Atrial fibrillation in cancer patients who develop stroke

Background

Acute ischemic stroke (Stroke) and transient ischemic attacks (TIA) are known complications in cancer patients and those with atrial fibrillation (AF). The role AF plays in Stroke/TIA in the setting of cancer is unclear. The purpose of this study was to assess the relationship between AF and Stroke/TIA in cancer patients.

Methods

We conducted a case-control study comparing all patients who developed Stroke/TIA from 2014 to 2019 following a cancer diagnosis at King Hussein Cancer Center (KHCC), matched to Stroke/TIA-free controls based on age, gender, and cancer site.

Results

Two hundred seventy-two patients were included (136 per group). The mean age was 63.95 ± 13.06 and 57% were females. The Stroke/TIA group had more AF at the time of event (14% vs. 4%, OR: 4.25, 95%-CI: 1.39 - 17.36) and had a larger proportion of death on study conclusion (OR: 9.4, 95%-CI: 3.74 - 23.64). On conditional logistic regression, patients in the Stroke/TIA group had higher odds of: AF (OR: 7.93, 95%-CI: 1.6 – 39.18), ischemic stroke before cancer diagnosis (OR: 9.18, 95%-CI: 2.66 – 31.74), being on active cancer treatment (OR: 3.11, 95%-CI: 1.46 – 6.62), dyslipidemia (OR: 3.78, 95%-CI: 1.32 – 10.82), and renal disease (OR: 4.25, 95%-CI: 1.55 – 11.63). On another conditional logistic regression model built to assess the role of the CHA2DS2-VASc score, a score of >=2 in males and >=3 in females significantly increased the risk of developing Stroke/TIA in cancer patients (OR: 2.45, 95%-CI: 1.08 - 5.58).

Conclusion

AF, previous ischemic stroke, active cancer treatment, dyslipidemia, and renal disease are independent risk factors for Stroke/TIA and a higher CHA2DS2-VASc score significantly increases the risk in cancer patients regardless of AF.

Clinical factors predicting asymptomatic atrial fibrillation in Middle Eastern patients

Introduction

Anticoagulation has been shown to be highly effective in stroke prevention in patients who have atrial fibrillation (AF). Many patients with AF do not have symptoms and may not seek medical attention. In this study we evaluated the clinical profiles of asymptomatic AF (AAF) patients and compared them to symptomatic ones to find what factors are associated with absence of symptoms.

Methods

We analyzed data of 2000 patients enrolled in the prospective multicenter Jordan AF study from May 2019 to October 2020. Symptoms included palpitations (43%), shortness of breath (34%), fatigue (21%), dizziness (11%), chest pain (2%) or syncope (2%) versus no symptoms (30%, n=591).

Findings

The average age of the whole group was 67.7±10.2 years and 47% were males. Clinical factors investigated in relation to absence of symptoms are presented in the attached table

Conclusion

AAF is associated with the following clinical features: male gender, age above 59 years, diabetes mellitus (DM), cerebrovascular accident (CVA), and chronic renal failure (CRF), CHA2DS2VASC score of 3 and above and HASBLED score of 3 and above, while first episode and paroxysmal AF (PAF) were more likely to be symptomatic. Individuals with these features should be closely evaluated for AAF by means such as pulse monitoring, smart devices and electrocardiogram.

Funding Acknowledgement

Type of funding sources: None.

Clinical profiles of atrial fibrillation patients with or without malignancy: analysis from the Jordan Atrial Fibrillation study

Introduction

Atrial Fibrillation (AF) is the most prevalent arrhythmia and is associated with high morbidity and mortality. Malignancy can predispose to AF directly or through adverse effects of certain chemotherapeutic agents. Moreover, AF in the presence of malignancy is a special subgroup with high risk of both thromboembolism and bleeding.

Purpose

To study the clinical characteristics of AF in patients with malignancy compared to those without malignancy in a Middle Eastern population.

Methods

A total of 2015 Consecutive adult patients with previously or newly diagnosed AF in 19 hospitals and 30 out-patient cardiology clinics were enrolled in the Jordan AF study from May 2019 to October 2020. Clinical and epidemiological characteristics of patients with coexisting malignancy were compared to those without malignancy.

Results

Of the 2015 patients enrolled in the study, 136 (6.7%) had a coexisting malignancy; with breast cancer being the most common type of cancer (19.8%). Patients with malignancy were older than patients without malignancy (71±10 vs 67.5±13.3 years, p=0.005) with no gender difference between the two groups.

Patients with malignancy were less symptomatic compared to those without malignancy; fatigue (6.6% vs. 21.9%, p=0.ehab724.28492), dizziness (2.9% vs. 11.8%, p=0.0006) and shortness of breath (8.1% vs. 35.2%, p<0.0001). Patients with AF and malignancy were more likely to have permanent AF at presentation compared to patients without malignancy (42.6% vs. 29.4%, P=0.0005).

While mean CHA2DS2-VASc in patients with malignancy was similar to those without malignancy (3.8±2.0 vs 3.5±2.0 p=0.269), the malignancy group had a higher proportion of patients with CHA2DS2-VASc score >2.0 compared to those without malignancy (91.9% vs. 84.8%, p=0.023). On the contrary, patients without malignancy had higher proportions with HAS-BLED score >3 compared to patients with malignancy (19.6% vs. 11.0%, p=0.014).

Left ventricular hypertrophy (LVH) and pulmonary hypertension (PAH) were diagnosed more frequently on echocardiography in patients with compared to those without malignancy (55.9% vs. 34.2%, p<0.0001) and (43.4 vs. 26.2%, p<0.ehab724.28498) respectively.

While patients with malignancy had a lower rate of direct oral anticoagulants (DOACs) utilization compared to patients without malignancy (34.6% vs. 48.1%, p=0.002), they had a higher rate of Low molecular weight heparin (LMWH) utilization (16.2% vs. 1.3%, p<0.0001). There was no difference in the utilization of vitamin K antagonist between the two groups (29.4% vs. 31.8%. p=0.568).

Conclusion

Middle Eastern patients who have AF and coexisting malignancy were older, had less symptoms at presentation, and higher prevalence of permanent AF than patients without malignancy. These patients were more likely to be prescribed LMWH and less likely to receive DOACs compared to those without malignancy. Prospective long-term follow-up and outcomes is underway.

Funding Acknowledgement

Type of funding sources: None.

Comparative safety of periablation anticoagulation strategies for atrial fibrillation: data from a large multicenter study

BACKGROUND

There are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior.

OBJECTIVE

To compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers.

METHODS AND RESULTS

In this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications.

CONCLUSIONS

When comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

QTc compared to JTc for monitoring drug-induced repolarization changes in the setting of ventricular pacing

BACKGROUND

QT prolongation is a risk factor for proarrhythmia when beginning antiarrhythmic drug therapy (AAD). However, there are no data regarding monitoring repolarization changes during a ventricular paced (VP) rhythm.

OBJECTIVE

The purpose of this study was to compare serial changes in corrected QT and JT intervals, during native conduction (NC) and VP rhythms when initiating Class III AADs.

METHODS

Twenty-two patients (73% men; mean age 65 ± 11 years) with an implantable device and with <10% VP were monitored during AAD initiation (16 sotalol, 6 dofetilide). QTc and JTc were measured from ECGs obtained during NC and VP at baseline (pre-AAD) and then after each AAD dose.

RESULTS

During AAD loading, mean QTc increased significantly during NC (431 ± 28 ms to 463 ± 33 ms, P = .002) but not with VP (520 ± 48 ms to 538 ± 45 ms, P = .07). Mean percent increase in peak QTc during NC was significantly greater than during VP (12% vs 7%, P = .003). In contrast, peak JTc during AAD loading was not significantly different between NC and VP (P = .67).

CONCLUSION

When initiating AAD, the change in QTc during VP does not correlate with the change in QTc during NC; thus, the VP QTc is inadequate for monitoring repolarization changes. However, VP JTc correlates well with JTc during NC. When initiating Class III AADs in patients with VP rhythms, the JTc, and not the QTc, interval is the useful marker for assessing repolarization.