EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

Comorbidity patterns and mortality in atrial fibrillation: a latent class analysis of the EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF)

BACKGROUND

Most older patients with atrial fibrillation (AF) have comorbidities. However, it is unclear whether specific comorbidity patterns are associated with adverse outcomes. We identified comorbidity patterns and their association with mortality in multimorbid older AF patients with different multidimensional frailty.

METHODS

Hospitalised adults aged ≥65 years with non-valvular AF were followed for 12 months in the multicentre EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF). Demographic characteristics, coexisting medical conditions, use of medications including anticoagulants, and the Multidimensional Prognostic Index (MPI) were captured on discharge. We used latent class analysis (LCA) to identify comorbidity phenotypes and Cox regression to determine associations between identified phenotypes and 12-month mortality.

RESULTS

Amongst n = 2,019 AF patients (mean ± SD age 82.9 ± 7.5 years), a 3-class LCA solution was considered optimal for phenotyping. The model identified phenotype 1 (hypertensive, other circulatory conditions, metabolic diseases; 33%), phenotype 2 (digestive diseases, infection, injury, non-specific clinical and laboratory abnormalities; 26%), and phenotype 3 (heart failure, respiratory diseases; 41%). Overall, 512 patients (25%) died within 12 months. Compared to phenotype 1, after adjusting for age, sex, use of anticoagulants, cardiovascular medications, and proton pump inhibitors, and individual MPI domains, phenotype 3 had a significantly higher risk of mortality (adjusted hazard ratio = 1.27, 95% CI = 1.01 to 1.60). In contrast, the risk of mortality in phenotype 2 was not different to phenotype 1.

CONCLUSION

We observed an association between comorbidity phenotypes identified using LCA and mortality in older AF patients. Further research is warranted to identify the mechanisms underpinning such associations.

The 2024 ESC guidelines on atrial fibrillation: essential updates for everyday clinical practice

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, and it is associated with substantial morbidity, mortality, and economic burden. Effective management of AF remains a critical focus in contemporary medicine, given its complex and multifaceted nature. In the present paper, we provide the essential updates for everyday clinical practice from the 2024 European Society of Cardiology (ESC) guidelines for AF management. We highlight seven key areas encompassing the adoption of the CHA₂DS₂-VA score for thromboembolic risk stratification, changes in bleeding risk assessment, expanded indications for catheter ablation, promotion of the multidisciplinary AF-CARE pathway for patient management, new recommendations for left atrial appendage closure, updates on clinical decision-making for atrial high-rate episodes, and considerations on the future role of artificial intelligence in advancing predictive analytics. We also compare the new recommendations proposed by the ESC 2024 AF guidelines with the ESC 2021 edition and the 2023 guidelines published by the American College of Cardiology/American Heart Association (ACC/AHA), reflecting regional perspectives and advancements in the field. By presenting these practical updates and their implications for routine practice, this paper aims to guide clinicians in adopting the latest evidence-based approaches to optimize AF patients' care.

Multidimensional prognostic index domain phenotypes identified using latent class analysis and mortality in the European Study of Older Subjects With Atrial Fibrillation (EUROSAF)

BACKGROUND

The multidimensional prognostic index (MPI), an established tool to predict adverse outcomes, classifies frailty using an aggregate-weighted tripartite scoring system based on 8 domains (low, moderate, or severe risk). However, this approach may fail to capture specific patient phenotypes that can be characterized by separate MPI domains and for whom health outcome risk also differs.

OBJECTIVE

We sought to identify latent patient phenotypes based on MPI domain data and to determine their association with mortality in older patients with atrial fibrillation (AF).

METHODS

Using data from the European Study of Older Subjects With Atrial Fibrillation, we used latent class analysis to identify phenotypes using individual MPI domains and Cox regression models to examine their association with 12-month mortality.

RESULTS

Four MPI domain phenotypes were identified in 2019 patients with AF (mean age 82.9 years [standard deviation, 7.5]; 57% females): phenotype 1 (relatively fit, few comorbidities; n = 672, 33%), phenotype 2 (functionally impaired, polypharmacy, comorbidities; n = 685, 34%), phenotype 3 (multidimensional frailty, comorbidities; n = 161, 8%), and phenotype 4 (relatively fit, polypharmacy, comorbidities; n = 501, 25%). Compared with phenotype 1, 12-month mortality was higher in phenotype 3 (adjusted hazard ratio [aHR], 4.68; 95% confidence interval [CI], 3.41-6.43), phenotype 2 (aHR, 1.98; 95% CI, 1.53-2.57), and phenotype 4 (aHR, 1.44; 95% CI, 1.07-1.94).

CONCLUSION

In a cohort of older patients with AF, latent class analysis identified 4 MPI domain phenotypes with different risks of mortality. Pending confirmatory studies, the identified subgroups might allow more targeted interventions to improve outcomes in this population.

Does Age Impact Safety and Efficacy During Pulse-Field Ablation for Atrial Fibrillation?

BACKGROUND

There is no evidence evaluating efficiency, effectiveness, and safety outcomes in older patients in the context of pulsed-field ablation technology for the ablation of atrial fibrillation. We aimed to compare safety, efficacy, and acute and long-term outcomes of pulsed-field ablation in older patients (≥75 years) with younger ones.

METHODS

We enrolled consecutive patients who had undergone atrial fibrillation ablation with the pulsed-field ablation FARAPULSE system (Boston Scientific) at 15 centers. Patients were stratified by age (<65, 65-74, and ≥75 years) and efficacy and safety profiles of these groups were compared.

RESULTS

A total of 1082 patients were included: 108 (10%) were ≥75 years old, 374 (34.6%) were 65-74 years old and 600 (55.4%) were <65 years old. Older patients displayed a more pronounced risk profile compared with their younger counterparts, characterized by a significant higher burden of comorbidities. No differences in terms of procedural metrics were found. Pulmonary vein isolation was achieved in all patients. An overall low rate of procedural-related complications was reported (3.0%) without difference between young and older patients (P=0.241). During a mean follow-up of 342±111 days, a primary efficacy end point occurred in 605 of 748 (80.9%) patients with available outcome information. The arrhythmia recurrence rate ranged from 14.4% in patients <65 years old to 26.9% of older patients (P=0.011).

CONCLUSIONS

Drawing from these findings, using the FARAPULSE system for atrial fibrillation ablation in older patients demonstrated swift, safe, and effective acute outcomes, mirroring a comparable pattern observed in younger patients and recurrence rates in line with the literature in older patients.

REGISTRATION

URL: clinicaltrials.gov; Unique Identifier: NCT05617456.

The developments and emerging trends of Autonomic Nervous System Research in Arrhythmia: a bibliometric study from 2004 to 2024

The role of the autonomic nervous system in cardiovascular diseases has increasingly attracted the attention of researchers. This study aims to review research on the autonomic nervous system in arrhythmias from 2004 to 2024, with a focus on understanding the development trends in this field. Data for this study were sourced from the Web of Science Core Collection. We constructed and analyzed bibliometric visualizations related to publication trends, countries/regions, institutions, journals, research categories, themes, references, and keywords. Over the past two decades, academic output related to the autonomic nervous system's role in arrhythmias has grown, although global research distribution remains uneven. The United States leads in publication volume and is home to many high-output institutions, providing it with significant academic influence and fostering international collaboration. By summarizing high-citation literature, clustering keywords, and performing a "burst detection" analysis of keywords, we identified that the mechanisms and assessment methods for autonomic nervous system regulation are major research focuses. Recent hotspots include the psychopathology related to the autonomic nervous system and autonomic regulation therapies. As the biomedical field shifts toward precision medicine, future research trends are likely to focus on identifying precise biomarkers for assessing autonomic nervous system function and developing novel strategies to regulate it. These strategies may include correcting immune dysfunction, psychological interventions, and surgical treatments. This study suggests that ganglionated plexi ablation may represent the most transformative intervention strategy for the Autonomic Nervous System currently available, and highlights electrodermal activity as an evaluation index with considerable potential for widespread application.

Correlation between self-management, psychological cognitive impairment, and quality of life in elderly chronic obstructive pulmonary disease patients

BACKGROUND

The correlation conclusions between self-management, frailty, and quality of life (QoL) of chronic obstructive pulmonary disease (COPD) patients are inconsistent.

AIM

To comprehensively assess the current status of self-management, psychological cognitive impairment, and QoL in elderly patients with COPD.

METHODS

Convenient sampling was employed to select 312 elderly patients with COPD who were receiving treatment in the respiratory and critical care medicine department of a tertiary grade A hospital from November 2023 to February 2024. The study utilized demographic information and clinical characteristics, self-management behavior, occurrence of psychological cognitive impairment, and QoL as evaluated through general information questionnaires, the COPD patient self-management scale, simple frailty scale, simple mental status scale, clinical dementia assessment scale, and the clinical COPD assessment test questionnaire. This research aims to describe the current status and correlations among self-management behavior, cognitive impairment occurrence, and QoL.

RESULTS

The average score for self-management behavior in elderly COPD patients was 136.00 (119.00, 164.50), indicating a moderate level overall. There were 98 cases of cognitive impairment, accounting for 31.4%, with a mental status score of 3 (2, 3.75). The average QoL score was 24 (19, 28), indicating a low level. Additionally, there was a negative correlation between total self-management behavior score and cognitive impairment occurrence (r = -0.589, P < 0.001), and QoL total score (r = -0.409, P < 0.001). Cognitive impairment occurrence was positively correlated with QoL total score (r = 0.345, P < 0.001). Disease course and self-management behavior score were independent factors affecting the total QoL score in elderly COPD patients (P < 0.05).

CONCLUSION

The self-management behavior of elderly patients with COPD is at a moderate level. However, the occurrence of cognitive impairment is high and significantly influenced by disease course, level of self-management, and mental status. The QoL is low, emphasizing the urgent need to intervene in the self-management behaviors of elderly COPD patients, actively reduce the occurrence of cognitive impairment, and mitigate the impact of the disease on QoL.

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.

Lifestyle and risk factor modification in atrial fibrillation: a European Heart Rhythm Association survey

AIMS

Lifestyle and risk factor modification (LRFM) forms a central pillar in the management of atrial fibrillation (AF). This European Heart Rhythm Association (EHRA) survey aims to assess current clinical practice regarding LRFM across EHRA countries.

METHODS AND RESULTS

A 31-item questionnaire was developed and distributed amongst healthcare professionals via the EHRA and social media, between 23 September and 21 October 2024. Of 258 respondents from 28 countries, 39.9% reported that their healthcare system is badly or very badly designed to deliver meaningful LRFM. Risk factors that respondents felt least confident managing included psychological distress (42.2% of respondents not confident), sleep-disordered breathing (33.8%), and obesity (22.4%). Respondents estimated that 70% of patients with AF at their institution may benefit from exercise-based cardiac rehabilitation but that only 10% are referred for this. The most important barrier to cardiac rehabilitation in AF was identified as local programmes not accepting patients with AF only (42.1% of respondents). Despite 37.7% of respondents using a body mass index cut-off when deciding on catheter ablation suitability (with a mean cut-off of 36.7 ± 5.4 kg/m2), only 23.5% of patients with obesity are referred for formal dietary advice. Lack of patient motivation or engagement was identified as the most important barrier to weight loss (41.3% of respondents). Moreover, 89.6% of respondents routinely assess their patient's alcohol intake, whilst only 23.9% systemically assess for psychological distress and 16.5% for sleep-disordered breathing.

CONCLUSION

Delivering comprehensive LRFM in AF poses significant challenges. Improvements to healthcare infrastructures are required to successfully implement meaningful LRFM.

Prediction of Recurrence of Atrial Fibrillation After Radiofrequency Ablation by Frailty

BACKGROUND

Previous studies have shown that frailty increases the risk of new-onset atrial fibrillation (AF). However, little is known about the association between frailty and the recurrence of AF after radiofrequency ablation. The objective of this study was to investigate the association between frailty and the recurrence in patients with AF who had undergone radiofrequency ablation.

METHODS AND RESULTS

A total of 450 patients >50 years of age with symptomatic drug-refractory AF who had undergone catheter ablation for the first time were retrospectively enrolled. Frailty status was evaluated by the 11-factor modified frailty index and 5-factor modified frailty index. Recurrence was defined as any documented atrial tachyarrhythmia lasting >30 seconds after a 3-month blanking period without any antiarrhythmic drugs during postablation follow-up. Patients in the frail group were older, and had a higher CHA2DS2-VASc score, HAS-BLED score, left atrial diameter, and a higher proportion of comorbidities than those in the nonfrail group. Circumferential pulmonary vein isolation was successfully done in all of the patients. During a median follow-up of 12 months, recurrence was recorded in 98 (21.8%) patients (paroxysmal AF, 20.6%; persistent AF, 23.2%). The Kaplan-Meier analysis showed that the survival rate of freedom from atrial tachyarrhythmias in the frail group was lower than that in nonfrail groups (log-rank P<0.001, 11-factor modified frailty index 31.3% versus 82.4%, 5-factor modified frailty index 44.9% versus 87.5%). After adjustment of additional risk factors in multivariable Cox analysis, 11-factor modified frailty index (hazard ratio [HR], 5.72 [95% CI, 3.79-8.64]; P<0.001) or 5-factor modified frailty index (HR, 5.62 [95% CI, 3.68-8.59]; P<0.001) was significantly associated with atrial tachyarrhythmia recurrence. The results remain significant in the subgroup analyses of different AF types, age groups, and sex. No significant differences of major complications were observed between the frail and nonfrail groups.

CONCLUSIONS

In patients with AF who had undergone catheter ablation, frail patients had around a 6-fold risk of recurrence as compared with the nonfrail patients. Frailty index may be a novel risk factor of recurrent AF.

Psychometric testing of the Arabic version of the arrhythmia-specific questionnaire in tachycardia and arrhythmia among older adult arrhythmic patients

OBJECTIVES

We aimed to translate and culturally adapt the Arrhythmia Specific Questionnaire in Tachycardia and Arrhythmia Health-Related Quality of Life (ASTA-HRQOL) scale into Arabic among older adult patients with any type of arrhythmia.

METHODS

A forward-backward translation method was used in translating the scale to Arabic. 130 older adults diagnosed with arrhythmia were recruited by convenience sampling from February 2023 to January 2024. Psychometric analysis involved internal consistency, test-retest reliability, convergent validity, floor and ceiling effects, discriminant validity, factorial validity, diagnosis accuracy, and calibration.

RESULTS

The scale showed excellent internal consistency and reliability. Convergent and discriminant validity were emphasized, and confirmatory factor analysis demonstrated a good fit of the model following modification. The cut-off point for discriminating between poor and good quality of life was 13.5, and the area under the curve was 0.95.

CONCLUSION

The ASTA-HRQOL Arabic questionnaire presented globally good psychometric properties among older adult patients with arrhythmia.

Integrated Care in Atrial Fibrillation: A Multidisciplinary Approach to Improve Clinical Outcomes and Quality of Life

Background: Atrial fibrillation (AF) is the most common arrhythmia globally, associated with serious complications such as stroke and heart failure, as well as significant impacts on patients' quality of life. Objectives: This theoretical article explores the role of integrated care in the management of AF, highlighting the need for a multidisciplinary approach that goes beyond rhythm and heart rate control. Methods: Through a review of the literature, this article explores the prevalence of AF, the challenges of diagnosis, the socioeconomic and psychological impact, as well as the benefits of integrating medical, psychological, and social interventions, drawing on insights from studies about integrative care in AF. Results: The findings highlight the challenges of managing AF, including its high prevalence, complex diagnosis, and significant socioeconomic and psychological impacts on patients. Integrated care models, combining medical, psychological, and social interventions, improve treatment adherence, reduce complications like stroke and heart failure, and enhance patient quality of life. Conclusions: Integrated care models hold significant promise in improving outcomes in AF patients through structured, multidisciplinary approaches. Evidence supports reductions in cardiovascular events, hospitalizations, and mortality when adhering to clinical guidelines, emphasizing patient education, and implementing individualized care strategies. Despite challenges, like regional disparities and suboptimal implementation, the integration of multidisciplinary teams and emerging technologies offers a way to enhance care delivery and accessibility. Future efforts should focus on personalizing care, promoting professional collaboration, and taking advantage of technological advances to optimize AF management and promote sustainable health systems.

Association between frailty and adverse outcomes after cardiac resynchronization therapy: a systematic review and meta-analysis

AIM

To synthesize evidence, using data from published studies, on the association of frailty with the outcomes after cardiac resynchronization therapy (CRT).

METHODS

The systematic search of PubMed, Web of Science, Scopus, and Embase databases was done to identify observational studies (cohort/case-control/cross-sectional) that used an objective method for frailty assessment and had presented adjusted effect sizes. STATA version 15.0 was used to conduct analysis, which was based on random effects model.

RESULTS

Fifteen studies were included. Frailty was found to be associated with an increased risk of in-hospital mortality (odds ratio (OR) 6.96, 95% confidence interval (CI) 5.48, 8.85). The effect of frailty on the response to CRT was not statistically significant (OR 0.55, 95% CI 0.19, 1.59). The pooled effect size indicated that frailty was associated with somewhat bigger but not statistically significant increase in the risk of complications (OR 1.70, 95% CI 0.93, 3.12). The risks of mortality and decompensated heart failure on long-term follow up were higher in frail patients (Hazard ratio (HR) 1.75, 95% CI 1.40, 2.17 and HR 3.03, 95% CI 1.33, 6.90, respectively) compared to patients without frailty. The risk of readmission was higher in frail patients, however, it did not achieve statistical significance (HR 2.63, 95% CI 0.89, 7.75).

CONCLUSION

Frail CRT patients could be at higher risks of mortality, decompensated heart failure, and may have potentially higher rates of complications. Integrating frailty assessment into pre-CRT evaluation and customizing interventions for frail patients might be an essential steps towards enhancing outcomes in this population.

Safety and Outcomes of Catheter Ablation for Consecutive Atrial Tachycardia in Elderly Patients After Previous Cardiac Interventions

Background: Age is a relevant risk factor for the development of atrial arrhythmias and an independent predictor of adverse cardiovascular outcomes. The incidence of atrial tachycardia (AT) is known to increase with aging, but so far, there are no data on elderly patients with AT. Therefore, we sought to assess the safety and outcomes of AT ablation in patients ≥75 years compared to those <75 years. Methods: A total of 420 consecutive patients undergoing AT ablation after previous cardiac interventions (mean 2.1 ± 0.1 prior ablation procedures) were analyzed. Safety, as well as acute and mid-term outcomes of AT ablation were compared between 140 patients ≥75 years (mean age 78.1 ± 0.2 years, 22.9% aged ≥80 years (range 80-86 years)) and 280 patients <75 years (mean age 62.2 ± 0.6 years). Results: Patients ≥75 years were more often female (54.3% vs. 38.2%; p = 0.0024) and presented with more cardiac comorbidities, including arterial hypertension (85.0% vs. 64.3%; p < 0.0001) and coronary artery disease (33.6% vs. 18.2%; p = 0.0006). Acute success of AT ablation was reached in 96.4% vs. 97.9% of patients (p = 0.5173). Major complications (1.4% vs. 0.7%; p = 0.6035) and duration of hospital stay (2 (IQR 2-4) days vs. 2 (IQR 2-3) days; p = 0.9125) did not differ significantly between groups. During a follow-up of 364 (IQR 183-729.5) days, arrhythmia recurrences occurred in 45.0% vs. 49.3% (p = 0.4684), whereas repeat ablation was less frequently performed in patients ≥75 years (25.7% vs. 36.1%; p = 0.0361). Conclusions: AT ablation in patients ≥75 years after previous cardiac interventions in tertiary arrhythmia centers is safe and effective. Therefore, AT ablation should not be ruled out in elderly patients due to age alone, but should be considered based on arrhythmia burden, symptom severity and concomitant clinical and procedural risk factors.

Cardiovascular diseases, prevention, and management of complications in older adults and frail patients treated for elective or post-traumatic hip orthopaedic interventions: a clinical consensus statement of the ESC Council for Cardiology Practice (CCP), the European Association of Preventive Cardiology (EAPC), the Association for Acute CardioVascular Care (ACVC), the Association of Cardiovascular Nursing & Allied Professions of the ESC (ACNAP), the ESC Working Group on Aorta and Peripheral Vascular Diseases (WG APVD), and the ESC Working Group on Thrombosis (WG T)

Due to the aging population, focusing on healthy aging has become a global priority. Cardiovascular diseases (CVDs) and frailty, characterized by increased vulnerability to adverse stress and health events, interact synergistically in advanced age. In older adults, hip fractures are a frequent dramatic "life-transition" event. Conditions such as arrhythmias, orthostatic hypotension, heart failure, peripheral artery disease and adverse drug reactions may facilitate falls and thus bone fractures in older adults. Cardiovascular complications or the worsening of previous CVDs may increase the degree of frailty and disability following this surgery. The close relationship between older age, CVDs, frailty and orthopaedic surgery leads to the need to focus on the various phases of interventions in a multidisciplinary approach. This document aims to provide practical support to prevent cardiovascular complications in older and frail patients undergoing hip procedures by suggesting specific assessments and interventions. In particular, in pre-operative care the focus should be on the assessment and management of concomitant CVD and frailty, while immediate peri- and post-operative care should highlight specific concerns for anesthesia, prevention and management of thrombotic complications, specific nursing needs, including the prevention of infections and delirium, and the establishment of an integrated rehabilitation program focusing on CVDs and the risk of new falls, with a positive role for care-givers. Furthermore, by optimizing the "hip surgery pathway" the objective is to help avoid the deterioration of health and loss of independence that often result from this surgery through the correct management of cardiovascular patients in this peculiar context.

Effects of intensive, targeted education by pharmacists on anticoagulant patients with atrial fibrillation: a multicentre randomized controlled trial from China

AIMS

Many people diagnosed with atrial fibrillation (AF) may lack awareness of AF and anticoagulants. The purpose of this study is to investigate the effects of intensive, targeted education by pharmacists on anticoagulant patients with AF.

METHODS AND RESULTS

Three hundred seventy-six AF patients were randomly assigned to receive standard care or pharmacist education. Follow-up is scheduled after 1, 3, 6, and 12 months. Pharmacists provided intensive education on knowledge deficits revealed by the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) during each visit. Patients also completed two questionnaires to assess their medication adherence and satisfaction. Clinical outcomes were recorded during follow-up. Three hundred sixty-one patients completed follow-up. Baseline scores on the JAKQ were similar in the education group (median: 31.3%) and the standard care group (median: 31.3%) (P = 0.911). Over time, the knowledge score of the education group increased significantly (1 month: 68.8%, 3 months: 81.3%; P < 0.001), while there was no significant improvement in the standard care group (1 month: 37.5%, 3 months: 37.5%; P = 0.314). Adherence scores improved significantly over time in the education group (P < 0.001) but not in the standard care group (P = 0.101). Compared with standard care, pharmacist education was associated with a significantly lower risk of bleeding (P = 0.034).

CONCLUSION

Given the knowledge deficiency of AF patients in China, standardized patient education should be a part of their daily care. Pharmacist-led education intervention can significantly improve the disease-related knowledge, medication adherence, and drug treatment satisfaction of AF patients while significantly reducing the risk of bleeding.

REGISTRATION

ChiCTR1900024455.

Sex differences in patients with atrial fibrillation and acute coronary syndrome or undergoing PCI: a real-world study

BACKGROUND

In patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), female patients have a worse short-term prognosis than male patients has been consistently concluded in many studies. However, the impact of sex differences on long-term prognosis remains uncertain. Additionally, women are underrepresented in clinical trials exploring optimal antithrombotic strategies in patients with atrial fibrillation (AF) and ACS or PCI. To bridge this gap, this study aimed to investigate sex differences in clinical characteristics, treatment, and long-term clinical outcomes in patients with AF and ACS or PCI.

PATIENTS AND METHODS

This study included a total of 1237 patients with AF and ACS and 539 patients with AF and stable coronary artery disease (SCAD) who underwent PCI at the Fuwai Hospital of the Chinese Academy of Medical Sciences from January 2017 to December 2019. Patients were followed up until the end of 2021 to observe the occurrence of major adverse cardiovascular events (MACE). The relationship between sex and MACE was evaluated using Cox regression models and Kaplan-Meier's survival curves.

RESULTS

In patients with AF and ACS, multivariable COX regression analysis revealed that female patients were independently associated with a higher risk of MACE (HR = 1.45, 95% CI 1.11-1.89, p = .006). However, in AF patients with SCAD who underwent PCI, the analysis showed that female patients were not independently associated with MACE risk (HR = 1.12, 95% CI 0.62-2.03, p = .717).

CONCLUSIONS

In patients with AF and ACS, females have a significantly higher risk of long-term MACE compared to males. However, among patients with AF and SCAD who underwent PCI, there was no significant difference in long-term MACE risk between males and females.

Patterns of Comorbidity, Disability, and Home Health Care Service for Older Adults With Physical Disability: A Latent Class Analysis and Visualized Illustration

Understanding the relationships between comorbidity, disability, and home health-care services aids in user-centered care design. This study identifies patterns of these factors among older adults with physical disability living at home and explores their associations. This cross-sectional study included community-dwelling older adults assessed for Long-term Care Insurance from September 1 to December 31, 2018, in Yiwu, Zhejiang, China. We analyzed deidentified data on sociodemographics, physical disability, chronic conditions, and care plans for 1882 participants using latent class analysis and multinomial logistic regression. Five comorbidity patterns (other sporadic diseases, cancer comorbidity, other sporadic comorbidities, coronary atherosclerotic heart disease, and fracture) and four home health-care service patterns (assistance & facilitation of elimination, bedridden assistance & stoma care, bedside assistance & stoma care, and assistance & tube feeding) were identified. Four disability patterns emerged (bedridden without incontinence, bedridden & with upper limb mobility, off-bed & ADLs limited, and bedridden with incontinence). Complex associations between these patterns were observed. The study highlights the heterogeneity and complexity of the above patterns, emphasizing the importance of person-centered home health-care services and technology-supported care strategies.

From geriatric assessment to inflammation. A pilot, observational, study about frailty components in older patients with persistent atrial fibrillation

Background

Atrial fibrillation (AF) is the most common arrhythmia diagnosed at an older age. AF is associated with frailty, a condition possibly justifying the higher rate of complications and mortality in aged individuals. This study was aimed at describing the characteristics correlated to frailty in older AF subjects.

Methods

After having excluded a < 3 months major surgery procedure, cancer or other conditions associated with activation of inflammation, and a life expectancy < 12 months, we consecutively enrolled patients ≥ 65 years with persistent AF. They underwent a Comprehensive Geriatric Assessment evaluation. In particular, Mini-Mental State Examination, 15-item Geriatric Depression Scale and Short-Physical Performance Battery (SPPB) described, respectively, cognitive profile, depressive symptoms and physical performance. A venous blood sample was collected to measure interleukin-6 (IL-6; marker of low-grade inflammation) and acylcarnitines, expression of mitochondrial dysfunction and abnormal energy production.

Results

Overall, 49 patients (mean age: 76 ± 6 years; women 30.6 %) were studied. Cluster analysis described two different patterns; the second (N = 18, 36.7 %), when compared to the first one (N = 31, 63.3 %), was characterized by a worse phenotype, identified by the simultaneous presence of lower body mass index, higher CHA2DS2-VASc score (index of clinical complexity), worse SPPB functional performance, and high IL-6 levels. Second cluster patients had a higher concentration of 13 of the 35 acylcarnitines evaluated and increased 5-year mortality. All these features can outline a frail condition.

Conclusions

Body size, clinical complexity, physical performance and low-grade inflammation seem to rapidly and adequately describe frailty.

Two-year outcomes of Micra AV leadless pacemakers in the Micra AV CED study

AIMS

Leadless pacing is a safe and effective alternative to transvenous pacing for bradycardia. Micra AV is a leadless, single-device solution that provides atrioventricular synchronous ventricular pacing therapy. Early results from the Micra AV CED study showed reductions in short-term complications associated with the Micra AV leadless pacemaker among US Medicare patients. The objective of this study is to compare chronic complications, re-interventions, and all-cause mortality at 2 years between patients implanted with a Micra AV leadless pacemaker and a traditional dual-chamber transvenous (DC-TV) pacemaker.

METHODS AND RESULTS

Patients implanted with a Micra AV leadless pacemaker (n = 7552) or a DC-TV pacemaker (n = 110 558) in 2020 and 2021 were identified using device registration-linked Medicare administrative claims data. Competing risk models compared the unadjusted and propensity score overlap weight-adjusted complication, re-intervention, and all-cause mortality rates of Micra AV and DC-TV patients at 2 years. Micra AV patients had significantly more comorbidities (end-stage renal disease 14.9 vs. 2.0%, P < 0.0001; renal dysfunction 47.9 vs. 34.2%, P < 0.0001; diabetes 46.2 vs. 38.3%, P < 0.001; congestive heart failure 41.4 vs. 30.6%, P < 0.0001). Two years post-implant, Micra AV patients had lower complication rates [adjusted 5.3 vs. 9.6%, hazard ratio (HR): 0.54, 95% confidence interval (CI) 0.49-0.61, P < 0.0001] and lower re-intervention rates (adjusted 3.5 vs. 5.6%, HR: 0.62, 95% CI 0.54-0.72, P < 0.0001) than DC-TV patients. Upgrades to cardiac resynchronization therapy were low in both groups (adjusted 1.6 vs. 1.7%, P = 0.40), as were Micra AV upgrades to a dual-chamber system (adjusted 1.4%). All-cause mortality rates remained higher in Micra AV than in DC-TV patients (unadjusted HR: 2.48, 95% CI 2.35-2.62, P < 0.0001; adjusted HR: 1.53, 95% CI 1.44-1.62, P < 0.0001).

CONCLUSION

Patients implanted with Micra AV had lower complications and re-intervention rates at 2 years than patients implanted with a traditional DC-TV pacemaker. All-cause mortality remained higher in Micra AV patients, likely due to their higher comorbidity burden and other differences in baseline characteristics.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04235491.

Predictors of death without prior appropriate therapy in ICD recipients: the comorbidities, frailty and functional status (COMFFORT study)

OBJECTIVE

Most patients who have an implantable cardioverter-defibrillator (ICD) implant do not receive life-prolonging therapy from it. Little research has been undertaken to determine which patients benefit the least from ICD therapy. As patients age and accumulate comorbidities, the risk of death increases and the benefit of ICDs diminishes. We sought to evaluate the impact of comorbidity, frailty, functional status on death with no prior appropriate ICD therapy.

METHODS

A prospective, multicentre, observational study involving 12 English hospitals was undertaken. Patients were eligible for inclusion for the study if they were scheduled to have a de novo, upgrade to or replacement of a transvenous or subcutaneous ICD or cardiac resynchronisation therapy device and defibrillator (CRT-D). Baseline characteristics were collected. Participants were asked to complete a frailty assessment (Fried score) and a functional status questionnaire (EuroQol 5-Dimension 5-Level (EQ-5D-5L)). The Charlson Comorbidity Index was calculated. Patients were prospectively followed up for 2.5 years. The primary outcome was death with no prior appropriate therapy.

RESULTS

In total, 675 patients were enrolled, mean age 65.7 (IQR 65-75) years. A total of 63 patients (9.5%) died during follow-up, 58 without receiving appropriate ICD therapy. Frailty was present in 86/675 (12.7%) and severe comorbidity in 69/675 (10.2%). Multivariate predictors of death with no appropriate therapy were identified and a risk score comprising frailty, comorbidity, increasing age, estimated glomerular filtration rate and EQ-5D-5L was developed.

CONCLUSION

Comorbidities, frailty and the EQ-5D-5L score are powerful, independent predictors of death with no prior appropriate therapy in ICD/CRT-D recipients.

The NORwegian atrial fibrillation self-SCREENing (NORSCREEN) trial: rationale and design of a randomized controlled trial

AIMS

Atrial fibrillation (AF) is a common arrhythmia, and many cases of AF may be undiagnosed. Whether screening for AF and subsequent treatment if AF is detected can improve long-term outcome remains an unsettled question. The primary aim of the NORwegian atrial fibrillation self-SCREENing (NORSCREEN) trial is to assess whether self-screening for AF with continuous electrocardiogram (ECG) for 3-7 days in individuals aged 65 years or older with at least one additional risk factor for stroke, and initiation of guideline-recommended therapy in patients with detected AF, will reduce the occurrence of stroke.

METHODS AND RESULTS

This study is a nationwide open, siteless, randomized, controlled trial. Individuals ≥65 years of age are randomly identified from the National Population Register of Norway and are invited to take a digital inclusion/exclusion test. Individuals passing the inclusion/exclusion test are randomized to either the intervention group or the control group. A total of 35 000 participants will be enrolled. In the intervention group, self-screening is performed continuously over 3-7 days at home with a patch ECG device (ECG247) at inclusion and after 12-18 months. If AF is detected, guideline-recommended therapy will be initiated. Patients will be followed up for 5 years through national health registries. The primary outcome is time to a first stroke (ischaemic or haemorrhagic stroke). The first participant in the NORSCREEN trial was enrolled on 1 September 2023.

CONCLUSION

The results from the NORSCREEN trial will provide new insights regarding the efficacy of digital siteless self-screening for AF with respect to stroke prevention in individuals at an increased risk of stroke.

TRIAL REGISTRATION

Clinical trials: NCT05914883.

Managing elderly patients with atrial fibrillation and multimorbidity: call for a systematic approach

INTRODUCTION

Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management, and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management.

AREAS COVERED

This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management.

EXPERT OPINION

Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.

Frailty and Cardiovascular Health

The incidence of frailty and cardiovascular disease (CVD) increases as the population ages. There is a bidirectional relationship between frailty and CVD, and both conditions share several risk factors and underlying biological mechanisms. Frailty has been established as an independent prognostic marker in patients with CVD. Moreover, its presence significantly influences both primary and secondary prevention strategies for adults with CVD while also posing a barrier to the inclusion of these patients in pivotal clinical trials and advanced cardiac interventions. This review discusses the current knowledge base on the relationship between frailty and CVD, how managing CVD risk factors can modify frailty, the influence of frailty on CVD management, and future directions for frailty detection and modification in patients with CVD.

High premature atrial complex burden and risk of renal function decline

Background

Atrial arrhythmia, particularly atrial fibrillation (AF), is known to be associated with renal function decline and increased risk of end-stage kidney disease. In recent years, premature atrial complexes (PACs) as subclinical arrhythmia have been proposed to be a marker of atrial cardiomyopathy and associated with poor clinical outcomes. However, the relationship between excessive daily PAC burden and renal outcomes remains unexplored.

Methods

This retrospective, all-comers cohort study analyzed 30 488 consecutive Holter monitoring records obtained from a validated Holter databank at a referral medical center in Taiwan between 2011 and 2018. After exclusion, 10 981 patients were categorized into three groups: high daily PAC burden (≥100 beats per day), low PAC burden (<100 beats per day) and the AF group. We used parallel propensity score matching to balance confounding factors between groups. The primary study interest was major adverse kidney events, including an estimated glomerular filtration rate (eGFR) decline of 40%, eGFR <15 mL/min/1.73 m2 or the initiation of hemodialysis.

Results

After a mean follow-up of 4.07 ± 3.03 years, patients with high PAC burden had a 1.24-fold higher incidence of major adverse kidney events compared with the low PAC burden group [95% confidence interval (CI) 1.03-1.50]. The risk of major adverse kidney events was similar between patients with AF and those with high PAC burden [adjusted hazard ratio (HR) 1.05, 95% CI 0.87-1.25], but significantly higher in the AF group than in the low PAC burden group (adjusted HR 1.29, 95% CI 1.07-1.56).

Conclusion

Excessive daily PAC burden is associated with a higher risk of major adverse kidney events and has a comparable impact as AF.

Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association

AIMS

The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial.

METHODS AND RESULTS

STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022-23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers.

CONCLUSION

The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT04396418.

Atrial fibrillation accelerates functional decline in older adults: a 15-year follow-up population-based study

AIMS

Atrial fibrillation (AF) has been associated with functional impairment. However, the role exerted by AF on the long-term trajectories of functional mobility remains to be elucidated. This study aimed to evaluate the impact of AF on functional mobility by tracing walking speed (WS) trajectories over 15 years of follow-up in a population-based cohort of individuals aged 60+ years.

METHODS AND RESULTS

This population-based cohort study included 3141 community-dwelling participants (mean age 73.7 years; 63.6% women) from the Swedish National Study on Aging and Care in Kungsholmen, who were regularly examined from 2001-2004 to 2016-2019. Functional mobility was assessed by measuring WS in a standardized way. The association between AF and WS trajectories was assessed by multivariable joint models accounting for the longitudinal dropouts due to death. Stratified analyses by demographic and clinical factors were performed. The effect-modifying role of oral anticoagulant therapy (OAC), incident heart failure (HF), and incident stroke was finally investigated. At baseline, 285 (9.1%) participants were ascertained to have AF. A faster annual WS decline was observed in persons with AF than in non-AF peers (adjusted β coefficient per year = -0.011, 95% confidence interval: -0.016 to -0.005). Incident HF and stroke were associated with greater WS decline in participants with AF. OAC use was not associated with a slower functional decline.

CONCLUSION

Atrial fibrillation is associated with a faster physical function decline in older individuals. Incident HF and stroke possibly accelerate WS decline over time in AF participants.

Comparative Safety and Effectiveness of Reduced Doses of Direct Acting Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation

BACKGROUND

This Nordic observational cohort study aims to assess the effectiveness and safety of reduced-dose direct-acting oral anticoagulants (DOACs) dabigatran, rivaroxaban, and apixaban compared to standard warfarin for stroke prevention in nonvalvular atrial fibrillation.

METHODS

The study, utilizing nationwide administrative databases from Denmark, Sweden, Norway, and Finland, spanned from January 1, 2011 to December 31, 2018 (2017 for Sweden). The cohort included 26,883 patients initiating reduced-dose DOACs and 108,014 comparable warfarin patients. Effectiveness was measured by the composite endpoint of ischemic stroke and systemic embolism, while safety was assessed through intracranial hemorrhage.

RESULTS

The meta-analysis across countries revealed similar or lower incidences of ischemic stroke and systemic embolism in patients on reduced-dose DOACs compared to standard warfarin (rivaroxaban: HR 0.93, dabigatran: HR 0.88, apixaban: HR 0.79). Incidences within warfarin groups ranged from 2.16 to 3.71 per 100 person-years, comparable to DOAC recipients. Intracranial hemorrhage rates were generally low, ranging from 0.16 to 1.85 per 100 person-years. In comparison with warfarin patients, meta-analyses yielded HRs for rivaroxaban (1.41), dabigatran (0.35), and apixaban (0.72).

CONCLUSIONS

In this study, atrial fibrillation patients initiating reduced-dose rivaroxaban and dabigatran exhibited incidences of ischemic stroke and systemic embolism similar to warfarin, and for apixaban, even lower. Rates of intracranial hemorrhage were comparable to or lower for patients on DOACs compared to warfarin.

Association between body mass index and results of cryoballoon ablation in Korean patients with atrial fibrillation: an analysis from the Korean Heart Rhythm Society Cryoablation registry

AIMS

Pulmonary vein isolation using cryoablation is effective and safe in patients with atrial fibrillation (AF). Although both obesity and underweight are associated with a higher risk for incident AF, there is limited data on the efficacy and safety following cryoablation according to body mass index (BMI) especially in Asians.

METHODS AND RESULTS

Using the Korean Heart Rhythm Society Cryoablation registry, a multicentre registry of 12 tertiary hospitals, we analysed AF recurrence and procedure-related complications after cryoablation by BMI (kg/m2) groups (BMI < 18.5, underweight, UW; 18.5-23, normal, NW; 23-25, overweight, OW; 25-30, obese Ⅰ, OⅠ; ≥30, obese Ⅱ, OⅡ). A total of 2648 patients were included (median age 62.0 years; 76.7% men; 55.6% non-paroxysmal AF). Patients were categorized by BMI groups: 0.9% UW, 18.7% NW, 24.8% OW, 46.1% OI, and 9.4% OII. Underweight patients were the oldest and had least percentage of non-paroxysmal AF (33.3%). During a median follow-up of 1.7 years, atrial arrhythmia recurred in 874 (33.0%) patients (incidence rate, 18.9 per 100 person-years). After multivariable adjustment, the risk of AF recurrence was higher in UW group compared with NW group (adjusted hazard ratio, 95% confidence interval; 2.55, 1.18-5.50, P = 0.02). Procedure-related complications occurred in 123 (4.7%) patients, and the risk was higher for UW patients (odds ratio, 95% confidence interval; 2.90, 0.94-8.99, P = 0.07), mainly due to transient phrenic nerve palsy.

CONCLUSION

Underweight patients showed a higher risk of AF recurrence after cryoablation compared with NW patients. Also, careful attention is needed on the occurrence of phrenic nerve palsy in UW patients.

Influence of multimorbidity and socioeconomic position on long-term healthcare utilization and prognosis in patients after cardiac resynchronization therapy implantation

Aims

We aimed to investigate the influence of socioeconomic position (SEP) and multimorbidity on cross-sectional healthcare utilization and prognosis in patients after cardiac resynchronization therapy (CRT) implantation.

Methods and results

We included first-time CRT recipients with left ventricular ejection fraction ≤35% implanted between 2000 and 2017. Data on chronic conditions, use of healthcare services, and demographics were obtained from Danish national administrative and health registries. Healthcare utilization (in- and outpatient hospitalizations, activities in general practice) was compared by multimorbidity categories and SEP by using a negative binomial regression model. The association between SEP, multimorbidity, and prognostic outcomes was analysed using Cox proportional hazards regression. We followed 2007 patients (median age of 70 years), 79% were male, 75% were on early retirement or state pension, 37% were living alone, and 41% had low education level for a median of 5.2 [inter-quartile range: 2.2-7.3) years. In adjusted regression models, a higher number of chronic conditions were associated with increased healthcare utilization. Both cardiovascular and non-cardiovascular hospital contacts were increased. Patients with low SEP had a higher number of chronic conditions, but SEP had limited influence on healthcare utilization. Patients living alone and those with low educational level had a trend towards a higher risk of all-cause mortality [adjusted hazard ratio (aHR): 1.17, 95% confidence interval (CI) 1.03-1.33, and aHR 1.09, 95% CI 0.96-1.24).

Conclusion

Multimorbidity increased the use of cross-sectional healthcare services, whereas low SEP had minor influence on the utilizations. Living alone and low educational level showed a trend towards a higher risk of mortality after CRT implantation.

Assessment and Management of Atrial Fibrillation in Older Adults with Frailty

Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.

Patterns of comorbidities in patients with atrial fibrillation and impact on management and long-term prognosis: an analysis from the Prospective Global GLORIA-AF Registry

BACKGROUND

Clinical complexity, as the interaction between ageing, frailty, multimorbidity and polypharmacy, is an increasing concern in patients with AF. There remains uncertainty regarding how combinations of comorbidities influence management and prognosis of patients with atrial fibrillation (AF). We aimed to identify phenotypes of AF patients according to comorbidities and to assess associations between comorbidity patterns, drug use and risk of major outcomes.

METHODS

From the prospective GLORIA-AF Registry, we performed a latent class analysis based on 18 diseases, encompassing cardiovascular, metabolic, respiratory and other conditions; we then analysed the association between phenotypes of patients and (i) treatments received and (ii) the risk of major outcomes. Primary outcome was the composite of all-cause death and major adverse cardiovascular events (MACE). Secondary exploratory outcomes were also analysed.

RESULTS

32,560 AF patients (mean age 70.0 ± 10.5 years, 45.4% females) were included. We identified 6 phenotypes: (i) low complexity (39.2% of patients); (ii) cardiovascular (CV) risk factors (28.2%); (iii) atherosclerotic (10.2%); (iv) thromboembolic (8.1%); (v) cardiometabolic (7.6%) and (vi) high complexity (6.6%). Higher use of oral anticoagulants was found in more complex groups, with highest magnitude observed for the cardiometabolic and high complexity phenotypes (odds ratio and 95% confidence interval CI): 1.76 [1.49-2.09] and 1.57 [1.35-1.81], respectively); similar results were observed for beta-blockers and verapamil or diltiazem. We found higher risk of the primary outcome in all phenotypes, except the CV risk factor one, with highest risk observed for the cardiometabolic and high complexity groups (hazard ratio and 95%CI: 1.37 [1.13-1.67] and 1.47 [1.24-1.75], respectively).

CONCLUSIONS

Comorbidities influence management and long-term prognosis of patients with AF. Patients with complex phenotypes may require comprehensive and holistic approaches to improve their prognosis.

Multimorbidity in patients with atrial fibrillation

There is an escalating trend in both the incidence and prevalence of atrial fibrillation (AF). AF is linked to numerous other comorbidities, contributing to the emergence of multimorbidity. The sustained rise in multimorbidity and AF prevalences exerts a significant strain on healthcare systems globally. The understanding of the relation between multimorbidity and AF is essential to determine effective healthcare strategies, improve patient outcomes to adequately address the burden of AF. It not only begins with the accurate identification of comorbidities in the setting of AF. There is also the need to understand the pathophysiology of the different comorbidities and their common interactions, and how multimorbidity influences AF perpetuation. To manage the challenges that rise from the increasing incidence and prevalence of both multimorbidity and AF, such as adverse events and hospitalisations, the treatment of comorbidities in AF has already gained importance and will need to be a primary focus in the forthcoming years. There are numerous challenges to overcome in the treatment of multimorbidity in AF, whereby the identification of comorbidities is essential. Integrated care strategies focused on a comprehensive multimorbidity management with an individual-centred approach need to be determined to improve healthcare strategies and reduce the AF-related risk of frailty, cardiovascular diseases and improve patient outcomes.

In-hospital safety outcomes of left atrial appendage occlusion in octogenarians and nonagenarians

AIMS

Data on safety outcomes of left atrial appendage occlusion (LAAO) in elderly patients are limited. This study aimed to compare the outcomes of LAAO between octogenarians (age 80-89) and nonagenarians (age ≥90) vs. younger patients (age ≤79).

METHODS AND RESULTS

We conducted a retrospective cohort study using the National Inpatient Sample database to identify patients hospitalized for LAAO from 2016 to 2020 and to compare in-hospital safety outcomes in octogenarians and nonagenarians vs. younger patients. The primary outcome was a composite of in-hospital all-cause mortality or stroke. Secondary outcomes included procedural complications, length of stay (LOS), and total costs. Outcomes were determined using logistic regression models. Among 84 140 patients hospitalized for LAAO, 32.9% were octogenarians, 2.8% were nonagenarians, and 64.3% were ≤79 years of age. Over the study period, the volume of LAAO increased in all age groups (all Ptrend < 0.01). After adjustment for clinical and demographic factors, octogenarians and nonagenarians had similar odds of in-hospital all-cause mortality or stroke [adjusted odds ratio (aOR) 1.41, 95% confidence interval (CI) 0.93-2.13 for octogenarians; aOR 1.69, 95% CI 0.67-3.92 for nonagenarians], cardiac tamponade, acute kidney injury, major bleeding, and blood transfusion, in addition to similar LOS and total costs compared with younger patients (all P > 0.05). However, octogenarians and nonagenarians had higher odds of vascular complications compared with younger patients (aOR 1.47, 95% CI 1.08-1.99 for octogenarians; aOR 1.60, 95% CI 1.18-2.97 for nonagenarians).

CONCLUSION

Octogenarians and nonagenarians undergoing LAAO have a similar safety profile compared with clinically similar younger patients except for higher odds of vascular complications.

Anticoagulation in atrial fibrillation. A large real-world update

INTRODUCTION

In a large nationwide administrative database including ∼35 % of Italian population, we analyzed the impact of oral anticoagulant treatment (OAT) in patients with a hospital diagnosis of non-valvular atrial fibrillation (NVAF).

METHODS AND RESULTS

Of 170404 OAT-naïve patients (mean age 78.7 years; 49.4 % women), only 61.1 % were prescribed direct oral anticoagulants, DOACs, or vitamin-K antagonists, VKAs; 14.2 % were given aspirin (ASA), and 24.8 % no anti-thrombotic drugs (No Tx). We compared ischemic stroke (IS), IS and systemic embolism (IS/SE), intracranial hemorrhage (ICH), major bleeding (MB), major gastro-intestinal bleeding, all-cause deaths and the composite outcome, across four propensity-score matched treatment cohorts with >15400 patients each. Over 2.9±1.5 years, the incidence of IS and IS/SE was slightly less with VKAs than with DOACs (1.62 and 1.84 vs 1.81 and 1.99 events.100 person-years; HR=0.85, 95%CI=0.76-0.95 and HR=0.87, 95%CI=0.78-0.97). This difference disappeared in a sensitivity analysis which excluded those patients treated with low-dose of apixaban, edoxaban, or rivaroxaban (41.7% of DOACs cohort). Compared with DOACs, VKAs were associated with greater incidence of ICH (1.09 vs 0.81; HR=1.38, 95%CI=1.17-1.62), MB (3.78 vs 3.31; HR=1.14, 95%CI=1.02-1.28), all-cause mortality (9.66 vs 10.10; HR=1.07, 95%CI=1.02-1.11), and composite outcome (13.72 vs 13.32; HR=1.04, 95%CI=1.01-1.08). IS, IS/SE, and mortality were more frequent with ASA or No Tx than with VKAs or DOACs (p<0.001 for all comparisons).

CONCLUSIONS

Beyond confirming the association with a better net clinical benefit of DOACs over VKAs, our findings substantiate the large proportion of NVAF patients still inappropriately anticoagulated, thereby reinforcing the need for educational programs.

Predictors and Outcomes of Oral Anticoagulant Deprescribing in Geriatric Inpatients With Atrial Fibrillation: A Retrospective Multicenter Cohort Study

OBJECTIVE

To investigate prevalence and predictors of oral anticoagulant therapy (OAT) deprescribing in older inpatients with atrial fibrillation (AF), and its association with 1-year incidence of major clinical outcomes.

DESIGN

Multicenter retrospective cohort study.

SETTING AND PARTICIPANTS

Inpatients aged ≥75 years with known AF on OAT at admission discharged from 3 Italian acute geriatric wards between January 2014 and July 2018.

METHODS

Data from a routine Comprehensive Geriatric Assessment (CGA), along with OAT status at discharge were recorded. One-year incidence of all-cause death, stroke or systemic embolism (SSE), and major and clinically relevant nonmajor bleeding (MB/CRNMB) were retrieved from administrative databases. Associations were explored through multilevel analysis.

RESULTS

Among 1578 patients (median age 86 years, 56.3% female), OAT deprescription (341 patients, 21.6%) was associated with bleeding risk, functional dependence and cognitive impairment, and inversely, with previous SSE and chronic AF. Incidences of death, SSE, and MB/CRNMB were 56.6%, 1.5%, and 4.1%, respectively, in OAT-deprescribed patients, and 37.6%, 2.9%, and 4.9%, respectively, in OAT-continued patients, without significant differences between groups. OAT deprescription was associated with all-cause mortality [adjusted odds ratio (aOR) 1.41, 95% CI 1.68-1.85], along with older age, comorbidity burden, cognitive impairment, and functional dependence, but with neither SSE nor MB/CRNMB incidence, as opposed to being alive and free from SSE and MB/CNRMB, respectively (aOR 0.68, 95% CI 0.25-1.82, and aOR 0.95 95% CI 0.49-1.85, respectively). Conversely, OAT deprescription was associated with higher odds of being dead than alive both in patients free from SSE and in those free from MB/CRNMB.

CONCLUSIONS AND IMPLICATIONS

CGA-based OAT deprescribing is common in acute geriatric wards and is not associated with increased SSE. The net clinical benefit of OAT in geriatric patients is strongly related with the competing risk of death, suggesting that functional and cognitive status, as well as residual life expectancy, should be considered in clinical decision making in this population.

Area-weighted unipolar voltage to predict heart failure outcomes in patients with ischaemic cardiomyopathy and ventricular tachycardia

AIMS

Patients with ischaemic cardiomyopathy (ICM) referred for catheter ablation of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodelling. Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV parameter reflecting global viable myocardium may predict prognosis. We evaluate if a newly proposed parameter, area-weighted unipolar voltage (awUV), can predict HF-related outcomes [HFO; HF death/left ventricular (LV) assist device/heart transplant] in ICM.

METHODS AND RESULTS

From endocardial voltage maps of consecutive patients with ICM referred for VT ablation, awUV was calculated by weighted interpolation of local UV. Associations between clinical and mapping parameters and HFO were evaluated and validated in a second cohort. The derivation cohort consisted of 90 patients [age 68 ±8 years; LV ejection fraction (LVEF) 35% interquartile range (IQR) (24-40)] and validation cohort of 60 patients [age 67 ± 9, LVEF 39% IQR (29-45)]. In the derivation cohort, during a median follow-up of 45 months [IQR (34-83)], 36 (43%) patients died and 23 (26%) had HFO. Patients with HFO had lower awUV [4.51 IQR (3.69-5.31) vs. 7.03 IQR (6.08-9.2), P < 0.001]. A reduction in awUV [optimal awUV (5.58) cut-off determined by receiver operating characteristics analysis] was a strong predictor of HFO (3-year HFO survival 97% vs. 57%). The cut-off value was confirmed in the validation cohort (2-year HFO-free survival 96% vs. 60%).

CONCLUSION

The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at high risk for HFO.

Index and Repeat Ablation for Atrial Fibrillation in Older versus Younger Patients: A Propensity-Score Matching Analysis

Catheter ablation is a well-established rhythm control therapy in atrial fibrillation (AF). Although the prevalence of AF increases dramatically with age, the prognosis and safety profile of index and repeat ablation procedures remain unclear in the older population. The primary endpoint of this study was to assess the arrhythmia recurrence, reablation and complication rates in older patients. Secondary endpoints were the identification of independent predictors of arrhythmia recurrence and reablation, including information on pulmonary vein (PV) reconnection and other atrial foci. Older (n=129, ≥70 years) and younger (n=129, <70 years) patients were compared using a propensity-score matching analysis based on age, gender, obesity, hypertension, dyslipidemia, diabetes mellitus, dilated left atrium, severe obstructive sleep apnea, cardiac disease, left systolic ventricular function, AF pattern and ablation technique. Arrhythmia recurrence and reablation were evaluated in both groups using a Cox regression analysis in order to identify predictors. During a 30-month follow-up period, there were no significant differences between older and younger patients in the arrhythmia-free survival (65.1% and 59.7%; log-rank test p=0.403) and complication (10.1% and 10.9%; p>0.999) rates after the index ablation. However, the reablation rate was significantly different (46.7% and 69.2%; p<0.05, respectively). In those patients who underwent reablation procedure (redo subgroups), there were no differences in the incidence of PV reconnection (38.1% redo-older and 27.8% redo-younger patients; p=0.556). However, the redo-older patients had lower reconnected PVs per patient (p<0.01) and lower atrial foci (2.3 and 3.7; p<0.01) than the redo-younger patients. A further important finding was that age was not an independent predictor of arrhythmia recurrence or reablation. Our data reveal that the AF index ablation in older patients had a similar efficacy and safety profile to younger patients. Therefore, age alone must not be considered a prognostic factor for AF ablation but the presence of limiting factors such as frailty and multiple comorbidities.

Familial hypercholesterolemia is related to cardiovascular disease, heart failure and atrial fibrillation. Results from a population-based study

BACKGROUND

Familial hypercholesterolemia (FH) is associated with atherosclerotic cardiovascular disease (ASCVD). However, the prevalence of FH among a general population remains unknown, and it is unclear if FH is associated with other cardiovascular complications, including heart failure (HF) and atrial fibrillation (AF).

METHODS

Analyses were conducted on individuals without a prior history of cardiovascular disease using a nationwide health claims database collected in the JMDC Claims Database between 2005 and 2022 (n = 4,126,642; median age, 44 years; 57.5% men). We defined FH as either LDL cholesterol ≥250 mg/dL or LDL cholesterol ≥175 mg/dL under the lipid-lowering medications under the assumption that lipid-lowering medications reduced LDL cholesterol by 30%. We assessed the associations between FH and composite outcomes, including, ASCVD (myocardial infarction, angina pectoris, and stroke), HF, and AF using Cox proportional hazard model.

RESULTS

We identified 11,983 (.29%) FH patients. In total, 181,150 events were recorded during the mean follow-up period of 3.5 years. The status FH was significantly associated with composite outcomes after adjustments (hazard ratio [HR]; 1.38, 95% confidence interval [CI]: 1.30-1.47, p < .001). Interestingly, the status FH was significantly associated with HF (HR: 1.48, 95% CI: 1.36-1.61, p < .001) and AF (HR: 1.33, 95% CI: 1.08-1.64, p < .001) in addition to angina pectoris (HR: 1.45, 95% CI: 1.33-1.58, p < .001) and stroke (HR: 1.19, 95% CI: 1.04-1.36, p < .001).

CONCLUSION

We found that the prevalence of FH was .29% in a general population. FH was significantly associated with a higher risk of developing cardiovascular disease, HF and AF.

LAY SUMMARY

We sought to identify the prevalence of FH among a general population, and to clarify whether FH increases the risk of not only ASCVD but also HF and AF.

Prevalence of Atrial Fibrillation and Long-Term Survival of Older Adults; Findings from the SNAC Study

Objective: This study examined the prevalence and long-term survival of atrial fibrillation (AF) in the older population. Methods: Data was recruited from the longitudinal SNAC study from baseline (2001-2004) for up to 10 years. Results: The population comprised 6,904 persons (59% women) (mean age 73.9 years). The prevalence of AF was 4.9% and increased with age. The hazard ratio (HR) for death in those with AF at baseline was 1.29 during the 10-year observation period. Cox regression analysis in persons with AF (n = 341) showed that men had a higher HR for death (1.57). CHA2DS2-VASc scores were significantly associated with death within 10 years (HR 1.29/score). Any form of anticoagulant use was reported in 146 (42.8%) and was significantly associated with survival (p = .031). Conclusions: The prevalence of AF in the general population was almost 5%, and it shortened life expectancy by nearly 2.4 years over a 10-year period. Despite the proven efficacy of OAC therapies, our results demonstrate that AF continues to be associated with increased mortality, especially among men, and that many older people are at high risk of developing a stroke because they do not receive appropriate anticoagulant therapy. These results emphasize the need for improved preventive and therapeutic modalities.

Association between remnant cholesterol and incident atherosclerotic cardiovascular disease, heart failure, and atrial fibrillation

BACKGROUND

It remains unclear if remnant cholesterol is associated with atherosclerotic cardiovascular disease (ASCVD) (myocardial infarction, angina pectoris and stroke), heart failure (HF), and atrial fibrillation (AF) under primary prevention settings.

OBJECTIVE

We aimed to clarify this issue among a general population without a history of ASCVD, HF or AF.

METHODS

Analyses were conducted with a nationwide health claims database collected in the JMDC Claims Database between 2005 and 2022 (n = 1,313,722; median age, 42 years; 54.6% men). We assessed the associations between remnant cholesterol calculated as total cholesterol minus HDL cholesterol minus LDL cholesterol and composite CVD outcomes, including, ASCVD, HF, and AF using Cox proportional hazard model, dividing the individuals into tertiles of remnant cholesterol (T1-T3).

RESULTS

The mean follow-up duration was 3.0 years. In total, 43,755 events were recorded. Remnant cholesterol was significantly associated with composite CVD outcomes after adjustments (T3 vs T1: hazard ratio [HR]; 1.07, 95% confidence interval [CI]: 1.04-1.10, p-trend<0.001). Remnant cholesterol was associated with myocardial infarction (T3 vs T1:HR: 1.20, 95% CI: 1.06-1.34, p-trend=0.002), angina pectoris (T3 vs T1:HR: 1.09, 95% CI: 1.05-1.14, p-trend<0.001), stroke (T3 vs T1:HR: 1.08, 95% CI: 1.02-1.14, p-trend=0.007), and HF (T3 vs T1:HR: 1.08, 95% CI: 1.04-1.12, p-trend<0.001), while we found a marginal inverse association between remnant cholesterol and AF (T3 vs T1:HR: 0.92, 95% CI: 0.86-1.00, p-trend=0.054).

CONCLUSION

Remnant cholesterol was positively associated with ASCVD and HF, while we found a marginal inverse association between remnant cholesterol and AF.

Anticoagulation in Patients with Atrial High-rate Episodes Detected by Cardiac Implantable Electronic Devices

Atrial high-rate episodes (AHRE) are atrial tachyarrhythmias that are identified by the use of continuous rhythm monitoring devices such as pacemakers, defibrillators, or implantable cardiac monitors. Nevertheless, the therapeutic implications of these rhythm disturbances remain uncertain. The presence of AHRE is associated with an increased risk of stroke as compared to patients who do not exhibit AHRE. The utilisation of oral anticoagulation has the ability to mitigate the likelihood of stroke occurrence in patients with AHRE. However, it is important to note that this treatment approach is also linked to a severe bleeding rate of approximately 2% per year. The stroke rate among individuals diagnosed with AHRE appears to be comparatively lower when compared to patients diagnosed with atrial fibrillation. The efficacy and safety of anticoagulation in patients with AHRE have yet to be definitively established. Further research is required to provide a comprehensive understanding of the effectiveness and safety of oral anticoagulation in individuals with AHRE.