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Doundoulakis I, Nedios S, Zafeiropoulos S, Vitolo M, Della Rocca DG, Kordalis A, Shamloo AS, Koliastasis L, Marcon L, Chiotis S, Sorgente A, Soulaidopoulos S, Imberti JF, Botis M, Pannone L, Gatzoulis KA, Sarkozy A, Stavrakis S, Boriani G, Boveda S, Tsiachris D, Chierchia GB, de Asmundis C. Atrial fibrillation burden: Stepping beyond the categorical characterization. Heart Rhythm 2025; 22:1179-1187. [PMID: 39197738 DOI: 10.1016/j.hrthm.2024.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 08/19/2024] [Accepted: 08/22/2024] [Indexed: 09/01/2024]
Abstract
Traditional classifications categorize atrial fibrillation (AF) into paroxysmal, persistent, or permanent, but recent advancements in monitoring have revealed AF as a continuous variable, challenging existing paradigms. AF burden, defined basically as the amount of time spent in AF during a monitored period, has emerged as a crucial metric. This review assesses the evolving landscape of AF burden and its measurement methods, diagnostic modalities, and impact on outcomes. Guidelines suggest individualized approaches, combining AF burden with clinical scores (CHA2DS2-VASc), but studies have challenged this. Addressing the impact of AF burden on patients' quality of life before or after ablation is also crucial. Although continuous monitoring technologies offer promising avenues, the field faces challenges, such as defining clinically relevant thresholds. Future research should focus on refining these, designing trials centered around AF burden, and evaluating the efficacy of interventions in reducing AF burden, ultimately paving the way for personalized management strategies.
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Affiliation(s)
- Ioannis Doundoulakis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Sotirios Nedios
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | | | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Athanasios Kordalis
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Alireza Sepehri Shamloo
- Department of Electrophysiology, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Leonidas Koliastasis
- Department of Cardiology, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Marcon
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Sotirios Chiotis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Antonio Sorgente
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Stergios Soulaidopoulos
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Michail Botis
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Andrea Sarkozy
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Serge Boveda
- Département de Rythmologie, Clinique Pasteur, Toulouse, France
| | - Dimitris Tsiachris
- First Department of Cardiology, National and Kapodistrian University, "Hippokration" Hospital, Athens, Greece
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, University Hospital Brussels-Free University Brussels, European Reference Networks Guard-Heart, Brussels, Belgium.
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Airaksinen KEJ, Langén V, Teppo K, Lip GYH. Myths and challenges around anticoagulation in atrial fibrillation: A practicing clinician's perspective. Eur J Clin Invest 2025; 55:e14390. [PMID: 39835416 DOI: 10.1111/eci.14390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Accepted: 01/12/2025] [Indexed: 01/22/2025]
Affiliation(s)
| | - Ville Langén
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Konsta Teppo
- Heart Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Medical University of Bialystok, Bialystok, Poland
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3
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Wolfes J, Ellermann C, Frommeyer G, Eckardt L. Comparison of the Latest ESC, ACC/AHA/ACCP/HRS, and CCS Guidelines on the Management of Atrial Fibrillation. JACC Clin Electrophysiol 2025; 11:836-849. [PMID: 39985521 DOI: 10.1016/j.jacep.2024.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Revised: 12/11/2024] [Accepted: 12/16/2024] [Indexed: 02/24/2025]
Abstract
The introduction of evidence-based and structured guidelines has undoubtedly improved the care of cardiologic patients and in many cases simplified decision-making for the treatment team. The European Society of Cardiology in collaboration with the European Association for Cardio-Thoracic Surgery, the American College of Cardiology, the American Heart Association, the American College of Clinical Pharmacy, and the Heart Rhythm Society, and the Canadian Cardiovascular Society/Canadian Heart Rhythm Society have developed guidelines for the management of patients with atrial fibrillation. Because all 3 guidelines refer to almost the same scientific data, their recommendations are undoubtedly largely in agreement. Nevertheless, there are some interesting differences based on different interpretations of the same study, different publication dates, or differences in local conditions and health care resources. The following article aims at lining out these similarities and differences.
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Affiliation(s)
- Julian Wolfes
- Department of Cardiology II (Electrophysiology), University Hospital Munster, Münster, Germany.
| | - Christian Ellermann
- Department of Cardiology II (Electrophysiology), University Hospital Munster, Münster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital Munster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Munster, Münster, Germany
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Papakonstantinou PE, Lip GYH. Rethinking Stroke Prevention in Atrial Fibrillation: One Size Does not Fit All. J Cardiovasc Electrophysiol 2025; 36:559-563. [PMID: 39807562 DOI: 10.1111/jce.16580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 12/25/2024] [Accepted: 01/05/2025] [Indexed: 01/16/2025]
Affiliation(s)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Medical University of Bialystok, Bialystok, Poland
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Chen J, Di J, Daizadeh N, Lu Y, Wang H, Shen Y, Kirk J, Rockhold FW, Pang H, Zhao J, He W, Potter A, Lee H. Decentralized Clinical Trials in the Era of Real-World Evidence: A Statistical Perspective. Clin Transl Sci 2025; 18:e70117. [PMID: 39972404 PMCID: PMC11839390 DOI: 10.1111/cts.70117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2024] [Revised: 12/11/2024] [Accepted: 12/12/2024] [Indexed: 02/21/2025] Open
Abstract
There has been a growing trend that activities relating to clinical trials take place at locations other than traditional trial sites (hence decentralized clinical trials or DCTs), some of which are at settings of real-world clinical practice. Although there are numerous benefits of DCTs, this also brings some implications on a number of issues relating to the design, conduct, and analysis of DCTs. The Real-World Evidence Scientific Working Group of the American Statistical Association Biopharmaceutical Section has been reviewing the field of DCTs and provides in this paper considerations for decentralized trials from a statistical perspective. This paper first discusses selected critical decentralized elements that may have statistical implications on the trial and then summarizes regulatory guidance, framework, and initiatives on DCTs. More discussions are presented by focusing on the design (including construction of estimand), implementation, statistical analysis plan (including missing data handling), and reporting of safety events. Some additional considerations (e.g., ethical considerations, technology infrastructure, study oversight, data security and privacy, and regulatory compliance) are also briefly discussed. This paper is intended to provide statistical considerations for decentralized trials of medical products to support regulatory decision-making.
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Affiliation(s)
- Jie Chen
- Data Science, ECR GlobalShanghaiChina
| | - Junrui Di
- Global Product DevelopmentPfizer IncCambridgeMassachusettsUSA
| | - Nadia Daizadeh
- Advanced Quantitative SciencesNovartis Pharmaceuticals CorporationEast HanoverNew JerseyUSA
| | - Ying Lu
- Department of Biomedical Data ScienceStanford UniversityStanfordCaliforniaUSA
| | - Hongwei Wang
- Data and Statistical Sciences AbbVieNorth ChicagoIllinoisUSA
| | - Yuan‐Li Shen
- Food and Drug AdministrationSilver SpringMarylandUSA
| | - Jennifer Kirk
- Food and Drug AdministrationSilver SpringMarylandUSA
| | - Frank W. Rockhold
- Department of Biostatistics and BioinformaticsDuke University Medical Center and Duke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Herbert Pang
- PD Data Sciences, GenentechSouth San FranciscoCaliforniaUSA
| | - Jing Zhao
- Biostatistics and Research Decision SciencesMerck & Co. Inc.North WalesPennsylvaniaUSA
| | - Weili He
- Data and Statistical Sciences AbbVieNorth ChicagoIllinoisUSA
| | - Andrew Potter
- Food and Drug AdministrationSilver SpringMarylandUSA
| | - Hana Lee
- Food and Drug AdministrationSilver SpringMarylandUSA
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Certo Pereira J, Lima MR, Moscoso Costa F, Gomes DA, Maltês S, Cunha G, Dores H, Adragão P. Stroke in Athletes with Atrial Fibrillation: A Narrative Review. Diagnostics (Basel) 2024; 15:9. [PMID: 39795537 PMCID: PMC11720530 DOI: 10.3390/diagnostics15010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Revised: 12/14/2024] [Accepted: 12/22/2024] [Indexed: 01/13/2025] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia, linked with a significantly heightened risk of stroke. While moderate exercise reduces AF risk, high-level endurance athletes paradoxically exhibit a higher incidence. However, their stroke risk remains uncertain due to their younger age, higher cardiovascular fitness, and lower rate of comorbidities. Several key studies highlight that AF may increase the risk of stroke in endurance athletes, particularly those over 65. However, the overall risk within this population remains relatively low. Notably, older male athletes show a higher AF incidence but experience lower stroke risk than their non-athletic counterparts. Regular physical activity prior to a first stroke appears to reduce mortality, though recurrent stroke risk in athletes with AF mirrors that of non-athletes, despite an elevated AF incidence. Management of AF in athletes is complex, with limited evidence guiding anti-thrombotic strategies. In this setting, specific recommendations are sparse, particularly in sports where bleeding risk is heightened. Individualized management, emphasizing shared decision-making, is critical to balance stroke prevention with athletic performance. Rhythm control strategies, such as catheter ablation, may be a reasonable first-line treatment option for athletes, particularly in those desiring to avoid long-term medication. This review synthesizes the current literature on the incidence, predictors, and management of stroke in athletes with AF.
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Affiliation(s)
- Joana Certo Pereira
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
| | - Maria Rita Lima
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
| | - Francisco Moscoso Costa
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
- Hospital da Luz, 1500-650 Lisbon, Portugal;
| | - Daniel A. Gomes
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
| | - Sérgio Maltês
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
| | - Gonçalo Cunha
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
| | - Hélder Dores
- Hospital da Luz, 1500-650 Lisbon, Portugal;
- CHRC, Comprehensive Health Research Center, 1600-560 Lisbon, Portugal
- Associate Laboratory REAL (LA-REAL), 1099-085 Lisbon, Portugal
- NOVA Medical School, NOVA University Lisbon, 1169-056 Lisbon, Portugal
- CoLab TRIALS, 7002-554 Évora, Portugal
| | - Pedro Adragão
- Hospital de Santa Cruz, 2790-134 Lisbon, Portugal; (M.R.L.); (F.M.C.); (D.A.G.); (S.M.); (G.C.); (P.A.)
- Hospital da Luz, 1500-650 Lisbon, Portugal;
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Gay HC, Passman RS. AI and Personal Digital Health Tools: Pioneering the Future of Precision Health Care. JACC Clin Electrophysiol 2024; 10:2655-2657. [PMID: 39520430 DOI: 10.1016/j.jacep.2024.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Accepted: 09/01/2024] [Indexed: 11/16/2024]
Affiliation(s)
- Hawkins C Gay
- Department of Medicine-Cardiology Division, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Rod S Passman
- Department of Medicine-Cardiology Division, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
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Johnson V, Eckardt L. [Everyone over the age of 65 years should wear a smartwatch : Pro and contra]. Herzschrittmacherther Elektrophysiol 2024; 35:290-295. [PMID: 39585406 DOI: 10.1007/s00399-024-01058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Accepted: 10/29/2024] [Indexed: 11/26/2024]
Abstract
Atrial fibrillation (AF) is one of the most common cardiac arrhythmias and has far-reaching consequences not only for patients, but also for our healthcare system. The prevalence of this condition is expected to double in the coming decades. On the one hand, this is due to our aging population, the increasing number of comorbidities, and the improved technical possibilities for detection. A major complication of AF is stroke, whereby at-risk patients can be protected by oral anticoagulation if AF is diagnosed. The extent to which continuous screening for AF in patients with an increased risk of thromboembolic events should be carried out using wearables remains an important point in the current debate.
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Affiliation(s)
- V Johnson
- Universitäres Herzzentrum, ZIM - Med. Klinik 3 - Kardiologie, Angiologie, Universitätsmedizin Frankfurt, Theodor-Stern-Kai 7, 60596, Frankfurt am Main, Deutschland.
| | - L Eckardt
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Straße 33, Münster, Deutschland.
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McIntyre WF, Benz AP, Healey JS, Connolly SJ, Yang M, Lee SF, Field TS, Alings M, Benezet-Mazuecos J, Boriani G, Nielsen JC, Gold MR, Pergolini F, Glotzer TV, Granger CB, Lopes RD. Risk of Stroke or Systemic Embolism According to Baseline Frequency and Duration of Subclinical Atrial Fibrillation: Insights From the ARTESiA Trial. Circulation 2024; 150:1747-1755. [PMID: 39229707 DOI: 10.1161/circulationaha.124.069903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 08/07/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND In the ARTESiA trial (Apixaban for the Reduction of Thromboembolism in Patients With Device-Detected Subclinical Atrial Fibrillation), apixaban, compared with aspirin, reduced stroke or systemic embolism in patients with device-detected subclinical atrial fibrillation (SCAF). Clinical guidelines recommend considering SCAF episode duration when deciding whether to prescribe oral anticoagulation for this population. METHODS We performed a retrospective cohort study in ARTESiA. Using Cox regression adjusted for CHA2DS2-VASc score and treatment allocation (apixaban or aspirin), we assessed frequency of SCAF episodes and duration of the longest SCAF episode in the 6 months before randomization as predictors of stroke risk and of apixaban treatment effect. RESULTS Among 3986 patients with complete baseline SCAF data, 703 (17.6%) had no SCAF episode ≥6 minutes in the 6 months before enrollment. Among 3283 patients (82.4%) with ≥1 episode of SCAF ≥6 minutes in the 6 months before enrollment, 2542 (77.4%) had up to 5 episodes, and 741 (22.6%) had ≥6 episodes. The longest episode lasted <1 hour in 1030 patients (31.4%), 1 to <6 hours in 1421 patients (43.3%), and >6 hours in 832 patients (25.3%). Higher baseline SCAF frequency was not associated with increased risk of stroke or systemic embolism: 1.1% for 1 to 5 episodes versus 1.2%/patient-year for ≥6 episodes (adjusted hazard ratio, 0.89 [95% CI, 0.59-1.34]). In an exploratory analysis, patients with previous SCAF but no episode ≥6 minutes in the 6 months before enrollment had a lower risk of stroke or systemic embolism than patients with at least one episode during that period (0.5% versus 1.1%/patient-year; adjusted hazard ratio, 0.48 [95% CI, 0.27-0.85]). The frequency of SCAF did not modify the reduction in stroke or systemic embolism with apixaban (Pinteraction=0.1). The duration of the longest SCAF episode in the 6 months before enrollment was not associated with the risk of stroke or systemic embolism during follow-up (<1 hour: 1.0%/patient-year [reference]; 1-6 hours: 1.2%/patient-year [adjusted hazard ratio, 1.27 (95% CI, 0.85-1.90)]; >6 hours: 1.0%/patient-year [adjusted hazard ratio, 1.02 (95% CI, 0.63-1.66)]). SCAF duration did not modify the reduction in stroke or systemic embolism with apixaban (Ptrend=0.1). CONCLUSIONS In ARTESiA, baseline SCAF frequency and longest episode duration were not associated with risk of stroke or systemic embolism and did not modify the effect of apixaban on reduction of stroke or systemic embolism. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01938248.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Canada (W.M., S.F.L., A.B., J.H., S.C.)
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada (W.M., S.F.L., A.B., J.H., S.C.)
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada (W.M., S.F.L., A.B., J.H., S.C.)
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada (W.M., S.F.L., A.B., J.H., S.C.)
| | - Mu Yang
- Population Health Research Institute, McMaster University, Hamilton, Canada (W.M., S.F.L., A.B., J.H., S.C.)
| | - Shun Fu Lee
- Population Health Research Institute, McMaster University, Hamilton, Canada (W.M., S.F.L., A.B., J.H., S.C.)
| | - Thalia S Field
- Vancouver Stroke Program, University of British Columbia, Canada (T.F.)
| | | | | | | | | | | | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University (R.L., C.G.), Durham, NC
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Mekary W, Campbell M, Bhatia NK, Westerman S, Shah A, Leal M, Delurgio D, Patel AM, Tompkins C, El-Chami MF, Merchant FM. Spontaneous fluctuation in atrial fibrillation burden and duration in patients with implantable loop monitors. Pacing Clin Electrophysiol 2024; 47:1454-1463. [PMID: 39248361 DOI: 10.1111/pace.15072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 08/02/2024] [Accepted: 08/27/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Most studies of device-detected atrial fibrillation (AF) have recommended indefinite anticoagulation once a patient crosses a particular threshold for AF duration or burden. However, durations and burdens are known to fluctuate over time, but little is known about the magnitude of spontaneous fluctuations and the potential impact on anticoagulation decisions. OBJECTIVE To quantify spontaneous fluctuations in AF duration and burden in patients with implantable loop recorders (ILRs) METHODS: We reviewed all ILR interrogations for patients with non-permanent AF at our institution from 2018 to 2023. We excluded patients treated with rhythm control. The duration of longest AF episode at each interrogation was classified as < 6, 6-24, and > 24 h, and the AF burden reported at each interrogation was classified as < 2%, 2%-11.4%, and > 11.4%. RESULTS Out of 156 patients, the mean age at ILR implant was 70.9 ± 12.5 years, CHA2DS2-VASc score was 4.2 ± 1.8, duration of ILR follow-up was 23.4 ± 11.2 months, and number of ILR interrogations per patient was 18.0 ± 8.9. The duration of longest AF episode at any point during follow-up was < 6 , 6-24 , and > 24 h in 110, 30, and 16 patients, respectively. Among the 30 patients with a longest AF episode of 6-24 h at some point during follow-up, out of 594 total ILR interrogations, only 75 (12%) showed a longest episode of 6-24 h. In the remaining 519 interrogations, the longest episode was < 6 h. In patients with a longest episode of > 24 h at any point during follow-up (n = 16), only 47 out of 320 total ILR interrogations (15%) showed an episode of > 24 h. When evaluating AF burden, 96, 38, and 22 patients had maximum reported AF burdens of < 2%, 2%-11.4%, and > 11.4% at any point during ILR follow-up. Among those with a maximum burden of 2%-11.4% at some point during follow-up (n = 38), out of 707 ILR interrogations, only 76 (11%) showed a burden of 2%-11.4%. In the remaining 631 interrogations, the burden was < 2%. In the 22 patients with a burden > 11.4% at some point during follow-up, only 80 out of 480 interrogations (17%) showed a burden of > 11.4%. In 65% of interrogations, the burden was < 2%. CONCLUSION Significant, spontaneous fluctuations in AF burden and duration are common in patients with ILRs. Even in patients with AF episodes of 6-24 h or > 24 h at some point during follow-up, the vast majority of interrogations show episodes of < 6 h. Similarly, in patients with burdens of 2%-11.4% or > 11.4% at some point during follow-up, the vast majority of interrogations show burdens of < 2%. More data are needed to determine whether crossing an AF burden or duration threshold once is sufficient to merit lifelong anticoagulation or whether spontaneous fluctuations in AF burden and duration should impact anticoagulation decisions.
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Affiliation(s)
- Wissam Mekary
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Martin Campbell
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Neal K Bhatia
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stacy Westerman
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anand Shah
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Miguel Leal
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David Delurgio
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anshul M Patel
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christine Tompkins
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mikhael F El-Chami
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Faisal M Merchant
- Cardiology Division, Emory University School of Medicine, Atlanta, Georgia, USA
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11
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Cheung CC, Gay H, Mendenhall GS. Managing data overload: AI, wearables, and apps. Heart Rhythm 2024; 21:e274-e276. [PMID: 39207351 DOI: 10.1016/j.hrthm.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Christopher C Cheung
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hawkins Gay
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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12
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Lampert R, Chung EH, Ackerman MJ, Arroyo AR, Darden D, Deo R, Dolan J, Etheridge SP, Gray BR, Harmon KG, James CA, Kim JH, Krahn AD, La Gerche A, Link MS, MacIntyre C, Mont L, Salerno JC, Shah MJ. 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm 2024; 21:e151-e252. [PMID: 38763377 DOI: 10.1016/j.hrthm.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/21/2024]
Abstract
Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.
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Affiliation(s)
- Rachel Lampert
- Yale University School of Medicine, New Haven, Connecticut
| | - Eugene H Chung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Rajat Deo
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joe Dolan
- University of Utah, Salt Lake City, Utah
| | | | - Belinda R Gray
- University of Sydney, Camperdown, New South Wales, Australia
| | | | | | | | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Andre La Gerche
- Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | | | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Jack C Salerno
- University of Washington School of Medicine, Seattle, Washington
| | - Maully J Shah
- Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania
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13
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Becher N, Metzner A, Toennis T, Kirchhof P, Schnabel RB. Atrial fibrillation burden: a new outcome predictor and therapeutic target. Eur Heart J 2024; 45:2824-2838. [PMID: 38953776 PMCID: PMC11328870 DOI: 10.1093/eurheartj/ehae373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/13/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024] Open
Abstract
Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is not a dichotomous disease trait. Technological innovations enable long-term rhythm monitoring in many patients and can estimate AF burden. These technologies are already used to detect and monitor AF. This review describes the relation between AF burden and outcomes and potential effects of AF burden reduction. A lower AF burden is associated with a lower risk of stroke and heart failure in patients with AF: stroke risk without anticoagulation is lower in patients with device-detected AF and a low AF burden (stroke rate 1%/year) than in patients with persistent and permanent AF (stroke rate 3%/year). Paroxysmal AF shows intermediate stroke rates (2%/year). Atrial fibrillation burden-reducing interventions can reduce cardiovascular outcomes in patients with AF: early rhythm control reduces cardiovascular events including stroke and heart failure in patients with recently diagnosed AF and cardiovascular conditions. In patients with heart failure and AF, early rhythm control and AF ablation, interventions that reduce AF burden, reduce mortality and heart failure events. Recent technological innovations allow to estimate AF burden in clinical care, creating opportunities and challenges. While evidence remains limited, the existing data already suggest that AF burden reduction could be a therapeutic goal. In addition to anticoagulation and treatment of cardiovascular conditions, AF burden reduction emerges as a therapeutic goal. Future research will define the AF burden that constitutes a relevant risk of stroke and heart failure. Technologies quantifying AF burden need careful validation to advance the field.
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Affiliation(s)
- Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Tobias Toennis
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
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14
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Cheung CC, Saad M. Wearable Devices and Psychological Wellbeing-Are We Overthinking It? J Am Heart Assoc 2024; 13:e035962. [PMID: 39011959 PMCID: PMC11964074 DOI: 10.1161/jaha.124.035962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Affiliation(s)
| | - Mussa Saad
- Sunnybrook Health Sciences CentreUniversity of TorontoOntarioCanada
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15
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Bengel P, Sossalla S, Dinov B. [Oral anticoagulation in supraventricular arrhythmia]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:770-777. [PMID: 39007961 DOI: 10.1007/s00108-024-01744-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/16/2024]
Abstract
Atrial fibrillation represents the most frequent persistent cardiac arrhythmia and is associated with an increased morbidity and mortality. An important component of the holistic treatment of atrial fibrillation is oral anticoagulation (OAC) for the prevention of stroke. The CHA2DS2-VASc score as a risk score is recommended for estimation of the individual stroke risk and the concomitant need of OAC in these patients. In the majority of patients the OAC is nowadays carried out with direct oral anticoagulants (DOAC), which have proved to be effective with a moderate side effect profile and have replaced vitamin K antagonists as the standard substance. In the meantime, these principles have become established as the usual practice but some issues regarding OAC in patients with atrial fibrillation are still insufficiently answered. Furthermore, it is unclear whether OACs need to be continued after successful treatment of atrial fibrillation with pulmonary vein ablation or in some cases can even be discontinued. Unanswered questions also remain regarding the treatment of subclinical atrial fibrillation and atrial high-frequency episodes detected by implanted heart rhythm devices. Especially the duration of atrial high-frequency episodes that should trigger the initiation of OAC treatment is still under debate. Therefore, currently the benefits of stroke prevention must be carefully weighed up against the risk of bleeding complications.
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Affiliation(s)
- Philipp Bengel
- Medizinischen Klinik I, Abteilung für Kardiologie, Universitätsklinikum Gießen, Klinikstr. 33, 35392, Gießen, Deutschland.
| | - Samuel Sossalla
- Medizinischen Klinik I, Abteilung für Kardiologie, Universitätsklinikum Gießen, Klinikstr. 33, 35392, Gießen, Deutschland
- Abteilung Kardiologie, Kerckhoff-Klinik, Bad Nauheim, Deutschland
| | - Borislav Dinov
- Medizinischen Klinik I, Abteilung für Kardiologie, Universitätsklinikum Gießen, Klinikstr. 33, 35392, Gießen, Deutschland
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16
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Yu MY, Caprio FZ, Bernstein RA. Cardioembolic Stroke. Neurol Clin 2024; 42:651-661. [PMID: 38937034 DOI: 10.1016/j.ncl.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Cardioembolism accounts globally for around 25% of ischemic strokes and is more often associated with higher rates of morbidity and mortality. Potential sources of cardioembolism into the intracranial circulation include paradoxic embolism, dysrhythmias, structural heart disease, and valvular heart disease. To identify the etiology of a patient's ischemic stroke, thorough investigation of the intracardiac structures, assessment of dysrhythmias, and consideration of high-risk events such as cardiac surgery are crucial. Treatment after cardioembolic stroke can be personalized based on the underlying cardioembolic source to minimize the risk of recurrent cerebral ischemic events.
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Affiliation(s)
| | - Fan Z Caprio
- Northwestern University, 625 N. Michigan Avenue, Suite 1150, Chicago, IL 60611, USA.
| | - Richard A Bernstein
- Northwestern University, 625 N. Michigan Avenue, Suite 1150, Chicago, IL 60611, USA
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17
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Ding WY, Calvert P, Lip GYH, Gupta D. Novel stroke prevention strategies following catheter ablation for atrial fibrillation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:690-696. [PMID: 38428582 DOI: 10.1016/j.rec.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
Stroke prevention following successful catheter ablation of atrial fibrillation remains a controversial topic. Oral anticoagulation is associated with a significant reduction in stroke risk in the general atrial fibrillation population but may be associated with an increased risk of major bleeding, and the benefit: risk ratio must be considered. Improvement in successful catheter ablation and widespread use of cardiac monitoring devices may allow for novel anticoagulation strategies in a subset of patients with atrial fibrillation, which may optimize stroke prevention while minimizing bleeding risk. In this review, we discuss stroke risk in atrial fibrillation and the effects of successful catheter ablation on thromboembolic risk. We also explore novel strategies for stroke prevention following successful catheter ablation.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Peter Calvert
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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18
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Hong N, Whittier DE, Glüer CC, Leslie WD. The potential role for artificial intelligence in fracture risk prediction. Lancet Diabetes Endocrinol 2024; 12:596-600. [PMID: 38942044 DOI: 10.1016/s2213-8587(24)00153-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/16/2024] [Accepted: 05/16/2024] [Indexed: 06/30/2024]
Abstract
Osteoporotic fractures are a major health challenge in older adults. Despite the availability of safe and effective therapies for osteoporosis, these therapies are underused in individuals at high risk for fracture, calling for better case-finding and fracture risk assessment strategies. Artificial intelligence (AI) and machine learning (ML) hold promise for enhancing identification of individuals at high risk for fracture by distilling useful features from high-dimensional data derived from medical records, imaging, and wearable devices. AI-ML could enable automated opportunistic screening for vertebral fractures and osteoporosis, home-based monitoring and intervention targeting lifestyle factors, and integration of multimodal features to leverage fracture prediction, ultimately aiding improved fracture risk assessment and individualised treatment. Optimism must be balanced with consideration for the explainability of AI-ML models, biases (including information inequity in numerically under-represented populations), model limitations, and net clinical benefit and workload impact. Clinical integration of AI-ML algorithms has the potential to transform osteoporosis management, offering a more personalised approach to reduce the burden of osteoporotic fractures.
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Affiliation(s)
- Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Institute for Innovation in Digital Healthcare, Yonsei University Health System, Seoul, Korea.
| | - Danielle E Whittier
- McCaig Institute for Bone and Joint Health and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Claus-C Glüer
- Section Biomedical Imaging, Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Kiel University, Kiel, Germany
| | - William D Leslie
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
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19
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Patel RB, Peigh G. Left Atrial Stiffness in Cryptogenic Stroke: On Solid Footing or Down the Rabbit Hole? JACC. ADVANCES 2024; 3:100904. [PMID: 38939687 PMCID: PMC11198701 DOI: 10.1016/j.jacadv.2024.100904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Ravi B. Patel
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Graham Peigh
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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20
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Peigh G, Passman RS. Stroke prevention in atrial fibrillation: not a "one size fits all" endeavor. J Interv Card Electrophysiol 2024; 67:429-431. [PMID: 38040853 DOI: 10.1007/s10840-023-01694-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Graham Peigh
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 251 E Huron St. Rm. 8-503, Chicago, IL, USA.
| | - Rod S Passman
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 251 E Huron St. Rm. 8-503, Chicago, IL, USA
- Center for Arrhythmia Research, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, IL, USA
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21
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Hanley DF, Bernard GR, Wilkins CH, Selker HP, Dwyer JP, Dean JM, Benjamin DK, Dunsmore SE, Waddy SP, Wiley KL, Palm ME, Mould WA, Ford DF, Burr JS, Huvane J, Lane K, Poole L, Edwards TL, Kennedy N, Boone LR, Bell J, Serdoz E, Byrne LM, Harris PA. Decentralized clinical trials in the trial innovation network: Value, strategies, and lessons learned. J Clin Transl Sci 2023; 7:e170. [PMID: 37654775 PMCID: PMC10465321 DOI: 10.1017/cts.2023.597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
New technologies and disruptions related to Coronavirus disease-2019 have led to expansion of decentralized approaches to clinical trials. Remote tools and methods hold promise for increasing trial efficiency and reducing burdens and barriers by facilitating participation outside of traditional clinical settings and taking studies directly to participants. The Trial Innovation Network, established in 2016 by the National Center for Advancing Clinical and Translational Science to address critical roadblocks in clinical research and accelerate the translational research process, has consulted on over 400 research study proposals to date. Its recommendations for decentralized approaches have included eConsent, participant-informed study design, remote intervention, study task reminders, social media recruitment, and return of results for participants. Some clinical trial elements have worked well when decentralized, while others, including remote recruitment and patient monitoring, need further refinement and assessment to determine their value. Partially decentralized, or "hybrid" trials, offer a first step to optimizing remote methods. Decentralized processes demonstrate potential to improve urban-rural diversity, but their impact on inclusion of racially and ethnically marginalized populations requires further study. To optimize inclusive participation in decentralized clinical trials, efforts must be made to build trust among marginalized communities, and to ensure access to remote technology.
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Affiliation(s)
- Daniel F. Hanley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, MD, USA
| | - Gordon R. Bernard
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Consuelo H. Wilkins
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA
| | - Harry P. Selker
- Department of Medicine, Tufts University, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Jamie P. Dwyer
- University of Utah Health, Salt Lake City, UT, USA
- Utah Clinical and Translational Sciences Institute, Salt Lake City, UT, USA
| | | | - Daniel Kelly Benjamin
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sarah E. Dunsmore
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Salina P. Waddy
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Kenneth L. Wiley
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Marisha E. Palm
- Department of Medicine, Tufts University, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - W. Andrew Mould
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins BIOS Clinical Trials Coordinating Center, Baltimore, MD, USA
| | - Daniel F. Ford
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, MD, USA
| | - Jeri S. Burr
- University of Utah Health, Salt Lake City, UT, USA
| | | | - Karen Lane
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, MD, USA
| | - Lori Poole
- Duke Clinical Research Institute, Durham, NC, USA
| | - Terri L. Edwards
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Nan Kennedy
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Leslie R. Boone
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Jasmine Bell
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Emily Serdoz
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Loretta M. Byrne
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Paul A. Harris
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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