Symptoms and functional status of patients with atrial fibrillation: state of the art and future research opportunities

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.

Fully Automated Photoplethysmography-Based Wearable Atrial Fibrillation Screening in a Hospital Setting

Background/Objectives: Atrial fibrillation (AF) remains a major risk factor for stroke. It is often asymptomatic and paroxysmal, making it difficult to detect with conventional electrocardiography (ECG). While photoplethysmography (PPG)-based devices like smartwatches have demonstrated efficacy in detecting AF, they are rarely integrated into hospital infrastructure. The study aimed to establish a seamless system for real-time AF screening in hospitalized high-risk patients using a wrist-worn PPG device integrated into a hospital's data infrastructure. Methods: In this investigator-initiated prospective clinical trial conducted at the University Hospital Basel, patients with a CHA2DS2-VASc score ≥ 2 and no history of AF received a wristband equipped with a PPG sensor for continuous monitoring during their hospital stay. The PPG data were automatically transmitted, analyzed, stored, and visualized. Upon detection of an absolute arrhythmia (AA) in the PPG signal, a Holter ECG was administered. Results: The analysis encompassed 346 patients (mean age 72 ± 10 years, 175 females (50.6%), mean CHA2DS2-VASc score 3.5 ± 1.3)). The mean monitoring duration was 4.3 ± 4.4 days. AA in the PPG signal was detected in twelve patients (3.5%, CI: 1.5-5.4%), with most cases identified within 24 h (p = 0.004). There was a 1.3 times higher AA burden during the nighttime compared to daytime (p = 0.03). Compliance was high (304/346, 87.9%). No instances of AF were confirmed in the nine patients undergoing Holter ECG. Conclusions: This study successfully pioneered an automated infrastructure for AF screening in hospitalized patients through the use of wrist-worn PPG devices. This implementation allowed for real-time data visualization and intervention in the form of a Holter ECG. The high compliance and early AA detection achieved in this study underscore the potential and relevance of this novel infrastructure in clinical practice.

Renal denervation plus cardiac ablation vs. cardiac ablation alone for patients with atrial fibrillation and uncontrolled arterial hypertension : A systematic review and updated meta-analysis of randomized controlled trials

BACKGROUND

Atrial fibrillation (AF) is a complex arrhythmia often worsened by hypertension (HTN). Pharmacological treatments frequently underperform, and the best approach, particularly combining renal denervation (RDN) with cardiac ablation (CA), remains unclear.

OBJECTIVE

We conducted an updated meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of RDN combined with CA versus CA alone in patients with AF and uncontrolled HTN.

METHODS

We performed a systematic review and meta-analysis of RCTs retrieved from PubMed, Embase, and the Cochrane Library up to July 2024. Primary outcomes included AF recurrence, periprocedural complications, blood pressure changes, and estimated glomerular filtration rate (eGFR). Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed using a random-effects model.

RESULTS

Eight RCTs were included, involving 689 patients (37% female). Of these, 355 underwent RDN + CA, and 334 underwent CA alone, with a mean follow-up of at least 12 months. The RDN + CA group exhibited a significant reduction in AF recurrence (RR: 0.77; 95% CI: 0.61-0.97). There were no significant differences in periprocedural complications (RR: 1.06; 95% CI: 0.60-1.89), systolic blood pressure (MD: -6.79; 95% CI: -14.71-1.14), diastolic blood pressure (MD: -2.47; 95% CI: -8.13-3.20), or eGFR (MD: 1.14; 95% CI: -11.95-14.23).

CONCLUSION

Our findings show that RDN combined with CA significantly reduces AF recurrence compared to CA alone, presenting a promising approach for patients with resistant HTN and AF.

Can partial cardiac denervation reduce postoperative atrial fibrillation following CABG?

This article provides a critical appraisal of the partial cardiac denervation-postoperative atrial fibrillation (pCAD-POAF) randomized clinical trial, which investigates the effectiveness of partial cardiac denervation in reducing POAF in patients undergoing coronary artery bypass grafting (CABG). The trial demonstrated a significant reduction in POAF incidence in the intervention group compared to the control group. Despite promising results, the study has several limitations, including the exclusion of high-risk patients with advanced comorbidities and a short follow-up period, which restricts the generalizability of the findings. This appraisal examines the trial's strengths, such as its novel approach and statistical design, while addressing areas for improvement. Future research should focus on long-term outcomes, broader patient inclusion, and the incorporation of health-related quality of life assessments.

Different effects of catheter ablation on exercise tolerance, leg strength, and quality of life in paroxysmal versus persistent atrial fibrillation

Background

Catheter ablation (CA) can improve exercise tolerance and quality of life (QOL) in patients with atrial fibrillation (AF). However, its differential effects on muscle strength between paroxysmal AF (PAF) and nonparoxysmal AF (Non-PAF) remain unclear.

Methods

We evaluated 94 patients (67.8 ± 10.3 years old, 71% male) who underwent CA (PAF/Non-PAF 46/48) without AF recurrence. Six-minute walk distance (6MWD), leg strength, and an AF-specific QOL questionnaire (AFQLQ) were evaluated at baseline, 3, and 6 months after CA.

Results

At baseline, the 6MWD and AFQLQ subset 3 score were significantly lower in patients with PAF than in those with Non-PAF, but the parameters of muscle strength were comparable between the two groups. Both 6MWD and AFQLQ significantly improved at 6 months after CA in both groups. However, leg strength at 6 months after CA significantly improved in the Non-PAF group (54.9 ± 16.5 to 58.4 ± 15.2, p < .05) but not in the PAF group.

Conclusion

Successful CA for both PAF and Non-PAF improved QOL and exercise tolerance. Additionally, CA improved leg strength in Non-PAF patients.

The one-minute sit-to-stand test is an alternative to the 6-minute walk test in patients with atrial fibrillation: A cross-sectional study and ROC curve analysis

BACKGROUND

The one-minute sit-to-stand test (1STST) is an easy-to-administer, space and time-saving test for determining functional exercise capacity in cardiac disease. This study aimed to investigate the 1STST -test-retest reliability and convergent validity and compare its physiological responses to the six-minute walk test (6MWT) in patients with Atrial fibrillation (AF).

METHODS

Forty-five patients with AF were included in this study. Functional exercise capacity was evaluated using the 1STST and 6MWT. For assessing test-retest reliability, the intraclass correlation coefficient and Bland-Altman plots were utilised. Convergent validity was determined by correlation analysis 1 STST and 6MWT, age, European Heart Rhythm Association score, ejection fraction, and quality of life. The cut-off point of 1STST was defined using ROC analysis.

RESULTS

With an intraclass correlation coefficient value of 0.975 [95 % confidence interval (CI) 0.954-0.986], the 1STST demonstrated excellent-test-retest reliability. Physiological responses after tests were similar in the 1STST and 6MWT (p > 0.05). The number of 1STST repetitions was strongly associated with 6MWT distance (r = 0.809; p < 0.001). A cut-off value of ≤13 repetitions in the number of 1STST repetitions was defined as functional impairment related to an increased risk of clinical events [sensitivity: 100 %, specificity: 84.6 %; AUC:0.94; 95 % CI 0.82 to 0.98; p < 0.001].

CONCLUSIONS

The 1STST is a reliable and valid assessment tool that produced comparable hemodynamic responses to the 6MWT in patients with AF. Considering its feasibility and time efficiency, healthcare professionals can use the 1STST rather than the 6MWT test to measure functional exercise status in a constrained environment for this patient group.

The Relationship between Using Renin-Angiotensin System Inhibitors with Mortality of Atrial Fibrillation: A Systematic Review and Meta-Analysis

BACKGROUND

Atrial fibrillation (AFib) is a highly prevalent cardiac arrhythmia associated with increased mortality in affected persons. Renin-angiotensin system inhibitors (RASIs) have been suggested as potential therapeutic agents for cardiovascular and renal diseases.

OBJECTIVES

However, the relationship between RASIs and mortality in AFib patients remains uncertain. Therefore, the present study was designed and implemented for this purpose.

METHODS

We searched PubMed/MEDLINE, Embase, Web of Science (WOS), Cochrane Library, and Scopus databases for studies published until 12 February 2024 with relevant keywords. We included studies that reported mortality outcomes in AFib patients treated with RASIs and non-users. The data extraction and quality assessment processes were conducted, and subgroup analyses and sensitivity analyses were done. The data were analyzed by Stata 15 using statistical tests, such as Chi-square and I2 tests.

RESULTS

A total of 15 studies (2007-2024; n=2,178,565 patients) examined the association between RASI drugs and mortality of patients with AFib. The results indicated that compared to the control group, the odds of AFib mortality in the group receiving RASIs were equal to 0.81(95% CI: 0.71-0.92; P-value ≤0.001). The study results did not indicate publication bias (Pvalue= 0.733). During the meta-regression analysis, none of the study variables demonstrated a significant relationship with the observed heterogeneity (P-value > 0.20). Cumulative OR results showed that from 2022 onwards, there was enough evidence to confirm the relationship using RASIs with mortality of patients with AFib.

CONCLUSION

Therefore, this meta-analysis suggests that the use of RASI drugs is associated with reduced AFib mortality. However, the authors emphasize the need for further high-quality studies and large-scale randomized clinical trials to validate these findings.

Efficacy, safety, and somatosensory comparison of pulsed-field ablation and thermal ablation: outcomes from a 2-year follow-up

BACKGROUND

Pulsed-field ablation (PFA), as a nonthermal ablative approach for atrial fibrillation, has attracted much attention in recent years. And there are few comparative studies on PFA versus conventional thermal ablation, including radiofrequency ablation (RFA) and cryoballoon ablation (CBA). The efficacy, safety, and somatic sensation of PFA and thermal ablation need to be further compared.

METHODS

A total of 109 patients with paroxysmal atrial fibrillation were divided into three groups (27 in the PFA group, 41 in the CBA group, and 41 in the RFA group), and the operation characteristics, efficacy, safety, and somatic sensation were recorded and analyzed. All patients were followed for 2 years.

RESULTS

All pulmonary veins were successfully isolated except for 1 pulmonary vein that was not successfully isolated during the CBA process (PFA vs. CBA vs. RFA = 100% vs. 99% vs. 100%). The total operation time for PFA is considerably shorter than that for thermal ablation (PFA vs. CBA vs. RFA = 65.28 ± 22.78 min vs. 75.38 ± 18.53 min vs. 96.26 ± 23.23 min, P < 0.001), and the same applies to all the sub-phases. PFA was similarly more dominant in terms of somatosensory perception, mainly in headache (PFA vs. CBA = 1.17 ± 0.48 vs. 2.31 ± 1.06, P < 0.001) and chest pain (PFA vs. RFA = 1.45 ± 0.88 vs. 2.52 ± 1.06, P < 0.001). All these three groups demonstrated good maintenance rates (PFA vs. CBA vs. RFA = 85.00% vs. 80.49% vs. 78.05%, 2 years after operation).

CONCLUSION

PFA demonstrates its excellent somatic sensation and favorable safety. And it also showed a great immediate success and maintenance rate, which is not inferior to thermal ablation.

Spotlight on the 2024 ESC/EACTS management of atrial fibrillation guidelines: 10 novel key aspects

Atrial fibrillation (AF) remains the most common cardiac arrhythmia worldwide and is associated with significant morbidity and mortality. The European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) have recently released the 2024 guidelines for the management of AF. This review highlights 10 novel aspects of the ESC/EACTS 2024 Guidelines. The AF-CARE framework is introduced, a structural approach that aims to improve patient care and outcomes, comprising of four pillars: [C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, and [E] Evaluation and dynamic reassessment. Additionally, graphical patient pathways are provided to enhance clinical application. A significant shift is the new emphasis on comorbidity and risk factor control to reduce AF recurrence and progression. Individualized assessment of risk is suggested to guide the initiation of oral anticoagulation to prevent thromboembolism. New guidance is provided for anticoagulation in patients with trigger-induced and device-detected sub-clinical AF, ischaemic stroke despite anticoagulation, and the indications for percutaneous/surgical left atrial appendage exclusion. AF ablation is a first-line rhythm control option for suitable patients with paroxysmal AF, and in specific patients, rhythm control can improve prognosis. The AF duration threshold for early cardioversion was reduced from 48 to 24 h, and a wait-and-see approach for spontaneous conversion is advised to promote patient safety. Lastly, strong emphasis is given to optimize the implementation of AF guidelines in daily practice using a patient-centred, multidisciplinary and shared-care approach, with the simultaneous launch of a patient version of the guideline.

Spinal Afferent Innervation From Left Dorsal Root Ganglia in the Flat-Mounts of Whole Atria of Rats: Anterograde Tracing

The spinal afferent innervation of the heart helps to regulate cardiac functions by sending sensory information through the dorsal root ganglia (DRG) to the brain. However, the distribution and morphology of spinal afferents in the heart are not well characterized due to tracer selections, the surgical access to upper thoracic DRGs, and the thickness of the heart tissues. In this study, we injected tracer dextran biotin (DB) into the left DRGs (C8-T3) of male Sprague-Dawley rats (3-5 months). After 16 days, flat-mounts of the whole left and right atria were prepared and diaminobenzidine stained. Then, the DB-labeled axons in the tissues were imaged, traced, and digitized using the Neurolucida system. Our results showed that the DB-labeled axons from left DRGs entered the left precaval vein and projected to the left and right atria, with predominant projection in the left atrial wall. DB-labeled varicose axons were observed in different layers, mostly in the epicardium and myocardium, but much less in the endocardium. In those layers, these spinal afferent axons branched out into simple to complex terminal arborizations, forming close appositions with cardiac muscles, intrinsic cardiac ganglia, blood vessels, and fat tissue. This work, for the first time, characterized cardiac spinal afferent distribution of the rat atria using anterograde tracing, which will provide the foundation for future studies of topographical cardiac spinal afferent innervation and remodeling in heart disease models.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Identification of senescence-related genes for potential therapeutic biomarkers of atrial fibrillation by bioinformatics, human histological validation, and molecular docking

Background

Cellular senescence is pivotal in the occurrence and progression of atrial fibrillation (AF). This study aimed to identify senescence-related genes that could be potential therapeutic biomarkers for AF.

Methods

AF-related differentially expressed genes (DEGs) were identified using the Gene Expression Omnibus dataset. Weighted gene co-expression network analysis (WGCNA) was used to analyze important modules and potential hub genes. Integrating senescence-related genes, potential biomarkers were identified. Their differential expression levels were then validated in human atrial tissue, HL-1 cells, and Angiotensin II-infused mice. Finally, molecular docking analysis was conducted to predict potential interactions between potential biomarkers and the senolytic drug Navitoclax.

Results

We identified seven genes common to AF-related DEGs and senescence-related genes. Three significant modules were selected from WGCNA analysis. Taken together, three senescence-related genes (ETS1, SP1, and WT1) were found to be significantly associated with AF. Protein-protein interaction network analysis revealed biological connections among the predicted target genes of ETS1, SP1, and WT1. Notably, ETS1, SP1, and WT1 exhibited significant differential expression in clinical samples as well as in vitro and in vivo models. Molecular docking revealed favorable binding affinity between senolytic Navitoclax and these potential biomarkers.

Conclusions

This study highlights ETS1, SP1, and WT1 as crucial senescence-related genes associated with AF, offering potential therapeutic targets, with supportive evidence of binding affinity with senolytic Navitoclax. These findings provide novel insights into AF pathogenesis from a senescence perspective.

Diltiazem reduces levels of NT-proBNP and improves symptoms compared with metoprolol in patients with permanent atrial fibrillation

AIMS

Short-term treatment with calcium channel blockers lowers levels of N-terminal pro B-type natriuretic peptide (NT-proBNP) and reduces rhythm-related symptoms compared to treatment with beta-blockers. The aim of this study was to compare the effects of metoprolol and diltiazem for rate control in patients with permanent atrial fibrillation (AF) after 6 months.

METHODS AND RESULTS

Men and women with permanent AF and preserved left ventricular systolic function were randomized to receive either diltiazem 360 mg or metoprolol 100 mg once daily. The primary endpoint was the level of NT-proBNP after a 6-month treatment period. Secondary endpoints included heart rate, rhythm-related symptoms and exercise capacity. A total of 93 patients (mean age 71 ± 7 years, 28 women) were randomized. After 6-months' treatment, mean levels of NT-proBNP decreased in the diltiazem group and increased in the metoprolol group, with a significant between-group difference (409.8 pg/mL, 95% CI: 230.6-589.1, P < 0.001). Treatment with diltiazem significantly reduced rhythm-related symptoms compared to baseline, but no change was observed in the metoprolol group. Diltiazem and metoprolol had similar effects on heart rate and exercise capacity.

CONCLUSION

Diltiazem reduced NT-proBNP levels and improved rhythm-related symptoms. Metoprolol increased peptide levels but had no impact on symptoms despite similar heart rate reduction. Non-dihydropyridine calcium channel blockers should be considered more often for rate control in permanent AF.

Beyond Clinical Factors: Harnessing Artificial Intelligence and Multimodal Cardiac Imaging to Predict Atrial Fibrillation Recurrence Post-Catheter Ablation

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, with catheter ablation being a key alternative to medical treatment for restoring normal sinus rhythm. Despite advances in understanding AF pathogenesis, approximately 35% of patients experience AF recurrence at 12 months after catheter ablation. Therefore, accurate prediction of AF recurrence occurring after catheter ablation is important for patient selection and management. Conventional methods for predicting post-catheter ablation AF recurrence, which involve the use of univariate predictors and scoring systems, have played a supportive role in clinical decision-making. In an ever-changing landscape where technology is becoming ubiquitous within medicine, cardiac imaging and artificial intelligence (AI) could prove pivotal in enhancing AF recurrence predictions by providing data with independent predictive power and identifying key relationships in the data. This review comprehensively explores the existing methods for predicting the recurrence of AF following catheter ablation from different perspectives, including conventional predictors and scoring systems, cardiac imaging-based methods, and AI-based methods developed using a combination of demographic and imaging variables. By summarising state-of-the-art technologies, this review serves as a roadmap for developing future prediction models with enhanced accuracy, generalisability, and explainability, potentially contributing to improved care for patients with AF.

More positive patient-reported outcomes in patients newly diagnosed with atrial fibrillation: a comparative longitudinal study

AIMS

To compare patient-reported outcomes (PROs) in patients newly (<6 months) diagnosed with atrial fibrillation (AF) with those who have had a longer diagnosis (≥6 months) and to investigate whether or not these outcomes change over a 6-month period.

METHODS AND RESULTS

In this longitudinal survey study, 129 patients with AF completed the Revised Illness Perception Questionnaire, the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia, and the Hospital Anxiety and Depression Scale at baseline and after 6 months. At baseline, patients newly diagnosed with AF (n = 53), compared with patients with a previous diagnosis (n = 76), reported AF as more temporary (P = 0.003) and had a higher belief in personal and treatment control (P = 0.004 and P = 0.041, respectively). At a 6-month follow-up, patients newly diagnosed reported a lower symptom burden (P = 0.004), better health-related quality of life (HRQoL); (P = 0.015), and a higher personal control (P < 0.001) than patients previously diagnosed. Over time, in patients newly diagnosed, symptom burden and the anxiety symptom score decreased (P = 0.001 and P = 0.014, respectively) and HRQoL improved (P = 0.002).

CONCLUSION

Patients newly diagnosed with AF reported more positive PROs both at baseline and at a 6-month follow-up than patients with a previous diagnosis of AF. Therefore, it is important to quickly capture patients newly diagnosed to support their belief in their own abilities. Such support may, alongside medical treatments, help patients manage the disease, which may lead to reduced symptom burden and better HRQoL over time.

Differentiating Left Atrial Pressure Responses in Paroxysmal and Persistent Atrial Fibrillation: Implications for Diagnosing Heart Failure With Preserved Ejection Fraction and Managing Atrial Fibrillation

BACKGROUND

Increased left atrial pressure (LAP) contributes to dyspnea and heart failure with preserved ejection fraction in patients with atrial fibrillation (AF). The purpose of this study was to investigate the differences in baseline LAP and LAP response to rapid pacing between paroxysmal and persistent AF.

METHODS AND RESULTS

This observational study prospectively enrolled 1369 participants who underwent AF catheter ablation, excluding those with reduced left ventricular ejection fraction. H2FPEF score was calculated by echocardiography and baseline characteristics. Patients underwent LAP measurements during AF, sinus rhythm, and heart rates of 90, 100, 110, and 120 beats per minute (bpm), induced by right atrial pacing and isoproterenol. The baseline LAP-peak in the persistent AF group consistently exceeded that in the paroxysmal AF (PAF) group across each H2FPEF score subgroup (all P<0.05). LAP-peak increased with pacing (19.5 to 22.5 mm Hg) but decreased with isoproterenol (20.4 to 18.4 mm Hg). Under pacing, patients with PAF exhibited a significantly lower LAP-peak (90 bpm) than those with persistent AF (17.7±8.2 versus 21.1±9.3 mm Hg, P<0.001). However, there was no difference in LAP-peak (120 bpm) between the 2 groups (22.1±8.1 versus 22.9±8.4 mm Hg, P=0.056) because the LAP-peak significantly increased with heart rate in the group with PAF.

CONCLUSIONS

Patients with PAF exhibited lower baseline LAP with greater increases during rapid pacing compared with individuals with persistent AF, indicating a need to revise the H2FPEF score for distinguishing PAF from persistent AF and emphasizing the importance of rate and rhythm control in PAF for symptom control.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02138695.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Nationwide Trends in Hospitalizations for Atrial Fibrillation and Flutter in the United States before and during the Outbreak of the COVID-19 Pandemic

Background/Objectives: Atrial fibrillation (AF) and flutter (AFL) are the most common cardiac arrhythmias worldwide. Cardiovascular complications are a common manifestation of acute and post-acute COVID-19 infection. We aimed to analyze the nationwide trends in clinical characteristics and outcomes of patients hospitalized for AF/AFL before and during the COVID-19 outbreak in the U.S. Methods: This study is a retrospective analysis of patients, aged 18 and older, hospitalized for AF/AFL in the U.S. between 2016 and 2020. We drew data from the National Inpatient Sample (NIS) database. Baseline sociodemographic and clinical data, as well as outcomes including stroke, acute coronary syndrome (ACS), and mortality, were analyzed. Multivariable analysis was performed to identify independent associations between the different clinical and demographic characteristics and the composite endpoint of Mortality/ACS/Stroke. Results: An estimated total of 2,163,699 hospitalizations for AF/AFL were identified. The hospitalization volume between 2016 and 2019 was stable, averaging 465,176 a year, followed by a significant drop to 302,995 in 2020. Patients' median age was 72 years (IQR 62-80), 50.9% were male, and 81.5% were white. The composite endpoint steadily increased from 6.5% in 2016 to 11.8% in 2020 (Ptrend < 0.001). In a multivariable regression analysis, age > 75 (OR: 1.35; 95% CI 1.304-1.399, p < 0.001), ischemic heart disease (OR: 1.466; 95% CI: 1.451-1.481; p < 0.001), and chronic kidney disease (OR: 1.635; 95% CI: 1.616-1.653; p < 0.001) were associated with the composite endpoint. COVID-19 was associated with the composite endpoint outcome in the year 2020 (OR: 1.147; 95% CI: 1.037-1.265; p = 0.007). Conclusions: Hospitalization for AF/AFL dropped significantly during the first year of the COVID-19 pandemic outbreak, possibly due to patients' avoidance of hospital visits. The composite endpoint of Mortality/ACS/Stroke uptrended significantly during the study period. COVID-19 was shown to be independently associated with the adverse composite outcome Mortality/ACS/Stroke.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

KAMLN: A Knowledge-aware Multi-label Network for Lung Cancer Complication Prediction

Surgical resection is now the only curative approach for early stage lung cancer patients. However, postoperative complications pose a significant threat to the health and life of patients. The current complication prediction methods usually ignore the potential causal relationships between different complications, which may limit their predictive performances. To exploit this knowledge, we propose a knowledge-aware multi-label network (KAMLN) for complication prediction. In this approach, we first construct a knowledge graph to describe the potential causal relationships between different complications. Then, we design a neural network based on this knowledge graph to learn the relationships between different complications to achieve better predictive performances. Experiments using 593 lung cancer patients' data show that the KAMLN achieves a micro-AUC value of 0.664±0.100, which is better than the baseline methods. The SHAP analysis indicates lymph node dissection has a significant impact on multiple complications. Based on the experimental results, the proposed KAMLN can effectively utilize prior knowledge between different complications to achieve more accurate and fine-grained complication prediction.

Antiarrhythmic drug therapy and catheter ablation in patients with paroxysmal or persistent atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Catheter ablation and antiarrhythmic drug therapy are utilized for rhythm control in atrial fibrillation (AF), but their comparative effectiveness, especially with contemporary treatment modalities, remains undefined. We conducted a systematic review and meta-analysis contrasting current ablation techniques against antiarrhythmic medications for AF.

METHODS

We searched PubMed, SCOPUS, Cochrane CENTRAL, and Web of Science until November 2023 for randomized trials comparing AF catheter ablation with antiarrhythmics, against antiarrhythmic drug therapy alone, reporting outcomes for > 6 months. Four investigators extracted data and appraised risk of bias (ROB) with ROB 2 tool. Meta-analyses estimated pooled efficacy and safety outcomes using R software.

RESULTS

Twelve trials (n = 3977) met the inclusion criteria. Catheter ablation was associated with lower AF recurrence (relative risk (RR) = 0.44, 95%CI (0.33, 0.59), P ˂ 0.0001) and hospitalizations (RR = 0.44, 95%CI (0.23, 0.82), P = 0.009) than antiarrhythmic medications. Catheter ablation also improved the physical quality of life component score (assessed by a 36-item Short Form survey) by 7.61 points (95%CI -0.70-15.92, P = 0.07); but, due to high heterogeneity, it was not statistically significant. Ablation was significantly associated with higher procedural-related complications [RR = 15.70, 95%CI (4.53, 54.38), P < 0.0001] and cardiac tamponade [RR = 9.22, 95%CI (2.16, 39.40), P = 0.0027]. All-cause mortality was similar between the two groups.

CONCLUSIONS

For symptomatic AF, upfront catheter ablation reduces arrhythmia and hospitalizations better than continued medical therapy alone, albeit with moderately more adverse events. Careful patient selection and risk-benefit assessment are warranted regarding the timing of ablation.

Study Design of a Brazilian Observational Study of Edoxaban in Patients with Atrial Fibrillation (EdoBRA)

BACKGROUND

Clinical trials showed the safety of Edoxaban, a non-vitamin K-dependent oral anticoagulant (NOAC), and its efficacy to prevent stroke and systemic embolism in non-valvular atrial fibrillation (NVAF) patients and also to prevent and treat venous thromboembolism. However, additional research is needed to evaluate the safety and effectiveness of Edoxaban in a real-world scenario in the Brazilian population.

OBJECTIVE

In order to understand the risks and benefits of Edoxaban use in routine clinical settings, the EdoBRA study is being conducted to gain insight into the safety and effectiveness of Edoxaban use in non-preselected patients with NVAF in Brazil.

METHODS

The EdoBRA study is a multicenter, prospective, observational study conducted in 36 sites in Brazil. NVAF patients ≥ 18 years treated with commercially available Edoxaban who initiated treatment for at least 14 days and no longer than 90 days prior to enrollment, and who are not simultaneously participating in any interventional study are eligible for this study. Seven hundred patients are planned to be enrolled and one-year of follow up, with data collections expected at baseline and 3, 6, and 12 months after the study enrollment. The primary safety objective is ISTH Clinically Relevant Bleeding, and the secondary effectiveness objective focuses on relevant cardiovascular outcomes related to NVAF.

CONCLUSION

EdoBRA observational study will generate relevant additional information about NOAC Edoxaban on various aspects of patient management in routine care, such as its safety and effectiveness profile in patients with NVAF in Brazil.

Photoplethysmography based atrial fibrillation detection: a continually growing field

Objective. Atrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with significant health ramifications, including an elevated susceptibility to ischemic stroke, heart disease, and heightened mortality. Photoplethysmography (PPG) has emerged as a promising technology for continuous AF monitoring for its cost-effectiveness and widespread integration into wearable devices. Our team previously conducted an exhaustive review on PPG-based AF detection before June 2019. However, since then, more advanced technologies have emerged in this field.Approach. This paper offers a comprehensive review of the latest advancements in PPG-based AF detection, utilizing digital health and artificial intelligence (AI) solutions, within the timeframe spanning from July 2019 to December 2022. Through extensive exploration of scientific databases, we have identified 57 pertinent studies.Significance. Our comprehensive review encompasses an in-depth assessment of the statistical methodologies, traditional machine learning techniques, and deep learning approaches employed in these studies. In addition, we address the challenges encountered in the domain of PPG-based AF detection. Furthermore, we maintain a dedicated website to curate the latest research in this area, with regular updates on a regular basis.

Association Between Atrial Fibrillation Symptoms and Clinical Outcomes: A Prospective Multicenter Registry Study

The presence of symptoms plays an important role in determining whether to focus on rhythm control or rate control when treating atrial fibrillation (AF). Previous comparative studies on the clinical outcomes of symptomatic and asymptomatic AF have yielded inconsistent results, and a link between AF symptoms and left atrial (LA) remodeling is not established. Patients selected from the COmparison study of Drugs for symptom control and complication prEvention of AF (CODE-AF) registry, which is a prospective, multicenter study consisting of patients with non-valvular AF, were grouped into 2 groups: symptomatic and asymptomatic. The primary outcome was a composite of the following cardiovascular outcomes: all-cause death, ischemic stroke, transient ischemic attack, systemic embolism, myocardial infarction, and heart failure hospitalization. Of 10,210 patients with AF, 4,327 (42%) had symptomatic AF. The asymptomatic group had an older mean age, more men, and more patients with hypertension and diabetes mellitus than the symptomatic group. The asymptomatic group had a larger left atrium (LA) diameter (43.6 vs 42.2 mm, p <0.001) than the symptomatic group. During a median follow-up of 32.9 (29.5 to 36.4) months, the asymptomatic and symptomatic groups showed similar incidences of the primary outcome (1.44 vs 1.45 per 100 person-years; log-rank, p = 0.8). In conclusion, the absence of AF symptoms is associated with increased LA. However, symptomatic and asymptomatic patients with AF have a similar risk of cardiovascular outcomes. This suggests that beneficial treatment for AF may be considered regardless of whether patients have symptomatic or asymptomatic AF.

Characterizing atrial fibrillation symptom improvement following de novo catheter ablation

AIMS

Atrial fibrillation (AF) symptom relief is a primary indication for catheter ablation, but AF symptom resolution is not well characterized. The study objective was to describe AF symptom documentation in electronic health records (EHRs) pre- and post-ablation and identify correlates of post-ablation symptoms.

METHODS AND RESULTS

We conducted a retrospective cohort study using EHRs of patients with AF (n = 1293), undergoing ablation in a large, urban health system from 2010 to 2020. We extracted symptom data from clinical notes using a natural language processing algorithm (F score: 0.81). We used Cochran's Q tests with post-hoc McNemar's tests to determine differences in symptom prevalence pre- and post-ablation. We used logistic regression models to estimate the adjusted odds of symptom resolution by personal or clinical characteristics at 6 and 12 months post-ablation. In fully adjusted models, at 12 months post-ablation patients, patients with heart failure had significantly lower odds of dyspnoea resolution [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.25-0.57], oedema resolution (OR 0.37, 95% CI 0.25-0.56), and fatigue resolution (OR 0.54, 95% CI 0.34-0.85), but higher odds of palpitations resolution (OR 1.90, 95% CI 1.25-2.89) compared with those without heart failure. Age 65 and older, female sex, Black or African American race, smoking history, and antiarrhythmic use were also associated with lower odds of resolution of specific symptoms at 6 and 12 months.

CONCLUSION

The post-ablation symptom patterns are heterogeneous. Findings warrant confirmation with larger, more representative data sets, which may be informative for patients whose primary goal for undergoing an ablation is symptom relief.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Catheter ablation versus medical therapy in atrial fibrillation: an umbrella review of meta-analyses of randomized clinical trials

This umbrella review synthesizes data from 17 meta-analyses investigating the comparative outcomes of catheter ablation (CA) and medical treatment (MT) for atrial fibrillation (AF). Outcomes assessed were mortality, risk of hospitalization, AF recurrence, cardiovascular events, pulmonary vein stenosis, major bleeding, and changes in left ventricular ejection fraction (LVEF) and MLHFQ score. The findings indicate that CA significantly reduces overall mortality and cardiovascular hospitalization with high strength of evidence. The risk of AF recurrence was notably lower with CA, with moderate strength of evidence. Two associations reported an increased risk of pulmonary vein stenosis and major bleeding with CA, supported by high strength of evidence. Improved LVEF and a positive change in MLHFQ were also associated with CA. Among patients with AF and heart failure, CA appears superior to MT for reducing mortality, improving LVEF, and reducing cardiovascular rehospitalizations. In nonspecific populations, CA reduced mortality and improved LVEF but had higher complication rates. Our findings suggest that CA might offer significant benefits in managing AF, particularly in patients with heart failure. However, the risk of complications, including pulmonary vein stenosis and major bleeding, is notable. Further research in understudied populations may help refine these conclusions.

Combination of frequency- and time-domain characteristics of the fibrillatory waves for enhanced prediction of persistent atrial fibrillation recurrence after catheter ablation

Catheter ablation (CA) remains the cornerstone alternative to cardioversion for sinus rhythm (SR) restoration in patients with atrial fibrillation (AF). Unfortunately, despite the last methodological and technological advances, this procedure is not consistently effective in treating persistent AF. Beyond introducing new indices to characterize the fibrillatory waves (f-waves) recorded through the preoperative electrocardiogram (ECG), the aim of this study is to combine frequency- and time-domain features to improve CA outcome prediction and optimize patient selection for the procedure, given the absence of any study that jointly analyzes information from both domains. Precisely, the f-waves of 151 persistent AF patients undergoing their first CA procedure were extracted from standard V1 lead. Novel spectral and amplitude features were derived from these waves and combined through a machine learning algorithm to anticipate the intervention mid-term outcome. The power rate index (φ), which estimates the power of the harmonic content regarding the dominant frequency (DF), yielded the maximum individual discriminant ability of 64% to discern between individuals who experienced a recurrence of AF and those who sustained SR after a 9-month follow-up period. The predictive accuracy was improved up to 78.5% when this parameter φ was merged with the amplitude spectrum area in the DF bandwidth (A M S A L F ) and the normalized amplitude of the f-waves into a prediction model based on an ensemble classifier, built by random undersampling boosting of decision trees. This outcome suggests that the synthesis of both spectral and temporal features of the f-waves before CA might enrich the prognostic knowledge of this therapy for persistent AF patients.

Identification of Fatigue Subtypes and Their Correlates in Prevalent Heart Failure: A Secondary Analysis of the Atherosclerosis Risk in Communities Study

BACKGROUND

Among patients with heart failure (HF), fatigue is common and linked to quality of life and functional status. Fatigue is hypothesized to manifest as multiple types, with general and exertional components. Unique subtypes of fatigue in HF may require differential assessment and treatment to improve outcomes. We conducted this study to identify fatigue subtypes in persons with prevalent HF in the ARIC study (Atherosclerosis Risk in Communities) and describe the distribution of characteristics across subtypes.

METHODS

We performed a cross-sectional analysis of 1065 participants with prevalent HF at ARIC visit 5 (2011-2013). We measured exertional fatigue using the Modified Medical Research Council Breathlessness scale and general fatigue using the Patient Reported Outcomes Measurement Information System fatigue scale. We used latent class analysis to identify subtypes of fatigue. Number of classes was determined using model fit statistics, and classes were interpreted and assigned fatigue severity rating based on the conditional probability of endorsing survey items given class. We compared characteristics across classes using multinomial regression.

RESULTS

Overall, participants were 54% female and 38% Black with a mean age of 77. We identified 4 latent classes (fatigue subtypes): (1) high general/high exertional fatigue (18%), (2) high general/low exertional fatigue (27%), (3) moderate general/moderate exertional fatigue (20%), and (4) low/no general and exertional fatigue (35%). Female sex, Black race, lower education level, higher body mass index, increased depressive symptoms, and higher prevalence of diabetes were associated with higher levels of general and exertional fatigue.

CONCLUSIONS

We identified unique subtypes of fatigue in patients with HF who have not been previously described. Within subtype, general and exertional fatigue were mostly concordant in severity, and exertional fatigue only occurred in conjunction with general fatigue, not alone. Further understanding these fatigue types and their relationships to outcomes may enhance our understanding of the symptom experience and inform prognostication and secondary prevention efforts for persons with HF.

Continuous Atrial Fibrillation Monitoring From Photoplethysmography: Comparison Between Supervised Deep Learning and Heuristic Signal Processing

BACKGROUND

Continuous monitoring for atrial fibrillation (AF) using photoplethysmography (PPG) from smartwatches or other wearables is challenging due to periods of poor signal quality during motion or suboptimal wearing. As a result, many consumer wearables sample infrequently and only analyze when the user is at rest, which limits the ability to perform continuous monitoring or to quantify AF.

OBJECTIVES

This study aimed to compare 2 methods of continuous monitoring for AF in free-living patients: a well-validated signal processing (SP) heuristic and a convolutional deep neural network (DNN) trained on raw signal.

METHODS

We collected 4 weeks of continuous PPG and electrocardiography signals in 204 free-living patients. Both SP and DNN models were developed and validated both on holdout patients and an external validation set.

RESULTS

The results show that the SP model demonstrated receiver-operating characteristic area under the curve (AUC) of 0.972 (sensitivity 99.6%, specificity: 94.4%), which was similar to the DNN receiver-operating characteristic AUC of 0.973 (sensitivity 92.2, specificity: 95.5%); however, the DNN classified significantly more data (95% vs 62%), revealing its superior tolerance of tracings prone to motion artifact. Explainability analysis revealed that the DNN automatically suppresses motion artifacts, evaluates irregularity, and learns natural AF interbeat variability. The DNN performed better and analyzed more signal in the external validation cohort using a different population and PPG sensor (AUC, 0.994; 97% analyzed vs AUC, 0.989; 88% analyzed).

CONCLUSIONS

DNNs perform at least as well as SP models, classify more data, and thus may be better for continuous PPG monitoring.

Diagnostic Delay and Disease Burden in Primary Aldosteronism: An International Patient Survey

BACKGROUND

Primary aldosteronism (PA) is a common but underdiagnosed cause of hypertension. Many patients experience preventable end-organ injury due to delayed or missed diagnosis but data on the experience of patients are limited.

METHODS

We evaluated the lived experience of PA and determines factors associated with diagnostic delay through an international anonymous online cross-sectional survey, codesigned by researchers and PA consumers. We distributed the survey through academic medical centers, Amazon Mechanical Turk, Twitter, PA patient advocacy groups, and hypertension support groups on Facebook between March 21 and June 5, 2022.

RESULTS

Of 684 eligible respondents, 66.5% were women. Diagnostic delay (defined as ≥5 years between the diagnosis of hypertension and PA) was reported in 35.6%. Delay was more likely in women than in men (odds ratio, 1.55 [95% CI, 1.10-2.20]) and respondents with ≥3 comorbidities versus none (odds ratio, 1.77 [95% CI, 1.05-3.02]), ≥10 symptoms versus none (odds ratio, 2.73 [95% CI, 1.74-4.44]), and on ≥4 antihypertensive medications versus none (odds ratio, 18.23 [95% CI, 6.24-77.72]). Three-quarters of patients (74.4%) experienced reduced symptom burden following targeted PA treatment. Quality of life improved in 62.3% of patients, and greater improvement was associated with being a woman (odds ratio, 1.42, [95% CI, 1.02-1.97]), receiving adrenalectomy (odds ratio, 2.36 [95% CI, 1.67-3.35]), and taking fewer antihypertensive medications following diagnosis (odds ratio, 5.28 [95% CI, 3.55-7.90]).

CONCLUSIONS

One-third of patients with PA experienced prolonged diagnostic delays. Targeted treatment led to reduced symptom burden and improved quality of life. Gender differences in diagnostic delay and symptom burden are prominent. These findings suggest that routine screening for PA at the onset of hypertension may reduce diagnostic delay and facilitate timely diagnosis.

Optimizing the management of electrophysiology labs in Chinese hospitals using a discrete event simulation tool

BACKGROUND

The growing demand for electrophysiology (EP) treatment in China presents a challenge for current EP care delivery systems. This study constructed a discrete event simulation (DES) model of an inpatient EP care delivery process, simulating a generalized inpatient journey of EP patients from admission to discharge in the cardiology department of a tertiary hospital in China. The model shows how many more patients the system can serve under different resource constraints by optimizing various phases of the care delivery process.

METHODS

Model inputs were based on and validated using real-world data, simulating the scheduling of limited resources among competing demands from different patient types. The patient stay consists of three stages, namely: the pre-operative stay, the EP procedure, and the post-operative stay. The model outcome was the total number of discharges during the simulation period. The scenario analysis presented in this paper covers two capacity-limiting scenarios (CLS): (1) fully occupied ward beds and (2) fully occupied electrophysiology laboratories (EP labs). Within each CLS, we investigated potential throughput when the length of stay or operative time was reduced by 10%, 20%, and 30%. The reductions were applied to patients with atrial fibrillation, the most common indication accounting for almost 30% of patients.

RESULTS

Model validation showed simulation results approximated actual data (137.2 discharges calculated vs. 137 observed). With fully occupied wards, reducing pre- and/or post-operative stay time resulted in a 1-7% increased throughput. With fully occupied EP labs, reduced operative time increased throughput by 3-12%.

CONCLUSIONS

Model validation and scenario analyses demonstrated that the DES model reliably reflects the EP care delivery process. Simulations identified which phases of the process should be optimized under different resource constraints, and the expected increases in patients served.

Cardioversion strategy impacts rate control during recurrences in patients with paroxysmal atrial fibrillation: A subanalysis of the RACE 7 ACWAS trial

BACKGROUND

In the Rate Control versus Electrical Cardioversion Trial 7-Acute Cardioversion versus Wait and See, patients with recent-onset atrial fibrillation (AF) were randomized to either early or delayed cardioversion.

AIM

This prespecified sub-analysis aimed to evaluate heart rate during AF recurrences after an emergency department (ED) visit identified by an electrocardiogram (ECG)-based handheld device.

METHODS

After the ED visit, included patients (n = 437) were asked to use an ECG-based handheld device to monitor for recurrences during the 4-week follow-up period. 335 patients used the handheld device and were included in this analysis. Recordings from the device were collected and assessed for heart rhythm and rate. Optimal rate control was defined as a target resting heart rate of <110 beats per minute (bpm).

RESULTS

In 99 patients (29.6%, mean age 67 ± 10 years, 39.4% female, median 6 [3-12] AF recordings) a total of 314 AF recurrences (median 2 [1-3] per patient) were identified during follow-up. The average median resting heart rate at recurrence was 100 ± 21 bpm in the delayed vs 112 ± 25 bpm in the early cardioversion group (p = .011). Optimal rate control was seen in 68.4% [21.3%-100%] and 33.3% [0%-77.5%] of recordings (p = .01), respectively. Randomization group [coefficient -12.09 (-20.55 to -3.63, p = .006) for delayed vs. early cardioversion] and heart rate on index ECG [coefficient 0.46 (0.29-0.63, p < .001) per bpm increase] were identified on multivariable analysis as factors associated with lower median heart rate during AF recurrences.

CONCLUSION

A delayed cardioversion strategy translated into a favorable heart rate profile during AF recurrences.

The validity and reliability of Indonesian version of atrial fibrillation effect on quality of life (AFEQT) questionnaire for atrial fibrillation patients

BACKGROUND

More than 60% of patients with atrial fibrillation (AF) have a significant health-related quality of life (HRQoL) impairment. HRQoL, a patient-reported outcome (PRO), has become an important endpoint to assess treatment success in AF patients. The Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire is an AF-specific HRQoL tool shown to be feasible, reliable, and valid, with translations in various languages. Since this questionnaire has never been translated or validated in Indonesian, we aimed to determine the validity and reliability of the Indonesian version of the AFEQT questionnaire for AF patients.

RESULTS

This cross-sectional, observational study was conducted in the Integrated Cardiovascular Service Polyclinic, Cipto Mangunkusumo Hospital, Indonesia, from December 2021 to March 2022. A total of 30 participants were recruited for cross-cultural adaptation process, which consisted of translation and adaptation process, and a total of 102 participants were consecutively recruited to participate in the validation process, which consisted of validity test (construct validity) and reliability tests (internal consistency and test-retest). The retest was conducted within a 1-2-week interval after the baseline assessment, by analyzing the intraclass correlation coefficient (ICC). The construct validity was determined by multitrait scaling analysis, and the convergent and divergent validity was compared to SF-36 domains. Multitrait scaling analysis revealed that all items in the Indonesian version of the AFEQT questionnaire had a strong negative correlation towards their respective domains (r -0.639--0.960). For convergent and divergent validity, AFEQT domains had weak to strong positive correlations to all SF-36 domains (r 0.338-0.693). This questionnaire also had acceptable internal consistency (Cronbach's α for overall score: 0.947; Domains: Symptoms: 0.818, Daily Activities: 0.943, Treatment Concern: 0.894, and Treatment Satisfaction: 0.865), as well as moderate-to-good test-retest reliability (0.521-0.828).

CONCLUSIONS

The Indonesian version of the AFEQT questionnaire has good validity and reliability for assessing quality of life of atrial fibrillation patients in Indonesia.

Changes in cardiac output, rhythm regularity, and symptom severity after electrical cardioversion of atrial fibrillation

OBJECTIVES

Symptoms in atrial fibrillation (AF) range from none to disabling. The physiological correlates of AF symptoms are not well characterized. This study investigated the association between physiological parameters and symptom severity before and after electrical cardioversion (EC) of AF.

DESIGN

We studied 44 patients with persistent AF (age 66.2 ± 7.9 years, 16% females) 4 ± 2 days before and 5 ± 2 days after EC. Physiological parameters included cardiac output (CO; non-invasive inert gas rebreathing), heart rate (HR), RR variability and resting and ambulatory blood pressure (BP). Symptoms and quality of life (QoL) were assessed by the modified European Heart Rhythm Association score (mEHRA), the Atrial Fibrillation Effect on Quality of Life (AFEQT) and the Symptom Checklist for frequency and severity of symptoms (SCL).

RESULTS

28 of 44 patients were still in sinus rhythm (SR) at post EC evaluation. Those in SR had a decreased HR (-15.4 ± 13.1 bpm, p < 0.001), and an increased CO (+0.8 ± 0.7 L/min, p < 0.001) as compared to those with recurrent AF. Changes in CO after EC correlated with symptom improvement as scored by AFEQT (r = 0.36; p < 0.05), AFEQT symptoms subscore (r = 0.46; p < 0.01), SCL for frequency (r = 0.62; p < 0.01) and severity (r = 0.33; p < 0.05) of symptoms, and the mEHRA score (r = 0.50; p < 0.01). A decrease in RR variability showed similar correlations with these measures of symptom improvement.

CONCLUSIONS

Improvements in symptoms and quality of life experienced by patients after electrical conversion of atrial fibrillation are correlated with an increase in CO and a decreased RR variability.

Quality of life among patients with atrial fibrillation: A theoretically-guided cross-sectional study

BACKGROUND

Patients with atrial fibrillation (AF) have significantly lower health-related quality of life (HRQoL) compared to the general population and patients with other heart diseases. The research emphasis on the influence of AF symptoms on HRQoL overshadows the role of individual characteristics. To address this gap, this study's purpose was to test an incremental predictive model for AF-related HRQoL following an adapted HRQoL conceptual model that incorporates both symptoms and individual characteristics.

METHODS

Patients attending an AF specialty clinic were invited to complete an online survey. Hierarchical regression analyses were conducted to examine whether individual characteristics (overall mental health, perceived stress, sex, age, AF knowledge, household and recreational physical activity) incremented prediction of HRQoL and AF treatment satisfaction beyond AF symptom recency and overall health.

RESULTS

Of 196 participants (mean age 65.3 years), 63% were male and 90% were Caucasian. Most reported 'excellent' or 'good' overall and mental health, had high overall AF knowledge scores, had low perceived stress scores, and had high household and recreation physical activity. The mean overall AF Effect On Quality-Of-Life Questionnaire (AFEQT) and AF treatment satisfaction scores were 70.62 and 73.84, respectively. Recency of AF symptoms and overall health accounted for 29.6% of the variance in overall HRQoL and 20.2% of the variance in AF treatment satisfaction. Individual characteristics explained an additional 13.6% of the variance in overall HRQoL and 7.6% of the variance in AF treatment satisfaction. Perceived stress and household physical activity were the largest contributors to overall HRQoL, whereas age and AF knowledge made significant contributions to AF treatment satisfaction.

CONCLUSIONS

Along with AF symptoms and overall health, individual characteristics are important predictors of HRQoL and AF treatment satisfaction in AF patients. In particular, perceived stress and household physical activity could further be targeted as potential areas to improve HRQoL.

Association between the atrial tachyarrhythmia recurrence period and long-term major adverse clinical events following catheter ablation for atrial fibrillation

Background

We previously demonstrated the clinical events in patients who underwent catheter ablation (CA) for atrial fibrillation (AF). Data on the association between the period of atrial tachyarrhythmia (ATA) recurrence after CA and long-term major adverse clinical events (MACE) remain unclear. In this study, we evaluated this issue in patients with systolic impairment (left ventricular ejection fraction < 50%) and heart failure with preserved ejection fraction (HFpEF).

Methods

We retrospectively collected data from 81 patients with systolic impairment and 83 patients with HFpEF who underwent CA for AF at our institution (median follow-up: 4.9 [3.6, 6.6] years). In each group, we compared the cumulative incidence of long-term MACE (since 1 year after CA) between patients with and without ATA recurrence at three follow-up periods (3, 6 months, and 1 year after index CA). We evaluated the period of recurrence, which was the most beneficial predictor of MACE among the periods.

Results

In the systolic impairment group, the cumulative long-term MACE incidence was significantly higher in patients with ATA recurrence than in those without it within 6 months and 1 year (P = 0.04 and P = 0.01, respectively). Recurrence within 1 year showed the highest feasibility for predicting long-term MACE (area under the curve with 95% confidence interval [CI]:0.73 [0.61-0.84]). However, there was no difference in the incidence of MACE between patients with and without recurrence in a group with HFpEF in each period.

Conclusion

ATA recurrence within 1 year could predict long-term MACE in patients with systolic impairment, but not in patients with HFpEF.

Clinical and economic outcomes associated with use of anti-arrhythmic drugs versus ablation in atrial fibrillation

Aim: To evaluate the clinical and economic impact of antiarrhythmic drugs (AADs) compared with ablation both as individual treatments and as combination therapy without/with considering the order of treatment among patients with atrial fibrillation (AFib). Materials & methods: A budget impact model over a one-year time horizon was developed to assess the economic impact of AADs (amiodarone, dofetilide, dronedarone, flecainide, propafenone, sotalol, and as a group) versus ablation across three scenarios: direct comparisons of individual treatments, non-temporal combinations, and temporal combinations. The economic analysis was conducted in accordance with CHEERS guidance as per current model objectives. Results are reported as costs per patient per year (PPPY). The impact of individual parameters was evaluated using one-way sensitivity analysis (OWSA). Results: In direct comparisons, ablation had the highest annual medication/procedure cost ($29,432), followed by dofetilide ($7661), dronedarone ($6451), sotalol ($4552), propafenone ($3044), flecainide ($2563), and amiodarone ($2538). Flecainide had the highest costs for long-term clinical outcomes ($22,964), followed by dofetilide ($17,462), sotalol ($15,030), amiodarone ($12,450), dronedarone ($10,424), propafenone ($7678) and ablation ($9948). In the non-temporal scenario, total costs incurred for AADs (group) + ablation ($17,278) were lower compared with ablation alone ($39,380). In the temporal scenario, AADs (group) before ablation resulted in PPPY cost savings of ($22,858) compared with AADs (group) after ablation ($19,958). Key factors in OWSA were ablation costs, the proportion of patients having reablation, and withdrawal due to adverse events. Conclusion: Utilization of AADs as individual treatment or in combination with ablation demonstrated comparable clinical benefits along with costs savings in patients with AFib.

Characterising symptom clusters in patients with atrial fibrillation undergoing catheter ablation

OBJECTIVE

This study aims to leverage natural language processing (NLP) and machine learning clustering analyses to (1) identify co-occurring symptoms of patients undergoing catheter ablation for atrial fibrillation (AF) and (2) describe clinical and sociodemographic correlates of symptom clusters.

METHODS

We conducted a cross-sectional retrospective analysis using electronic health records data. Adults who underwent AF ablation between 2010 and 2020 were included. Demographic, comorbidity and medication information was extracted using structured queries. Ten AF symptoms were extracted from unstructured clinical notes (n=13 416) using a validated NLP pipeline (F-score=0.81). We used the unsupervised machine learning approach known as Ward's hierarchical agglomerative clustering to characterise and identify subgroups of patients representing different clusters. Fisher's exact tests were used to investigate subgroup differences based on age, gender, race and heart failure (HF) status.

RESULTS

A total of 1293 patients were included in our analysis (mean age 65.5 years, 35.2% female, 58% white). The most frequently documented symptoms were dyspnoea (64%), oedema (62%) and palpitations (57%). We identified six symptom clusters: generally symptomatic, dyspnoea and oedema, chest pain, anxiety, fatigue and palpitations, and asymptomatic (reference). The asymptomatic cluster had a significantly higher prevalence of male, white and comorbid HF patients.

CONCLUSIONS

We applied NLP and machine learning to a large dataset to identify symptom clusters, which may signify latent biological underpinnings of symptom experiences and generate implications for clinical care. AF patients' symptom experiences vary widely. Given prior work showing that AF symptoms predict adverse outcomes, future work should investigate associations between symptom clusters and postablation outcomes.

Cardiac rehabilitation for heart failure and atrial fibrillation: a propensity- matched study

BACKGROUND

Atrial fibrillation (AF) is common in individuals with heart failure (HF). Individuals with HF and AF may have a reduced functional capacity and quality of life (QoL) which leads to hospital admission and burden on clinical services. Evidence supported the effect of exercise training in individuals with HF. However, there is no existing data on the effectiveness of comprehensive cardiac rehabilitation (CR) in individuals with coexisting HF and AF.

AIM

To explore the effect of CR in individuals with HF and AF compared with those with HF and no-coexisting AF.

METHODS

Using CR database, individuals with HF and AF were identified and propensity matched to those with no coexisting AF. The change in incremental shuttle walking test, Heart Disease Quality of Life questionnaire, Hospital Anxiety and Depression Scores were compared between groups pre-CR and post-CR.

RESULTS

149 individuals were propensity matched from each group. The mean±SD age of the matched sample was 73.4±8 years, body mass index 29±5.5 kg/m2, left ventricular ejection fraction 35.2±9.8% and 56% were male.A statistically significant improvements in exercise capacity, heart disease QoL, anxiety and depression scores were observed within each group. There were no significant differences between groups for any of these outcome measures.

CONCLUSIONS

Individuals with HF and AF gain a similar improvement in exercise capacity and health related QoL outcomes as individuals with no coexisting AF following CR. The presence of AF did not compromise the effectiveness of CR.

Predicting ischemic stroke risk from atrial fibrillation based on multi-spectral fundus images using deep learning

Background

Ischemic stroke (IS) is one of the most common serious secondary diseases of atrial fibrillation (AF) within 1 year after its occurrence, both of which have manifestations of ischemia and hypoxia of the small vessels in the early phase of the condition. The fundus is a collection of capillaries, while the retina responds differently to light of different wavelengths. Predicting the risk of IS occurring secondary to AF, based on subtle differences in fundus images of different wavelengths, is yet to be explored. This study was conducted to predict the risk of IS occurring secondary to AF based on multi-spectrum fundus images using deep learning.

Methods

A total of 150 AF participants without suffering from IS within 1 year after discharge and 100 IS participants with persistent arrhythmia symptoms or a history of AF diagnosis in the last year (defined as patients who would develop IS within 1 year after AF, based on fundus pathological manifestations generally prior to symptoms of the brain) were recruited. Fundus images at 548, 605, and 810 nm wavelengths were collected. Three classical deep neural network (DNN) models (Inception V3, ResNet50, SE50) were trained. Sociodemographic and selected routine clinical data were obtained.

Results

The accuracy of all DNNs with the single-spectral or multi-spectral combination images at the three wavelengths as input reached above 78%. The IS detection performance of DNNs with 605 nm spectral images as input was relatively more stable than with the other wavelengths. The multi-spectral combination models acquired a higher area under the curve (AUC) scores than the single-spectral models.

Conclusions

The probability of IS secondary to AF could be predicted based on multi-spectrum fundus images using deep learning, and combinations of multi-spectrum images improved the performance of DNNs. Acquiring different spectral fundus images is advantageous for the early prevention of cardiovascular and cerebrovascular diseases. The method in this study is a beneficial preliminary and initiative exploration for diseases that are difficult to predict the onset time such as IS.

Validity of MENARI plus (self-pulse assessment and clinical scoring) mobile apps for detecting atrial fibrillation in high-risk population

Background

Even before it is clinically diagnosed, atrial fibrillation (AF) can cause a stroke. This study validates self-pulse assessment and clinical scoring (MENARI Plus) based on android apps.

Objective

The aim of this study was to examine the validity of AF screening using MENARI Plus compared with an ECG recording.

Methods

We collected a total of 1385 subjects from high-risk population according to CHA2DS2-VASc score ≥2, attending 8 primary care centers (PCCs) in Malang between July 2021 and December 2021. Every participant underwent self-pulse assessment, and then was evaluated for MENARI Plus Score on android Apps. These cases had been classified as low or high probability for AF (cut-off score 7). After that, electrocardiography examinations were performed and classified with AF and Sinus Rhythm group.

Results

In this study, the mean age of these patients was 61.5 ± 6.9 years old. We found that 156/1385 (11%) patients had AF. There were 68/156 (43.5%) new cases of AF. The sensitivity for self-pulse palpation was 73.1% (95% CI: 68%-76%) and specificity was 68.3% (95% CI: 65%-72%). MENARI Plus had an area under the receiver operating curve (AUC) of 0.86 (95% CI: 0.82-0.89) with sensitivity per measurement occasion was (84%, 95% CI: 82%-88%) and specificity was (87.9%, 95% CI: 82%-90%).

Conclusion

In this study, we found that MENARI Plus has high sensitivity and specificity for AF. It is therefore useful for ruling out AF. It may also be a useful screen that can be applied opportunistically for previously undetected AFs.

Cognitive Behavioral Therapy Improves Quality of Life in Patients With Symptomatic Paroxysmal Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is often associated with troubling symptoms leading to impaired quality of life (QoL) and high health care use. Symptom preoccupation, that is, fear of cardiac-related symptoms and avoidance behavior, potentially contributes to disability in AF but is not targeted by current interventions.

OBJECTIVES

We sought to evaluate the effect of online cognitive behavior therapy (AF-CBT) on QoL in patients with symptomatic paroxysmal AF.

METHODS

Patients with symptomatic paroxysmal AF (n = 127) were randomly assigned to receive AF-CBT (n = 65) or standardized AF education (n = 62). Online AF-CBT lasted 10 weeks and was therapist guided. The main components were exposure to cardiac-related symptoms and reduction of AF-related avoidance behavior. Patients were evaluated at baseline, posttreatment, and at the 3-month follow-up. Primary outcome was AF-specific QoL as assessed by the Atrial Fibrillation Effect on Quality of Life summary score (range: 0-100) at the 3-month follow-up. Secondary outcomes included AF-specific health care consumption and AF burden assessed by 5-day continuous electrocardiogram recording. The AF-CBT group was followed for 12 months.

RESULTS

AF-CBT led to large improvements in AF-specific QoL (Atrial Fibrillation Effect on Quality of Life summary score) by 15.0 points (95% CI: 10.1-19.8; P < 0.001). Furthermore, AF-CBT reduced health care consumption by 56% (95% CI: 22-90; P = 0.025). The AF burden remained unchanged. Results on self-assessed outcomes were sustained 12 months after treatment.

CONCLUSIONS

In patients with symptomatic paroxysmal AF, online CBT led to large improvements in AF-specific QoL and reduced health care use. If these results are replicated, online CBT may constitute an important addition to AF management. (Internet-Delivered Cognitive Behavior Therapy for Atrial Fibrillation; NCT03378349).

MANAGEMENT OF ATRIAL FIBRILLATION, VENTRICULAR ARRHYTHMIA, LEFT VENTRICULAR DYSFUNCTION, AND SUBSEQUENT CARDIOPATHOLOGIC EVALUATION IN AN ORANGUTAN (PONGO PYGMAEUS × ABELII)

A 37-yr-old male vasectomized hybrid orangutan (Pongo pygmaeus × abelii) was diagnosed with left ventricular dysfunction during a preventative health care examination. Treatment was initiated with carvedilol. The following year, this orangutan was evaluated for intermittent lethargy. Following observation of an irregular cardiac rhythm during an echocardiogram, a lead II electrocardiogram revealed atrial fibrillation and ventricular arrhythmia. Additional treatment included amiodarone, furosemide, spironolactone, clopidogrel, and aspirin. An improved activity level was noted, and follow-up testing showed restoration of a sinus rhythm, reduced frequency of ventricular arrhythmia, and improved left ventricular function. The orangutan died 27 mon after initial diagnosis of heart disease, and a complete necropsy was performed. This article describes successful diagnosis and management of structural and arrhythmic heart disease in an orangutan, emphasizing the role of cardiac disease screening and behavioral training in apes, as well as the value of matching thorough antemortem and postmortem cardiac evaluation.

[Tactics of anticoagulant therapy in patients with cardiac implantable electronic devices and subclinical atrial fibrillation: A review]

Screening for atrial fibrillation (AF) has attracted considerable attention recently. Of special interest are patients with cardiac implantable electronic devices (CIEDs) that allow for recording episodes of atrial arrhythmias of various durations, including asymptomatic ones, in which case they are referred to as subclinical atrial fibrillation (SCAF). The available data suggest that the risk of thromboembolic events varies between patients with SCAF and clinically overt AF. As of today, the question regarding anticoagulant therapy in patients with SCAF remains unresolved. The article presents an overview of previous and ongoing studies on this issue, as well as current guidelines on anticoagulant use in patients with SCAF and CIEDs.

Insertable cardiac monitoring devices versus external cardiac monitoring for detecting atrial fibrillation and preventing the recurrence of stroke: A systematic review and meta-analysis

BACKGROUND

Atrial Fibrillation (AF) is a major risk factor for stroke, which is the second leading cause of death worldwide. It remains uncertain whether insertable cardiac monitors (ICMs) enhance the ability to recognize AF over external cardiac monitoring in patients who have experienced a stroke.

AIM

We conducted a systematic review and meta-analysis to determine whether ICM devices are more effective than external cardiac monitoring for the detection of AF in stroke patients.

METHODS

We included studies that reported an AF detection rate in stroke patients with a follow-up of at least 12 months. We analyzed the data of 1233 patients from 3 randomized control trials (RCTs).

RESULTS

When compared to external cardiac monitoring, ICM devices (Medtronic Reveal LINQ and Reveal XT) showed a significantly higher detection rate of AF (RR = 5.04, 95% CI = 2.93-8.68; p < 0.05; ARR = 10.47%, NNT = 10). The ICM arm had significantly higher usage of oral anticoagulants (OAC) as compared to the control arm. (RR = 2.76, 95% CI = 1.89-4.02, p < 0.05). Additionally, ICM usage was associated with a higher incidence of mild to moderate adverse events (RR = 10.52, 95% CI =1.35-82.14; p = 0.02) and a higher number of severe adverse events as compared to the control arm (RR = 7.61, 95% CI = 1.36-42.51; p = 0.02).

CONCLUSION

ICM devices are associated with better detection rates of AF and higher usage of OAC as compared to external cardiac monitoring in post-stroke patients. However, ICM insertion is associated with a higher incidence of mild/moderate and severe adverse effects.

The Efficacy of Telemedicine Rehabilitation Programs In Regard Of Risk Factors Control In Patients With Paroxysmal Atrial Fibrillation Aftercatheter Ablation

Aim      To evaluate changes in traditional risk factors (RF) during cardiac rehabilitation (CR) programs with remote support in patients with paroxysmal atrial fibrillation (AF) after catheter ablation (CA).Material and methods  The lack of control of cardiovascular RFs is a predictor for AF recurrence after CA, development of complications, and decreased life expectancy. Telemedical CR programs may improve the control of RF and enhance the CR efficacy. This randomized controlled clinical study in three parallel groups included 135 patients aged 35 to 79 years. In groups 1 and 2, CR programs with remote support were performed, which included a single personal consulting for the disease, achieving control of all patient's RFs, and remote support during 3 months (group 1, by phone and group 2, by e-mail). Participants of group 3 received standard recommendations. Body weight, blood pressure (BP), blood lipids, smoking status, and physical activity (PA) were determined at baseline and at 12 months after CA with the IPAQ questionnaire.Results In both intervention groups at 12 months, there were positive changes in RF: body weight index decreased by 3.6 % in group 1 (р=0.01) and by 2.3 % in group 2 (р=0.002) vs. 0 in the control group; systolic BP decreased by 7.1 % (p&lt;0.001) and 1.5 % (p=0.003) in groups 1 and 2 (vs. increases by 3.3 % in group 2); total cholesterol decreased by 9.4 % (p&lt;0.001) and by 6.3 % (p=0.003), respectively, (vs. 0 in group 3); values of metabolic equivalents (METs) used for walking increased by 55.0 % (р=0.014), 75.0 % (р=0.001), and 1.4 % in groups 1, 2 and 3, respectively. No significant intergroup differences in the frequency of AF recurrence, repeated CA, and hospitalizations were found.Conclusion      CR programs with remote support provide improved control of BP, body weight, blood cholesterol, and AF in patients with AF after CA, according to the results of the one-year follow-up.

Multidisciplinary Integrated Care in Atrial Fibrillation (MICAF): A Systematic Review and Meta-Analysis

Objective: To assess the effectiveness of multidisciplinary integrated care in the clinical outcomes of atrial fibrillation patients.Methods: Medline, EMBASE, and the CENTRAL trials registry of the Cochrane Collaboration were searched for articles on multidisciplinary integrated care in atrial fibrillation patients. The systematic review and meta-analysis included six and five articles, respectively, that compared the outcomes between the integrated care group and control group.Results: Multidisciplinary integrated care was concomitant with a decrease in all-cause mortality (OR 0.52, 95%CI 0.36-0.74, P=0.0003) and cardiovascular hospitalization (OR 0.66, 95%CI 0.49-0.89, P=0.007). Multidisciplinary integrated care had no significant impact on major adverse cardiovascular event (MACE) (OR 0.76, 95%CI 0.37-1.53, P=0.44), cardiovascular deaths (OR 0.49, 95% CI 0.21-1.17, P=0.11), atrial fibrillation (AF)-related hospitalization (OR 0.76, 95%CI 0.53-1.09, P=0.14), major bleeding (OR 1.02, 95%CI 0.59-1.75, P=0.94), minor bleeding (OR 1.12, 95%CI 0.55-2.26, P=0.76), and cerebrovascular events (OR 0.72, 95%CI 0.45-1.18, P=0.19).Conclusion: In comparison to usual care, a multidisciplinary integrated care approach (i.e., nurse-led care along with usual specialist care) in AF patients is associated with reduced all-cause mortality and cardiovascular hospitalization.

The Virtual Inclusive Digital Health Intervention Design to Promote Health Equity (iDesign) Framework for Atrial Fibrillation: Co-design and Development Study

Background

Smartphone ownership and mobile app use are steadily increasing in individuals of diverse racial and ethnic backgrounds living in the United States. Growing adoption of technology creates a perfect opportunity for digital health interventions to increase access to health care. To successfully implement digital health interventions and engage users, intervention development should be guided by user input, which is best achieved by the process of co-design. Digital health interventions co-designed with the active engagement of users have the potential to increase the uptake of guideline recommendations, which can reduce morbidity and mortality and advance health equity.

Objective

We aimed to co-design a digital health intervention for patients with atrial fibrillation, the most common cardiac arrhythmia, with patient, caregiver, and clinician feedback and to describe our approach to human-centered design for building digital health interventions.

Methods

We conducted virtual meetings with patients with atrial fibrillation (n=8), their caregivers, and clinicians (n=8). We used the following 7 steps in our co-design process: step 1, a virtual meeting focused on defining challenges and empathizing with problems that are faced in daily life by individuals with atrial fibrillation and clinicians; step 2, a virtual meeting focused on ideation and brainstorming the top challenges identified during the first meeting; step 3, individualized onboarding of patients with an existing minimally viable version of the atrial fibrillation app; step 4, virtual prototyping of the top 3 ideas generated during ideation; step 5, further ranking by the study investigators and engineers of the ideas that were generated during ideation but were not chosen as top-3 solutions to be prototyped in step 4; step 6, ongoing engineering work to incorporate top-priority features in the app; and step 7, obtaining further feedback from patients and testing the atrial fibrillation digital health intervention in a pilot clinical study.

Results

The top challenges identified by patients and caregivers included addressing risk factor modification, medication adherence, and guidance during atrial fibrillation episodes. Challenges identified by clinicians were complementary and included patient education, addressing modifiable atrial fibrillation risk factors, and remote atrial fibrillation episode management. Patients brainstormed more than 30 ideas to address the top challenges, and the clinicians generated more than 20 ideas. Ranking of the ideas informed several novel or modified features aligned with the Theory of Health Behavior Change, features that were geared toward risk factor modification; patient education; rhythm, symptom, and trigger correlation for remote atrial fibrillation management; and social support.

Conclusions

We co-designed an atrial fibrillation digital health intervention in partnership with patients, caregivers, and clinicians by virtually engaging in collaborative creation through the design process. We summarize our experience and describe a flexible approach to human-centered design for digital health intervention development that can guide innovative clinical investigators.