additional method for device selection and real-time monitoring during device deployment. However, TOE has significant shortcomings, including the need for general anaesthesia/deep sedation as well as a significant risk of procedure-related adverse events. More recently, intracardiac echocardiography has been proposed as an alternative to TOE guidance during LAAO procedures. In this review, we summarise the available evidence as well as providing a step-by-step approach for intracardiac echocardiography-guided LAAO.

Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at "Humanitas Gavazzeni Hospital", Bergamo, Italy. Robot-assisted epicardial ablation performed using the "Epi-Sense AtriCure" device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

Outcomes of mechanical thrombectomy in acute stroke patients with atrial fibrillation detected after stroke versus known atrial fibrillation

We aim to compare the outcomes in patients with atrial fibrillation detected after stroke (AFDAS) and their counterparts with known AF (KAF) presenting with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT). This observational, prospective study included consecutive patients with acute LVO ischemic stroke of the anterior circulation with AFDAS, KAF and without AF. The primary study outcome was functional independence at 90 days after stroke. The secondary study outcomes were variation of the NIHSS score at 24 h, rate of successful reperfusion, death at 90 days and rate of immediate complications post-procedure. Overall, our cohort included 518 patients with acute ischemic stroke and LVO treated with MT, with 289 (56.8%) without a diagnosis of AF; 107 (21%) with AFDAS; 122 (22.2%) with KAF. There was no significant difference in terms of functional independence at 90 days after stroke between the three groups. Regarding the secondary study outcome, the rate of symptomatic intracranial haemorrhage (sICH) and/or parenchymal hematoma (PH) were significantly higher in the group of patients without AF (respectively, P = 0.030 and  < 0.010). Logistic regression analysis showed that the subtypes of AF were not statistically significantly associated with functional independence at 90 days after stroke and with the likelihood of any ICH. Our results suggest that the subtypes of AF are not associated with clinical and safety outcomes of MT in patients with acute stroke and LVO. Further studies are needed to confirm our findings.

Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Aims

Whilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed or prematurely discontinued. The aim of this study was to evaluate the effect of inequalities in anti-coagulant prescribing by assessing stroke/systemic embolism (SSE) and bleeding risk in people with AF who continue anti-coagulation compared with those who stop transiently, permanently, or never start.

Methods and results

This retrospective cohort study utilized linked Scottish healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2-VASC score of ≥2. They were sub-categorized based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing risk regression was utilized to compare SSE and bleeding risks between cohorts during 5-year follow-up. Of an overall cohort of 47 427 people, 26 277 (55.41%) were never anti-coagulated, 7934 (16.72%) received continuous anti-coagulation, 9107 (19.2%) temporarily discontinued, and 4109 (8.66%) permanently discontinued. Lower socio-economic status, elevated frailty score, and age ≥ 75 were associated with a reduced likelihood of initiation and continuation of anti-coagulation. Stroke/systemic embolism risk was significantly greater in those with discontinuous anti-coagulation, compared with continuous [subhazard ratio (SHR): 2.65; 2.39-2.94]. In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation and continuous cohorts (SHR 0.94; 0.42-2.14).

Conclusion

Our data suggest significant inequalities in anti-coagulation prescribing, with substantial opportunity to improve initiation and continuation. Decision-making should be patient-centred and must recognize that discontinuation or cessation is associated with considerable thromboembolic risk not offset by mitigated bleeding risk.

Effect of China national centralized drug procurement policy on anticoagulation selection and hemorrhage events in patients with AF in Suining

Background: Launched in March 2019, the National Centralized Drug Procurement (NCDP) initiative aimed to optimize the drug utilization framework in public healthcare facilities. Following the integration of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) into the procurement catalog, healthcare establishments in Suining swiftly transitioned to the widespread adoption of NOACs, beginning 1 March 2020. Objective: This study aims to comprehensively assess the impact of the NCDP policy on the efficacy of anticoagulation therapy, patient medication adherence, and the incidence of hemorrhagic events in individuals with non-valvular atrial fibrillation (NVAF) residing in Suining. The analysis seeks to elucidate the broader impacts of the NCDP policy on this patient demographic. Methods: This study analyzed patient hospitalization records from the Department of Cardiology at Suining County People's Hospital, spanning 1 January 2017, to 30 June 2022. The dataset included demographic details (age, sex), type of health insurance, year of admission, hospitalization expenses, and comprehensive information on anticoagulant therapy utilization. The CHA2DS2-VASc scoring system, an established risk assessment tool, was used to evaluate stroke risk in NVAF patients. Patients with a CHA2DS2-VASc score of 2 or higher were categorized as high-risk, while those with scores below 2 were considered medium or low-risk. Results: 1. Treatment Cost Analysis: The study included 3,986 patients diagnosed with NVAF. Following the implementation of the NCDP policy, a significant increase in the average treatment cost for hospitalized patients was observed, rising from 8,900.57 ± 9,023.02 CNY to 9,829.99 ± 10,886.87 CNY (p < 0.001). 2. Oral Anticoagulant Utilization: Overall, oral anticoagulant use increased from 40.02% to 61.33% post-NCDP (p < 0.001). Specifically, NOAC utilization among patients dramatically rose from 15.41% to 90.99% (p < 0.001). 3. Hemorrhagic Events: There was a significant decrease in hemorrhagic events following the NCDP policy, from 1.88% to 0.66% (p = 0.01). Hypertension [OR = 1.979, 95% CI (1.132, 3.462), p = 0.017], history of stroke [OR = 1.375, 95% CI (1.023, 1.847), p = 0.035], age ≥65 years [OR = 0.339, 95% CI (0.188, 0.612), p < 0.001], combination therapy of anticoagulants and antiplatelets [OR = 3.620, 95% CI (1.752, 7.480), p < 0.001], hepatic and renal insufficiency [OR = 4.294, 95% CI (2.28, 8.084), p < 0.001], and the NCDP policy [OR = 0.295, 95% CI (0.115, 0.753), p = 0.011] are significant risk factors for bleeding in patients with atrial fibrillation. 4. Re-hospitalization and Anticoagulant Use: Among the 219 patients requiring re-hospitalization, there was a notable increase in anticoagulant usage post-NCDP, from 36.07% to 59.82% (p < 0.001). NOACs, in particular, saw a substantial rise in usage among these patients, from 11.39% to 80.92% (p < 0.001). 5. Anticoagulant Type Change: The NCDP policy [OR = 28.223, 95% CI (13.148, 60.585), p < 0.001] and bleeding events [OR = 27.772, 95% CI (3.213, 240.026), p = 0.003] were significant factors influencing the alteration of anticoagulant medications in patients. Conclusion: The NCDP policy has markedly improved anticoagulation management in patients with AF. This policy has played a crucial role in enhancing medication adherence and significantly reducing the incidence of hemorrhagic events among these patients. Additionally, the NCDP policy has proven to be a key factor in guiding the selection and modification of anticoagulant therapies in the AF patient population.

A novel contact force sensing pulsed field ablation catheter in a porcine model

BACKGROUND

Pulsed field ablation (PFA) has emerged as a novel non-thermal modality with highly myocardium-specific. However, the PFA catheter based on contact force (CF)-sensing has not been reported. The study aimed to evaluate the efficacy and safety of a novel CF-sensing PFA catheter.

METHODS

First, different CF (5, 15, 25, and 35 g) of the novel PFA catheter were evaluated on lesion dimensions during ablation on right and left ventricle in two pigs. Next, this catheter was further evaluated on four typical sites of superior vena cava (SVC), cavotricuspid isthmus (CTI), right superior pulmonary vein (RSPV), and right inferior pulmonary vein (RIPV) for atrial ablation in another six pigs. Electrical isolation was evaluated immediately after ablation and 30-day survival. Chronic lesions were assessed via histopathology after euthanasia. Acute and chronic safety outcomes were observed peri- and post-procedurally.

RESULTS

In ventricular ablation, increased CF from 5 to 15 g produced significantly greater lesion depth but nonsignificant increases from 15 to 35 g. In atrial ablation, the novel CF-sensing PFA deliveries produced an acute attenuation of local electrograms and formation of a continuous line of block in all 6 pigs. The ablation line remained sustained blockage at the 30-day survival period. The CF of SVC, CTI, RSPV, and RIPV was 9.4 ± 1.5, 14.5 ± 3.2, 17.2 ± 2.6, and 13.4 ± 2.8 g, respectively. Moreover, no evidence of damage to esophagus or phrenic nerve was observed.

CONCLUSION

The novel CF-sensing PFA catheter potentiated efficient, safe, and durable ablation, without causing damage to the esophagus or phrenic nerve.

Assessing the Safety and Efficacy of Rivaroxaban for Stroke Prevention in Patients With Atrial Fibrillation: A Systemic Review and Meta-Analysis

An effective anticoagulation therapy is required for patients with atrial fibrillation because it presents a significant risk of stroke. The current study evaluates the relative safety as well as efficacy of rivaroxaban in patients who are diagnosed with atrial fibrillation. A thorough literature review of relevant databases was conducted, focusing on academic and clinical studies that were published from 2017 onward. Inclusion criteria comprised randomized controlled trials and other observational studies comparing the incidence of stroke and the safety index of rivaroxaban in atrial fibrillation. We followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) for data overview reporting and overview. A total of 21 studies were selected based on the inclusion criteria. A total of 19/21 studies advocated the adoption of rivaroxaban for minimizing stroke incidence. Rivaroxaban also showed superiority in achieving the therapeutic objectives, i.e., reduction in the incidence of stroke. The results for rivaroxaban against warfarin showed an improved safety index and effectiveness of rivaroxaban. The total effect size for the analysis was calculated to be Z=2.62 (p-value=0.009). The individual effect of all studies favored the "rivaroxaban" group. The heterogeneity in the study was as follows: tau2=0.10; chi2=110.10, df=6; I2=95%. The second analysis for risk reduction and incidence of stroke after rivaroxaban therapy also showed a bias towards rivaroxaban therapy. The combined effect for the analysis was found to be as follows: HR=0.73 ((95% CI: 0.50, 1.07). The total effect was calculated to be Z=1.61 (p-value= 0.10). The heterogeneity was found to be as follows: tau2= 0.20, chi2=89.97, df=6, I2=93%. Standard dosing of rivaroxaban emerges as a preferred strategy for stroke prevention, balancing efficacy and safety. Clinical decision-making should consider individual patient characteristics and future research should delve into specific subpopulations and long-term outcomes to further refine treatment guidelines.

Cross-sectional and longitudinal association between atrial fibrillation and sarcopenia: Findings from the Korean frailty and aging cohort study

BACKGROUND

Sarcopenia is commonly observed in patients with cardiovascular diseases. However, studies on the association between sarcopenia and atrial fibrillation and their causal relationships are limited. We performed cross-sectional and longitudinal analyses to investigate the association between sarcopenia and atrial fibrillation among community-dwelling older adults.

METHODS

A total of 2225 participants from the Korean Frailty and Aging Cohort Study (KFACS) from 2016 to 2017 were included in this cross-sectional analysis. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 consensus. Atrial fibrillation was diagnosed on the basis of electrocardiographic findings. We investigated whether atrial fibrillation increased the risk of incident sarcopenia 2 years later and whether sarcopenia, in turn, increased the 2-year risk of developing atrial fibrillation using KFACS data from 2018 to 2019.

RESULTS

Of the 2225 participants (54.2% women; mean age 76.0 ± 3.9 years), 509 (22.9%) had sarcopenia at baseline. In the cross-sectional analysis, sarcopenia was associated with atrial fibrillation after multivariate adjustment [odd ratio (OR), 2.127; 95% confidence interval (CI), 1.240-3.648; P = 0.006]. Among the sarcopenia components, low physical performance was associated with atrial fibrillation (OR, 1.872; 95% CI, 1.123-3.120; P = 0.016). During the 2-year follow-up period, atrial fibrillation was not associated with new-onset of sarcopenia (OR, 1.483; 95% CI, 0.597-3.685; P = 0.396), and sarcopenia also did not significantly increase the risk of incident atrial fibrillation (OR, 1.120; 95% CI, 0.384-3.264; P = 0.836).

CONCLUSIONS

Although we found a significant association between sarcopenia and atrial fibrillation in a cross-sectional analysis, we could not establish a causal relationship between the two based on 2 years of follow-up. Further research with long-term follow-up is required to identify causal relationship between atrial fibrillation and sarcopenia.

Anticoagulation in chronic kidney disease: current status and future perspectives

Chronic kidney disease (CKD) is being diagnosed increasingly worldwide. It is often identified in individuals with comorbidities, which may increase the already heightened risk of thrombosis and hemorrhage associated with CKD. Oral anticoagulation is an effective means of reducing rates of ischemic stroke and systemic embolism in patients with atrial fibrillation and minimizes the morbidity and mortality caused by venous thromboembolic disease. Despite the proven benefits in the majority of patients, these have not been so clearly realized in patients with CKD due to the precarious balance between bleeding and thromboembolic complications. In this review, the current status of anticoagulant utilization in CKD is examined, and some practical recommendations are put forward to assist in the decision-making process of safely anticoagulating patients with CKD diagnosed with atrial fibrillation and venous thromboembolism.