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Fabritz L, Chua W, Cardoso VR, Al-Taie C, Borof K, Suling A, Krause L, Kany S, Magnussen C, Wegscheider K, Breithardt G, Crijns HJGM, Camm AJ, Gkoutos G, Ellinor PT, Goette A, Schotten U, Wienhues-Thelen UH, Zeller T, Schnabel RB, Zapf A, Kirchhof P. Blood-based cardiometabolic phenotypes in atrial fibrillation and their associated risk: EAST-AFNET 4 biomolecule study. Cardiovasc Res 2024:cvae067. [PMID: 38613511 DOI: 10.1093/cvr/cvae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Atrial fibrillation (AF) and concomitant cardiometabolic disease processes interact and combine to lead to adverse events such as stroke, heart failure, myocardial infarction, and cardiovascular death. Circulating biomolecules provide quantifiable proxies for cardiometabolic disease processes. Their role in defining subphenotypes of AF is not known. METHODS AND RESULTS This prespecified analysis of the EAST-AFNET4 biomolecule study assigned patients to clusters using polytomous variable latent class analysis (poLCA) based on baseline concentrations of thirteen precisely-quantified biomolecules potentially reflecting ageing, cardiac fibrosis, metabolic dysfunction, oxidative stress, cardiac load, endothelial dysfunction, and inflammation. In each cluster, rates of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome, the primary outcome of EAST-AFNET 4, were calculated and compared between clusters over median 5.1 years follow-up. Findings were independently validated in a prospective cohort of 748 patients with AF (BBC-AF; median follow up 2.9 years).Unsupervised biomolecule analysis assigned 1586 patients (71 years old, 46% women) into four clusters. The highest-risk cluster was dominated by elevated BMP10, IGFBP7, NT-proBNP, ANGPT2 and GDF15. Patients in the lowest-risk cluster showed low concentrations of these biomolecules. Two intermediate-risk clusters differed by high or low concentrations of hsCRP, IL-6, and D-dimer. Patients in the highest-risk cluster had a 5-fold higher cardiovascular event rate than patients in the low-risk cluster. Early rhythm control was effective across clusters (pinteraction = 0.63). Sensitivity analyses and external validation in BBC-AF replicated clusters and risk gradients. CONCLUSIONS Biomolecule concentrations identify cardiometabolic subphenotypes in patients with atrial fibrillation at high and low cardiovascular risk.
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Affiliation(s)
- Larissa Fabritz
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
- AFNET, Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Victor R Cardoso
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Christoph Al-Taie
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Katrin Borof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Shino Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Christina Magnussen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
- Center for Population Health Innovation (POINT), University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl Wegscheider
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | | | - Harry J G M Crijns
- Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands
| | - A John Camm
- Clinical Sciences, St George´s University, London, UK
| | - George Gkoutos
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ulrich Schotten
- AFNET, Münster, Germany
- Department of Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- AFNET, Münster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom
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Lip GYH, Nikorowitsch J, Sehner S, Becher N, Bertaglia E, Blomstrom-Lundqvist C, Brandes A, Beuger V, Calvert M, Camm AJ, Chlouverakis G, Dan GA, Dichtl W, Diener HC, Fierenz A, Goette A, de Groot JR, Hermans A, Lubinski A, Marijon E, Merkely B, Mont L, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Schnabel RB, Schotten U, Simantirakis E, Toennis T, Vardas P, Wichterle D, Zapf A, Kirchhof P. Oral anticoagulation in device-detected atrial fibrillation: effects of age, sex, cardiovascular comorbidities, and kidney function on outcomes in the NOAH-AFNET 6 trial. Eur Heart J 2024:ehae225. [PMID: 38591192 DOI: 10.1093/eurheartj/ehae225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024] Open
Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Julius Nikorowitsch
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Susanne Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | | | - Carina Blomstrom-Lundqvist
- Department of Medical Science, Uppsala University, Uppsala, Sweden
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Axel Brandes
- Department of Cardiology, Department of Regional Health Research, Esbjerg Hospital-University Hospital of Southern Denmark, University of Southern Denmark, Esbjerg, Denmark
| | | | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre and NIHR Applied Research Collaboration West Midlands, University of Birmingham, Edgbaston, Birmingham, UK
| | - A John Camm
- Cardiovascular and Genetics Research Institute, St George's, University of London, London, UK
| | | | - Gheorghe-Andrei Dan
- Medicine University 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck, Austria
| | - Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Alexander Fierenz
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
- Otto-von-Guericke Universität Magdeburg, Magdeburg, Germany
| | - Joris R de Groot
- The Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid Hermans
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | - Andrzej Lubinski
- Department of Cardiology and Internal Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Eloi Marijon
- Cardiology Division, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Lluís Mont
- Department of Cardiology, Hospital Clinic, Universtitat de Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigacion Biomedica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Kim Rajappan
- Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Austria
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | | | - Tobias Toennis
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - Panos Vardas
- Department of Cardiology, Heraklion University Hospital, Heraklion, Crete, Greece
- Biomedical Research Foundation Academy of Athens (BRFAA), Greece and Hygeia Hospitals Group, Athens, Greece
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
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Winters J, Kawczynski MJ, Gilbers MD, Isaacs A, Zeemering S, Bidar E, Maesen B, Rienstra M, van Gelder I, Verheule S, Maessen JG, Schotten U. Circulating BMP10 Levels Associate With Late Postoperative Atrial Fibrillation and Left Atrial Endomysial Fibrosis. JACC Clin Electrophysiol 2024:S2405-500X(24)00184-1. [PMID: 38639699 DOI: 10.1016/j.jacep.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Serum bone morphogenetic protein 10 (BMP10) blood levels are a marker for history of atrial fibrillation (AF) and for major adverse cardiovascular events in patients with AF, including stroke, AF recurrences after catheter ablations, and mortality. The predictive value of BMP10 in patients undergoing cardiac surgery and association with morphologic properties of atrial tissues are unknown. OBJECTIVES This study sought to study the correlation between BMP10 levels and preoperative clinical traits, occurrence of early and late postoperative atrial fibrillation (POAF), and atrial fibrosis in patients undergoing cardiac surgery. METHODS Patients with and without preoperative AF history undergoing first cardiac surgery were included (RACE V, n = 147). Preoperative blood biomarkers were analyzed, left (n = 114) and right (n = 125) atrial appendage biopsy specimens were histologically investigated after WGA staining, and postoperative rhythm was monitored continuously with implantable loop recorders (n = 133, 2.5 years). RESULTS Adjusted multinomial logistic regression indicated that BMP10 accurately reflected a history of persistent AF (OR: 1.24, 95% CI: 1.10-1.40, P = 0.001), similar to NT-pro-BNP. BMP10 levels were associated with increased late POAF90 occurrence after adjustment for age, sex, AF history, and early POAF occurrence (HR: 1.07 [per 0.1 ng/mL increase], 95% CI: 1.00-1.14, P = 0.041). Left atrial endomysial fibrosis (standardized β = 0.22, P = 0.041) but not overall fibrosis (standardized Β = 0.12, P = 0.261) correlated with circulating BMP10 after adjustment for age, sex, AF history, reduced LVF, and valvular surgery indication. CONCLUSIONS Increased BMP10 levels were associated with persistent AF history, increased late POAF incidence, and LAA endomysial fibrosis in a diverse sample of patients undergoing cardiac surgery.
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Affiliation(s)
- Joris Winters
- Department of Physiology, Maastricht University, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Michal J Kawczynski
- Department of Physiology, Maastricht University, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martijn D Gilbers
- Department of Physiology, Maastricht University, Maastricht, the Netherlands
| | - Aaron Isaacs
- Department of Physiology, Maastricht University, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Maastricht Centre for Systems Biology, University Maastricht, Maastricht, the Netherlands
| | - Stef Zeemering
- Department of Physiology, Maastricht University, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Elham Bidar
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bart Maesen
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, the Netherlands
| | - Isabelle van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, the Netherlands
| | - Sander Verheule
- Department of Physiology, Maastricht University, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Jos G Maessen
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Department of Cardiothoracic Surgery, Heart and Vascular Centre Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
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4
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Farnir F, Chaldoupi SM, Farnir F, Schotten U, Vernooy K, Luermans J, Linz D. Focal point-by-point biphasic monopolar pulsed field ablation for posterior wall isolation. Europace 2024; 26:euae077. [PMID: 38517287 PMCID: PMC11017520 DOI: 10.1093/europace/euae077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/19/2024] [Indexed: 03/23/2024] Open
Affiliation(s)
- Florent Farnir
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Frédéric Farnir
- Department of Biostatistics and Bioinformatics, FARAH, Faculty of Veterinary Medicine, University of Liege, Liege, Belgium
| | - Ulrich Schotten
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Justin Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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5
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Linz D, Andrade JG, Arbelo E, Boriani G, Breithardt G, Camm AJ, Caso V, Nielsen JC, De Melis M, De Potter T, Dichtl W, Diederichsen SZ, Dobrev D, Doll N, Duncker D, Dworatzek E, Eckardt L, Eisert C, Fabritz L, Farkowski M, Filgueiras-Rama D, Goette A, Guasch E, Hack G, Hatem S, Haeusler KG, Healey JS, Heidbuechel H, Hijazi Z, Hofmeister LH, Hove-Madsen L, Huebner T, Kääb S, Kotecha D, Malaczynska-Rajpold K, Merino JL, Metzner A, Mont L, Ng GA, Oeff M, Parwani AS, Puererfellner H, Ravens U, Rienstra M, Sanders P, Scherr D, Schnabel R, Schotten U, Sohns C, Steinbeck G, Steven D, Toennis T, Tzeis S, van Gelder IC, van Leerdam RH, Vernooy K, Wadhwa M, Wakili R, Willems S, Witt H, Zeemering S, Kirchhof P. Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference. Europace 2024; 26:euae070. [PMID: 38591838 PMCID: PMC11003300 DOI: 10.1093/europace/euae070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
AIMS Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). METHODS AND RESULTS Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. CONCLUSIONS Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.
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Affiliation(s)
- Dominik Linz
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jason G Andrade
- Division of Cardiology, Vancouver General Hospital, Vancouver, Canada
- Montreal Heart Institute, Montreal, Canada
| | - Elena Arbelo
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Guenter Breithardt
- Department of Cardiovascular Medicine, University Hospital, Münster, Germany
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | | | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Dobromir Dobrev
- Institute of Pharmacology, Faculty of Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicolas Doll
- Department of Cardiac Surgery, Schüchtermann-Klinik, Bad Rothenfelde, Germany
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Lars Eckardt
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology II—Electrophysiology, University Hospital Münster, Münster, Germany
| | | | - Larissa Fabritz
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- University Center of Cardiovascular Science, UHZ, UKE, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Michal Farkowski
- Department of Cardiology, Ministry of Interior and Administration, National Medical Institute, Warsaw, Poland
| | - David Filgueiras-Rama
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Novel Arrhythmogenic Mechanisms Program, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, C/ Profesor Martín Lagos, Madrid, Spain
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
| | - Eduard Guasch
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Clinic Barcelona, University of Barcelona, Barcelona, Spain
| | - Guido Hack
- Bristol-Myers Squibb GmbH & Co. KGaA, Munich, Germany
| | | | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Jeff S Healey
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Hein Heidbuechel
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
| | - Ziad Hijazi
- Antwerp University Hospital, Cardiovascular Sciences, University of Antwerp, Antwerp, Belgium
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Leif Hove-Madsen
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Biomedical Research Institute Barcelona (IIBB-CSIC), Barcelona, Spain
- IR Sant Pau, Hospital de Sant Pau, Barcelona, Spain
| | | | - Stefan Kääb
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart—ERN GUARD-Heart
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich, Munich Heart Alliance, Munich, Germany
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Katarzyna Malaczynska-Rajpold
- Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, UK
- Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - José Luis Merino
- La Paz University Hospital, IdiPaz, Autonomous University of Madrid, Madrid, Spain
| | - Andreas Metzner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Lluís Mont
- Institut Clínic Cardiovascular, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institut d’Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ghulam Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Michael Oeff
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Cardiology Department, Medizinische Hochschule Brandenburg, Brandenburg/Havel, Germany
| | - Abdul Shokor Parwani
- Department of Cardiology, Deutsches Herzzentrum der Charité (CVK), Berlin, Germany
| | | | - Ursula Ravens
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Experimental Cardiovascular Medicine, University Clinic Freiburg, Freiburg, Germany
| | - Michiel Rienstra
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Daniel Scherr
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Renate Schnabel
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Christian Sohns
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Klinik für Elektrophysiologie—Rhythmologie, Bad Oeynhausen, Germany
| | - Gerhard Steinbeck
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Daniel Steven
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Heart Center, Department of Electrophysiology, University Hospital Cologne, Cologne, Germany
| | - Tobias Toennis
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
| | | | - Isabelle C van Gelder
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Manish Wadhwa
- Medical Office, Philips Ambulatory Monitoring and Diagnostics, San Diego, CA, USA
| | - Reza Wakili
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Department of Medicine and Cardiology, Goethe University, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Stephan Willems
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Asklepios Hospital St. Georg, Department of Cardiology and Internal Care Medicine, Faculty of Medicine, Semmelweis University Campus, Hamburg, Germany
| | | | - Stef Zeemering
- Departments of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
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6
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Becher N, Toennis T, Bertaglia E, Blomström-Lundqvist C, Brandes A, Cabanelas N, Calvert M, Camm AJ, Chlouverakis G, Dan GA, Dichtl W, Diener HC, Fierenz A, Goette A, de Groot JR, Hermans ANL, Lip GYH, Lubinski A, Marijon E, Merkely B, Mont L, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Schnabel RB, Schotten U, Sehner S, Simantirakis E, Vardas P, Velchev V, Wichterle D, Zapf A, Kirchhof P. Anticoagulation with edoxaban in patients with long atrial high-rate episodes ≥24 h. Eur Heart J 2024; 45:837-849. [PMID: 37956458 PMCID: PMC10919916 DOI: 10.1093/eurheartj/ehad771] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND AIMS Patients with long atrial high-rate episodes (AHREs) ≥24 h and stroke risk factors are often treated with anticoagulation for stroke prevention. Anticoagulation has never been compared with no anticoagulation in these patients. METHODS This secondary pre-specified analysis of the Non-vitamin K antagonist Oral anticoagulants in patients with Atrial High-rate episodes (NOAH-AFNET 6) trial examined interactions between AHRE duration at baseline and anticoagulation with edoxaban compared with placebo in patients with AHRE and stroke risk factors. The primary efficacy outcome was a composite of stroke, systemic embolism, or cardiovascular death. The safety outcome was a composite of major bleeding and death. Key secondary outcomes were components of these outcomes and electrocardiogram (ECG)-diagnosed atrial fibrillation. RESULTS Median follow-up of 2389 patients with core lab-verified AHRE was 1.8 years. AHRE ≥24 h were present at baseline in 259/2389 patients (11%, 78 ± 7 years old, 28% women, CHA2DS2-VASc 4). Clinical characteristics were not different from patients with shorter AHRE. The primary outcome occurred in 9/132 patients with AHRE ≥24 h (4.3%/patient-year, 2 strokes) treated with anticoagulation and in 14/127 patients treated with placebo (6.9%/patient-year, 2 strokes). Atrial high-rate episode duration did not interact with the efficacy (P-interaction = .65) or safety (P-interaction = .98) of anticoagulation. Analyses including AHRE as a continuous parameter confirmed this. Patients with AHRE ≥24 h developed more ECG-diagnosed atrial fibrillation (17.0%/patient-year) than patients with shorter AHRE (8.2%/patient-year; P < .001). CONCLUSIONS This hypothesis-generating analysis does not find an interaction between AHRE duration and anticoagulation therapy in patients with device-detected AHRE and stroke risk factors. Further research is needed to identify patients with long AHRE at high stroke risk.
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Affiliation(s)
- Nina Becher
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Tobias Toennis
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Emanuele Bertaglia
- Department of Cardiac, Vascular, Thoracic and Public Health Sciences, Azienda Ospedaliera, Padua, Italy
| | - Carina Blomström-Lundqvist
- Department of Medical Science, Uppsala University, Uppsala, Sweden
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Axel Brandes
- Department of Cardiology, Esbjerg Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Nuno Cabanelas
- Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre and NIHR Applied Research Collaboration West Midlands, University of Birmingham, Edgbaston, Birmingham, UK
| | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, St George’s, University of London, and Imperial College, London, UK
| | | | - Gheorghe-Andrei Dan
- Medicine University ‘Carol Davila’, Colentina University Hospital, Bucharest, Romania
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck, Austria
| | - Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University Duisburg-Essen, Essen, Germany
| | - Alexander Fierenz
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine, St Vincenz-Hospital Paderborn, Paderborn, Germany
- Atrial Fibrillation NETwork (AFNET), Mendelstrasse 11, 48149 Muenster, Germany
| | - Joris R de Groot
- Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Astrid N L Hermans
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Andrzej Lubinski
- Department of Cardiology and Internal Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Eloi Marijon
- Cardiology Division, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Lluís Mont
- Hospital Clinic, Universtitat de Barcelona, Catalonia, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Catalonia, Barcelona, Spain
- Centro de Investigacion Biomedica en Red Cardiovascular (CIBERCV), Madrid, Spain
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Kim Rajappan
- Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrea Sarkozy
- HRMC, University Hospital Brussels, VUB, Brussels, Belgium
| | - Daniel Scherr
- Department of Cardiology, University Hospital Graz, Graz, Austria
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Mendelstrasse 11, 48149 Muenster, Germany
- Departments of Cardiology and Physiology, Maastricht University, Maastricht, The Netherlands
| | - Susanne Sehner
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Panos Vardas
- Department of Cardiology, Heraklion University Hospital, Crete, Greece
- Biomedical Research Foundation Academy of Athens (BRFAA), Greece and Hygeia Hospitals Group, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St.Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, Hamburg 20246, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Postdamer Str. 58, 10785 Berlin, Germany
- Atrial Fibrillation NETwork (AFNET), Mendelstrasse 11, 48149 Muenster, Germany
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7
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Chua W, Khashaba A, Canagarajah H, Nielsen JC, di Biase L, Haeusler KG, Hindricks G, Mont L, Piccini J, Schnabel RB, Schotten U, Wienhues-Thelen UH, Zeller T, Fabritz L, Kirchhof P. Disturbed atrial metabolism, shear stress, and cardiac load contribute to atrial fibrillation after ablation: AXAFA biomolecule study. Europace 2024; 26:euae028. [PMID: 38266130 PMCID: PMC10873713 DOI: 10.1093/europace/euae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/21/2023] [Indexed: 01/26/2024] Open
Abstract
AIMS Different disease processes can combine to cause atrial fibrillation (AF). Their contribution to recurrent AF after ablation in patients is not known. Cardiovascular processes associated with recurrent AF after AF ablation were determined by quantifying biomolecules related to inflammation, metabolism, proliferation, fibrosis, shear stress, atrial pressure, and others in the AXAFA biomolecule study. METHODS AND RESULTS Twelve circulating cardiovascular biomolecules (ANGPT2, BMP10, CA125, hsCRP, ESM1, FABP3, FGF23, GDF15, IGFBP7, IL6, NT-proBNP, and hsTnT) were quantified in plasma samples obtained prior to a first AF ablation using high-throughput, high-precision assays. Cox regression was used to identify biomolecules associated with recurrent AF during the first 3 months after AF ablation. In 433 patients (64 years [58, 70]; 33% women), baseline concentrations of ANGPT2, BMP10, hsCRP, FGF23, FABP3, GDF15, and NT-proBNP were elevated in patients with recurrent AF (120/433; 28%). After adjustment for 11 clinical features and randomized treatment, elevated NT-proBNP [hazard ratio (HR) 1.58, 95% confidence interval (1.29, 1.94)], ANGPT2 [HR 1.37, (1.12, 1.67)], and BMP10 [HR 1.24 (1.02, 1.51)] remained associated with recurrent AF. Concentrations of ANGPT2, BMP10, and NT-proBNP decreased in patients who remained arrhythmia free, but not in patients with recurrent AF, highlighting their connection to AF. The other eight biomarkers showed unchanged concentrations. CONCLUSION Elevated concentrations of ANGPT2, BMP10, and NT-proBNP are associated with recurrent AF after a first AF ablation, suggesting that processes linked to disturbed cardiomyocyte metabolism, altered atrial shear stress, and increased load contribute to AF after AF ablation in patients.
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Affiliation(s)
- Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
| | - Alya Khashaba
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
| | - Hansel Canagarajah
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
| | | | - Luigi di Biase
- Albert Einstein College of Medicine, Montefiore Hospital, New York, New York, USA
- Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Houston, TX, USA
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET), Münster, DE
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Gerhard Hindricks
- Department of Cardiology, German Heart Center Charite, Campus Charite Mitte, Berlin, Germany
| | - Lluis Mont
- Hospital Clinic Barcelona, University of Barcelona, Barcelona, ES
| | - Jonathan Piccini
- Duke Clinical Research Institute (DCRI), Durham, NC, USA
- Division of Cardiology, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Renate B Schnabel
- Atrial Fibrillation NETwork (AFNET), Münster, DE
- German Centre for Cardiovascular Research (DZHK), partner site: Hamburg/Kiel/Lübeck, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Building O70, Martinistrasse 52, 20246 Hamburg, Germany
| | - Ulrich Schotten
- Atrial Fibrillation NETwork (AFNET), Münster, DE
- Department of Physiology, University Maastricht, Maastricht, NL
| | | | - Tanja Zeller
- German Centre for Cardiovascular Research (DZHK), partner site: Hamburg/Kiel/Lübeck, Germany
- University Center of Cardiovascular Sciences, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
- Atrial Fibrillation NETwork (AFNET), Münster, DE
- German Centre for Cardiovascular Research (DZHK), partner site: Hamburg/Kiel/Lübeck, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Building O70, Martinistrasse 52, 20246 Hamburg, Germany
- University Center of Cardiovascular Sciences, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Wolfson Drive, Birmingham, UK
- Atrial Fibrillation NETwork (AFNET), Münster, DE
- German Centre for Cardiovascular Research (DZHK), partner site: Hamburg/Kiel/Lübeck, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Building O70, Martinistrasse 52, 20246 Hamburg, Germany
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8
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Mulder BA, Khalilian Ekrami N, Van De Lande ME, Nguyen BO, Weberndorfer V, Crijns HJ, Geelhoed B, Blaauw Y, Hemels ME, Tieleman RG, Scheerder CO, De Melis M, Schotten U, Linz D, Van Gelder IC, Rienstra M. Women have less progression of paroxysmal atrial fibrillation: data from the RACE V study. Open Heart 2023; 10:e002534. [PMID: 38135341 DOI: 10.1136/openhrt-2023-002534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Sex differences in atrial fibrillation (AF) are observed in terms of comorbidities, symptoms, therapies received, AF progression and cardiovascular complications. METHODS We assessed the differences in prevalence and the determinants of AF progression, as well as the clinical characteristics and quality of life (QoL), between women and men with paroxysmal AF included in the RACE V (Reappraisal of Atrial Fibrillation: Interaction between hyperCoagulability, Electrical remodeling, and Vascular Destabilisation in the Progression of AF) study. At baseline, extensive phenotyping was done. To assess AF progression, implantable loop recorder (ILR) monitoring was used throughout follow-up. AF progression was defined as (1) progression to persistent or permanent AF or (2) progression of paroxysmal AF (>3% burden increase). RESULTS 417 patients were included, 179 (43%) of whom were women. Women were older (median 67 years vs 63 years, p<0.001), less often had coronary artery disease (n=11 (6%) vs n=36 (16%), p=0.003), had more obesity (n=57 (32%) vs n=50 (21%), p=0.013), had less epicardial and pericardial fat (median 144 (interquartile range [IQR] 94-191) mL vs 199 (IQR 146-248) mL, p<0.001; and median 89 (ICQ 61-121) mL vs 105 (IQR 83-133) mL, p<0.001, respectively) and had more impaired left atrial function. The median follow-up was 2.2 (1.6-2.8) years. 51 of 417 patients (5.5% per year) showed AF progression (15/179 (8.4%) women and 36/238 (15.1%) men, p=0.032). Multivariable analysis showed tissue factor pathway inhibitor, N-terminal prohormone brain natriuretic peptide (NT-proBNP) and PR interval being associated with AF progression in women and factor XIIa:C1 esterase, NT-proBNP and proprotein convertase subtilisin/kexin type 9 in men. QoL was not different between sexes. CONCLUSION Despite older age, the incidence of AF progression was lower in women. Parameters associated with AF progression varied in part between sexes, suggesting different underlying pathophysiological mechanisms.
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Affiliation(s)
- Bart A Mulder
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Neda Khalilian Ekrami
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Martijn E Van De Lande
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Bao-Oanh Nguyen
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Harry J Crijns
- Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yuri Blaauw
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin Ew Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud Universiteit Nijmegen, Nijmegen, The Netherlands
| | | | | | - Mirko De Melis
- Medtronic Bakken Research Center BV, Maastricht, The Netherlands
| | - Ulrich Schotten
- Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Physiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Dominik Linz
- Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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9
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Haeusler KG, Eichner FA, Heuschmann PU, Fiebach JB, Engelhorn T, Callans D, De Potter T, Debruyne P, Scherr D, Hindricks G, Al-Khalidi HR, Mont L, Kim WY, Piccini JP, Schotten U, Themistoclakis S, Di Biase L, Kirchhof P. Detection of brain lesions after catheter ablation depends on imaging criteria: insights from AXAFA-AFNET 5 trial. Europace 2023; 25:euad323. [PMID: 37897713 PMCID: PMC10963060 DOI: 10.1093/europace/euad323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/30/2023] [Accepted: 10/05/2023] [Indexed: 10/30/2023] Open
Abstract
AIMS Left atrial catheter ablation is well established in patients with symptomatic atrial fibrillation (AF) but associated with risk of embolism to the brain. The present analysis aims to assess the impact of diffusion-weighted imaging (DWI) slice thickness on the rate of magnetic resonance imaging (MRI)-detected ischaemic brain lesions after ablation. METHODS AND RESULTS AXAFA-AFNET 5 trial (NCT02227550) participants underwent MRI using high-resolution (hr) DWI (slice thickness: 2.5-3 mm) and standard DWI (slice thickness: 5-6 mm) within 3-48 h after ablation. In 321 patients with analysable brain MRI (mean age 64 years, 33% female, median CHA2DS2-VASc 2), hrDWI detected at least one acute brain lesion in 84 (26.2%) patients and standard DWI in 60 (18.7%; P < 0.01) patients. High-resolution diffusion-weighted imaging detected more lesions compared to standard DWI (165 vs. 104; P < 0.01). The degree of agreement for lesion confirmation using hrDWI vs. standard DWI was substantial (κ = 0769). Comparing the proportion of DWI-detected lesions, lesion distribution, and total lesion volume per patient, there was no difference in the cohort of participants undergoing MRI at 1.5 T (n = 52) vs. 3 T (n = 269). CONCLUSION The pre-specified AXAFA-AFNET 5 sub-analysis revealed significantly increased rates of MRI-detected acute brain lesions using hrDWI instead of standard DWI in AF patients undergoing ablation. In comparison to DWI slice thickness, MRI field strength had a no significant impact in the trial. Comparing the varying rates of ablation-related MRI-detected brain lesions across previous studies has to consider these technical parameters. Future studies should use hrDWI, as feasibility was demonstrated in the multicentre AXAFA-AFNET 5 trial.
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Affiliation(s)
- Karl Georg Haeusler
- Atrial Fibrillation NETwork association (AFNET), Mendelstr. 11, 48149 Münster, Germany
- Department of Neurology, Universitätsklinikum Würzburg Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Felizitas A Eichner
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University Würzburg, Würzburg, Germany
- Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
- Institute of Medical Data Science, University Hospital Würzburg, Würzburg, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - David Callans
- Hospital of the University of Pennsylvania, Philadelphia, USA
| | | | | | - Daniel Scherr
- Division of Cardiology, Medical University Graz, Austria
| | | | - Hussein R Al-Khalidi
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, IDIBAPS, Barcelona, Spain
| | - Won Yong Kim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jonathan P Piccini
- Duke Clinical Research Institute (DCRI), Durham, NC, USA
- Division of Cardiology Duke University Medical Center, Duke University, Durham NC, USA
| | - Ulrich Schotten
- Atrial Fibrillation NETwork association (AFNET), Mendelstr. 11, 48149 Münster, Germany
- Departments of Cardiology and Physiology, University Maastricht, Maastricht, The Netherlands
| | | | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
- Texas Cardiac Arrhythmia Institute at St.David’s Medical Center, Austin, TX, USA
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork association (AFNET), Mendelstr. 11, 48149 Münster, Germany
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
- Department of Cardiology, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research, Partner site Hamburg/Kiel/Lübeck, Germany
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10
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Hermans BJ, Bijvoet GP, Holtackers RJ, Mihl C, Luermans JG, Maesen B, Vernooy K, Linz D, Chaldoupi SM, Schotten U. Multi-modal characterization of the left atrium by a fully automated integration of pre-procedural cardiac imaging and electro-anatomical mapping. Int J Cardiol Heart Vasc 2023; 49:101276. [PMID: 37854978 PMCID: PMC10579959 DOI: 10.1016/j.ijcha.2023.101276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023]
Abstract
Background The combination of information obtained from pre-procedural cardiac imaging and electro-anatomical mapping (EAM) can potentially help to locate new ablation targets. In this study we developed and evaluated a fully automated technique to align left atrial (LA) anatomies obtained from CT- and MRI-scans with LA anatomies obtained from EAM. Methods Twenty-one patients scheduled for a pulmonary vein (PV) isolation with a pre-procedural MRI were enrolled. Additionally, a recent computed tomography (CT) scan was available in 12 patients. LA anatomies were segmented from MRI-scans using ADAS-AF (Galgo Medical, Barcelona) and from the CT-scans using Slicer3D. MRI and CT anatomies were aligned with the EAM anatomy using an iterative closest plane-to-plane algorithm. Initially, the algorithm included the PVs, LA appendage and mitral valve anulus as they are the most distinctive landmarks. Subsequently, the algorithm was applied again, excluding these structures, with only three iterative steps to refine the alignment of the true LA surface. The result of the alignments was quantified by the Euclidian distance between the aligned anatomies after excluding PVs, LA appendage and mitral anulus. Results Our algorithm successfully aligned 20/21 MRI anatomies and 11/12 CT anatomies with the corresponding EAM anatomies. The average median residual distances were 1.9 ± 0.6 mm and 2.5 ± 0.8 mm for MRI and CT anatomies respectively. The average LA surface with a residual distance less than 5.00 mm was 89 ± 9% and 89 ± 10% for MRI and CT anatomies respectively. Conclusion An iterative closest plane-to-plane algorithm is a reliable method to automatically align pre-procedural cardiac images with anatomies acquired during ablation procedures.
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Affiliation(s)
- Ben J.M. Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Geertruida P. Bijvoet
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Robert J. Holtackers
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Justin G.L.M. Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
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11
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Hereijgers MJ, van der Velden RM, el Moussaoui N, Verhaert DV, Habibi Z, Luermans J, den Uijl D, Chaldoupi SM, Vernooy K, Schotten U, Baumert M, Gietema HA, Mihl C, Koltowski L, Franssen FM, Simons SO, Linz D. Repurposing catheter ablation work-up to detect expiratory airflow limitation in patients with atrial fibrillation. Int J Cardiol Heart Vasc 2023; 49:101305. [PMID: 38053981 PMCID: PMC10694302 DOI: 10.1016/j.ijcha.2023.101305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/07/2023]
Abstract
Background In atrial fibrillation (AF) patients, presence of expiratory airflow limitation may negatively impact treatment outcomes. AF patients are not routinely screened for expiratory airflow limitation, but existing examinations can help identify at-risk individuals. We aimed to assess the diagnostic value of repurposing existing assessments from the pre-ablation work-up to identify and understand the characteristics of affected patients. Methods We screened 110 consecutive AF patients scheduled for catheter ablation with handheld spirometry. Routine pre-ablation work-up included cardiac computed tomographic angiography (CCTA), transthoracic echocardiography and polygraphy. CCTA was analyzed qualitatively for emphysema and airway abnormalities. Multivariate logistic regression analysis was performed to determine predictors of expiratory airflow limitation. Results We found that 25 % of patients had expiratory airflow limitation, which was undiagnosed in 86 % of these patients. These patients were more likely to have pulmonary abnormalities on CCTA, including emphysema (odds ratio [OR] 4.2, 95 % confidence interval [CI] 1.12-15.1, p < 0.05) and bronchial wall thickening (OR 2.6, 95 % CI 1.0-6.5, p < 0.05). The absence of pulmonary abnormalities on CCTA accurately distinguished patients with normal lung function from those with airflow limitation (negative predictive value: 85 %). Echocardiography and polygraphy did not contribute significantly to identifying airflow limitation. Conclusions In conclusion, routine pre-ablation CCTA can detect pulmonary abnormalities in AF patients with airflow limitation, guiding further pulmonary assessment. Future studies should investigate its impact on ablation procedure success.
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Affiliation(s)
- Maartje J.M. Hereijgers
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Rachel M.J. van der Velden
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Nora el Moussaoui
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dominique V.M. Verhaert
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Zarina Habibi
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Justin Luermans
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Dennis den Uijl
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Mathias Baumert
- Discipline of Biomedical Engineering, The University of Adelaide, Adelaide, Australia
| | - Hester A. Gietema
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Casper Mihl
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lukasz Koltowski
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Frits M.E. Franssen
- Department of Research and Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sami O. Simons
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- NUTRIM Research Institute of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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12
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Winters J, Isaacs A, Zeemering S, Kawczynski M, Maesen B, Maessen J, Bidar E, Boukens B, Hermans B, van Hunnik A, Casadei B, Fabritz L, Chua W, Sommerfeld L, Guasch E, Mont L, Batlle M, Hatem S, Kirchhof P, Wakili R, Sinner M, Stoll M, Goette A, Verheule S, Schotten U. Heart Failure, Female Sex, and Atrial Fibrillation Are the Main Drivers of Human Atrial Cardiomyopathy: Results From the CATCH ME Consortium. J Am Heart Assoc 2023; 12:e031220. [PMID: 37982389 PMCID: PMC10727294 DOI: 10.1161/jaha.123.031220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/22/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Atrial cardiomyopathy (atCM) is an emerging prognostic factor in cardiovascular disease. Fibrotic remodeling, cardiomyocyte hypertrophy, and capillary density are hallmarks of atCM. The contribution of etiological factors and atrial fibrillation (AF) to the development of differential atCM phenotypes has not been quantified. This study aimed to evaluate the association between histological features of atCM and the clinical phenotype. METHODS AND RESULTS We examined left atrial (LA, n=95) and right atrial (RA, n=76) appendages from a European cohort of patients undergoing cardiac surgery. Quantification of histological atCM features was performed following wheat germ agglutinin/CD31/vimentin staining. The contributions of AF, heart failure, sex, and age to histological characteristics were determined with multiple linear regression models. Persistent AF was associated with increased endomysial fibrosis (LA: +1.13±0.47 μm, P=0.038; RA: +0.94±0.38 μm, P=0.041), whereas total extracellular matrix content was not. Men had larger cardiomyocytes (LA: +1.92±0.72 μm, P<0.001), while women had more endomysial fibrosis (LA: +0.99±0.56 μm, P=0.003). Patients with heart failure showed more endomysial fibrosis (LA: +1.85±0.48 μm, P<0.001) and extracellular matrix content (LA: +3.07±1.29%, P=0.016), and a higher capillary density (LA: +0.13±0.06, P=0.007) and size (LA: +0.46±0.22 μm, P=0.044). Fuzzy k-means clustering of histological features identified 2 subtypes of atCM: 1 characterized by enhanced endomysial fibrosis (LA: +3.17 μm, P<0.001; RA: +2.86 μm, P<0.001), extracellular matrix content (LA: +3.53%, P<0.001; RA: +6.40%, P<0.001) and fibroblast density (LA: +4.38%, P<0.001), and 1 characterized by cardiomyocyte hypertrophy (LA: +1.16 μm, P=0.008; RA: +2.58 μm, P<0.001). Patients with fibrotic atCM were more frequently female (LA: odds ratio [OR], 1.33, P=0.002; RA: OR, 1.54, P=0.004), with persistent AF (LA: OR, 1.22, P=0.036) or heart failure (LA: OR, 1.62, P<0.001). Hypertrophic features were more common in men (LA: OR=1.33, P=0.002; RA: OR, 1.54, P=0.004). CONCLUSIONS Fibrotic atCM is associated with female sex, persistent AF, and heart failure, while hypertrophic features are more common in men.
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Affiliation(s)
- Joris Winters
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
| | - Aaron Isaacs
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
- Maastricht Centre for Systems Biology University Maastricht Maastricht The Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
| | - Michal Kawczynski
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
- Department of Cardiothoracic Surgery Maastricht University Medical Centre+ Maastricht The Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery Maastricht University Medical Centre+ Maastricht The Netherlands
| | - Jos Maessen
- Department of Cardiothoracic Surgery Maastricht University Medical Centre+ Maastricht The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery Maastricht University Medical Centre+ Maastricht The Netherlands
| | - Bas Boukens
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
| | - Ben Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
| | - Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
| | - Barbara Casadei
- Division of Cardiovascular Medicine, BHF Centre of Research Excellence University of Oxford Oxford United Kingdom
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences Birmingham United Kingdom
- University Center of Cardiovascular Science UKE Hamburg Hamburg Germany
- University Heart and Vascular Center, University Hospital Hamburg Eppendorf Hamburg Germany
- DZHK, Standort Hamburg/Kiel/Lübeck Lübeck Germany
| | - Winnie Chua
- Institute of Cardiovascular Sciences Birmingham United Kingdom
| | - Laura Sommerfeld
- Institute of Cardiovascular Sciences Birmingham United Kingdom
- University Center of Cardiovascular Science UKE Hamburg Hamburg Germany
- University Heart and Vascular Center, University Hospital Hamburg Eppendorf Hamburg Germany
- DZHK, Standort Hamburg/Kiel/Lübeck Lübeck Germany
| | - Eduard Guasch
- Institute of Biomedical Research August Pi Sunyer (IDIBAPS) Barcelona Spain
| | - Luis Mont
- Clinic Barcelona, Universitat de Barcelona Barcelona Spain
| | - Montserrat Batlle
- Institute of Biomedical Research August Pi Sunyer (IDIBAPS) Barcelona Spain
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBERCV) Madrid Spain
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences Birmingham United Kingdom
- University Heart and Vascular Center, University Hospital Hamburg Eppendorf Hamburg Germany
- DZHK, Standort Hamburg/Kiel/Lübeck Lübeck Germany
| | - Reza Wakili
- Department of Medicine and Cardiology Goethe University Frankfurt Germany
| | - Mortiz Sinner
- University Heart and Vascular Center, University Hospital Hamburg Eppendorf Hamburg Germany
- DZHK, Standort Hamburg/Kiel/Lübeck Lübeck Germany
- Department of Cardiology University Hospital of Munich Munich Germany
| | - Monica Stoll
- Maastricht Centre for Systems Biology University Maastricht Maastricht The Netherlands
- Department of Biochemistry, Genetic Epidemiology and Statistical Genetics University Maastricht Maastricht The Netherlands
- Department of Genetic Epidemiology, Institute of Human Genetics University of Münster Münster Germany
| | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine St. Vincenz Hospital Paderborn Paderborn Germany
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht University Maastricht Maastricht The Netherlands
- Department of Cardiology Maastricht University Medical Centre+ Maastricht The Netherlands
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13
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Chua W, Cardoso VR, Guasch E, Sinner MF, Al-Taie C, Brady P, Casadei B, Crijns HJGM, Dudink EAMP, Hatem SN, Kääb S, Kastner P, Mont L, Nehaj F, Purmah Y, Reyat JS, Schotten U, Sommerfeld LC, Zeemering S, Ziegler A, Gkoutos GV, Kirchhof P, Fabritz L. An angiopoietin 2, FGF23, and BMP10 biomarker signature differentiates atrial fibrillation from other concomitant cardiovascular conditions. Sci Rep 2023; 13:16743. [PMID: 37798357 PMCID: PMC10556075 DOI: 10.1038/s41598-023-42331-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 09/08/2023] [Indexed: 10/07/2023] Open
Abstract
Early detection of atrial fibrillation (AF) enables initiation of anticoagulation and early rhythm control therapy to reduce stroke, cardiovascular death, and heart failure. In a cross-sectional, observational study, we aimed to identify a combination of circulating biomolecules reflecting different biological processes to detect prevalent AF in patients with cardiovascular conditions presenting to hospital. Twelve biomarkers identified by reviewing literature and patents were quantified on a high-precision, high-throughput platform in 1485 consecutive patients with cardiovascular conditions (median age 69 years [Q1, Q3 60, 78]; 60% male). Patients had either known AF (45%) or AF ruled out by 7-day ECG-monitoring. Logistic regression with backward elimination and a neural network approach considering 7 key clinical characteristics and 12 biomarker concentrations were applied to a randomly sampled discovery cohort (n = 933) and validated in the remaining patients (n = 552). In addition to age, sex, and body mass index (BMI), BMP10, ANGPT2, and FGF23 identified patients with prevalent AF (AUC 0.743 [95% CI 0.712, 0.775]). These circulating biomolecules represent distinct pathways associated with atrial cardiomyopathy and AF. Neural networks identified the same variables as the regression-based approach. The validation using regression yielded an AUC of 0.719 (95% CI 0.677, 0.762), corroborated using deep neural networks (AUC 0.784 [95% CI 0.745, 0.822]). Age, sex, BMI and three circulating biomolecules (BMP10, ANGPT2, FGF23) are associated with prevalent AF in unselected patients presenting to hospital. Findings should be externally validated. Results suggest that age and different disease processes approximated by these three biomolecules contribute to AF in patients. Our findings have the potential to improve screening programs for AF after external validation.
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Affiliation(s)
- Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Victor R Cardoso
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- MRC Health Data Research UK (HDR), Midlands Site, London, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Eduard Guasch
- Hospital Clinic de Barcelona, Institute of Biomedical Research August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Moritz F Sinner
- Department of Medicine I, University Hospital, LMU, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Christoph Al-Taie
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, UKE Martinistrasse 52, 20246, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Brady
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Harry J G M Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Elton A M P Dudink
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Stéphane N Hatem
- IHU-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | | | - Lluis Mont
- Hospital Clinic de Barcelona, Institute of Biomedical Research August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Frantisek Nehaj
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Yanish Purmah
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Jasmeet S Reyat
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Laura C Sommerfeld
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, UKE Martinistrasse 52, 20246, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stef Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - André Ziegler
- Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Georgios V Gkoutos
- MRC Health Data Research UK (HDR), Midlands Site, London, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, UKE Martinistrasse 52, 20246, Hamburg, Germany.
- German Centre for Cardiovascular Research (DZHK), Partner Site: Hamburg/Kiel/Lübeck, Hamburg, Germany.
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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14
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Carstensen H, Nissen SD, Saljic A, Hesselkilde EM, van Hunnik A, Hohl M, Sattler SM, Fløgstad C, Hopster-Iversen C, Verheule S, Böhm M, Schotten U, Jespersen T, Buhl R. Long-Term Training Increases Atrial Fibrillation Sustainability in Standardbred Racehorses. J Cardiovasc Transl Res 2023; 16:1205-1219. [PMID: 37014465 PMCID: PMC10615936 DOI: 10.1007/s12265-023-10378-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/14/2023] [Indexed: 04/05/2023]
Abstract
Atrial fibrillation (AF) is more prevalent in athletes, and currently, the mechanisms are not fully understood. Atrial fibrillation inducibility and stability was investigated in trained and untrained Standardbred racehorses. The horses underwent echocardiography for evaluation of atrial size. High-density mapping during AF was performed, and the presence of structural remodeling, as well as the expression of inflammatory and pro-inflammatory markers in the atria, was studied. Atrial fibrillation sustained significantly longer after tachypacing in the trained horses, whereas no difference in AF inducibility was found. The untrained horses displayed a significant difference in the AF complexity when comparing right and left atria, whereas such difference was not observed in the trained animals. No evidence of increased structural remodeling or inflammation could be identified. Left atrial dimensions were not significantly increased. The increased AF sustainability in trained horses was not related to fibrosis or inflammation as seen in other animal exercise models.
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Affiliation(s)
- Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Sarah Dalgas Nissen
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
| | - Arnela Saljic
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Eva Melis Hesselkilde
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Arne van Hunnik
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | - Mathias Hohl
- Department of Internal Medicine III, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Stefan Michael Sattler
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Cecilie Fløgstad
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Charlotte Hopster-Iversen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
| | - Sander Verheule
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, Maastricht, Netherlands
| | - Thomas Jespersen
- Laboratory of Cardiac Physiology, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Højbakkegaard Allé 5, 2630, Taastrup, Denmark
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15
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Kirchhof P, Toennis T, Goette A, Camm AJ, Diener HC, Becher N, Bertaglia E, Blomstrom Lundqvist C, Borlich M, Brandes A, Cabanelas N, Calvert M, Chlouverakis G, Dan GA, de Groot JR, Dichtl W, Kravchuk B, Lubiński A, Marijon E, Merkely B, Mont L, Ozga AK, Rajappan K, Sarkozy A, Scherr D, Sznajder R, Velchev V, Wichterle D, Sehner S, Simantirakis E, Lip GYH, Vardas P, Schotten U, Zapf A. Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes. N Engl J Med 2023; 389:1167-1179. [PMID: 37622677 DOI: 10.1056/nejmoa2303062] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND Device-detected atrial high-rate episodes (AHREs) are atrial arrhythmias detected by implanted cardiac devices. AHREs resemble atrial fibrillation but are rare and brief. Whether the occurrence of AHREs in patients without atrial fibrillation (as documented on a conventional electrocardiogram [ECG]) justifies the initiation of anticoagulants is not known. METHODS We conducted an event-driven, double-blind, double-dummy, randomized trial involving patients 65 years of age or older who had AHREs lasting for at least 6 minutes and who had at least one additional risk factor for stroke. Patients were randomly assigned in a 1:1 ratio to receive edoxaban or placebo. The primary efficacy outcome was a composite of cardiovascular death, stroke, or systemic embolism, evaluated in a time-to-event analysis. The safety outcome was a composite of death from any cause or major bleeding. RESULTS The analysis population consisted of 2536 patients (1270 in the edoxaban group and 1266 in the placebo group). The mean age was 78 years, 37.4% were women, and the median duration of AHREs was 2.8 hours. The trial was terminated early, at a median follow-up of 21 months, on the basis of safety concerns and the results of an independent, informal assessment of futility for the efficacy of edoxaban; at termination, the planned enrollment had been completed. A primary efficacy outcome event occurred in 83 patients (3.2% per patient-year) in the edoxaban group and in 101 patients (4.0% per patient-year) in the placebo group (hazard ratio, 0.81; 95% confidence interval [CI], 0.60 to 1.08; P = 0.15). The incidence of stroke was approximately 1% per patient-year in both groups. A safety outcome event occurred in 149 patients (5.9% per patient-year) in the edoxaban group and in 114 patients (4.5% per patient-year) in the placebo group (hazard ratio, 1.31; 95% CI, 1.02 to 1.67; P = 0.03). ECG-diagnosed atrial fibrillation developed in 462 of 2536 patients (18.2% total, 8.7% per patient-year). CONCLUSIONS Among patients with AHREs detected by implantable devices, anticoagulation with edoxaban did not significantly reduce the incidence of a composite of cardiovascular death, stroke, or systemic embolism as compared with placebo, but it led to a higher incidence of a composite of death or major bleeding. The incidence of stroke was low in both groups. (Funded by the German Center for Cardiovascular Research and others; NOAH-AFNET 6 ClinicalTrials.gov number, NCT02618577; ISRCTN number, ISRCTN17309850.).
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Affiliation(s)
- Paulus Kirchhof
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Tobias Toennis
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Andreas Goette
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - A John Camm
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Hans Christoph Diener
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Nina Becher
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Emanuele Bertaglia
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Carina Blomstrom Lundqvist
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Martin Borlich
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Axel Brandes
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Nuno Cabanelas
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Melanie Calvert
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Gregory Chlouverakis
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Gheorghe-Andrei Dan
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Joris R de Groot
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Wolfgang Dichtl
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Borys Kravchuk
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Andrzej Lubiński
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Eloi Marijon
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Béla Merkely
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Lluís Mont
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Ann-Kathrin Ozga
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Kim Rajappan
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Andrea Sarkozy
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Daniel Scherr
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Rafał Sznajder
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Vasil Velchev
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Dan Wichterle
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Susanne Sehner
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Emmanuel Simantirakis
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Gregory Y H Lip
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Panos Vardas
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Ulrich Schotten
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
| | - Antonia Zapf
- From the Atrial Fibrillation Network, Münster (P.K., A.G., U.S.), the Department of Cardiology, University Heart and Vascular Center Hamburg (P.K., T.T., N.B.), and the Institute of Medical Biometry and Epidemiology (A.-K.O., S.S., A.Z.), University Medical Center Hamburg-Eppendorf, and the German Center for Cardiovascular Research (DZHK) Partner Site Hamburg-Kiel-Lübeck (P.K., T.T., N.B.), Hamburg, the Department of Cardiology and Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn (A.G.), the Department of Neuroepidemiology, Institute for Medical Informatics, Biometry, and Epidemiology, University Duisburg-Essen, Essen (H.C.D.), and the Heart Center, Segeberger Kliniken, Bad Segeberg (M.B.) - all in Germany; the Institute of Cardiovascular Sciences (P.K.) and the Centre for Patient Reported Outcome Research, Institute of Applied Health Research, the National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, and the NIHR Applied Research Collaboration West Midlands (M.C.), University of Birmingham, Birmingham, the Cardiovascular and Cell Sciences Research Institute, St. George's University of London, and Imperial College London, London (A.J.C.), the Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford (K.R.), and Liverpool Centre for Cardiovascular Science at University of Liverpool, John Moores University, and Liverpool Heart and Chest Hospital, Liverpool (G.Y.H.L.) - all in the United Kingdom; Unità Operativa Complessa Cardiologia-Azienda Ospedale Università di Padova, Padua, Italy (E.B.); the Department of Medical Science, Uppsala University, Uppsala, and the Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro - both in Sweden (C.B.L.); the Department of Cardiology, Odense University Hospital, Odense, and the Department of Cardiology, Esbjerg Hospital-University Hospital of Southern Denmark, Esbjerg (A.B.), and the Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg (G.Y.H.L.) - all in Denmark; the Cardiology Department, Fernando Fonseca Hospital, Amadora, Portugal (N.C.); the Biostatistics Lab, School of Medicine, University of Crete (G.C.), and the Department of Cardiology, Heraklion University Hospital (E.S.), Heraklion, and the Biomedical Research Foundation Academy of Athens and Hygeia Hospitals Group, Athens (P.V.) - all in Greece; Medicine University Carol Davila, Colentina University Hospital, Bucharest, Romania (G.-A.D.); the Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam (J.R.G.), and the Departments of Cardiology and Physiology, Maastricht University, Maastricht (U.S.) - both in the Netherlands; the Department of Internal Medicine III, Cardiology and Angiology, Innsbruck Medical University, Innsbruck (W.D.), and the Department of Cardiology, Medical University of Graz, Graz (D.S.) - both in Austria; the National Institute of Cardiovascular Surgery, Academy of Medical Sciences of Ukraine, Kyiv (B.K.); the Department of Cardiology and Internal Disease, Medical University of Gdansk, Gdansk (A.L.), and the Department of Electrocardiology and Heart Failure, Leszek Giec Upper Silesian Medical Center, Katowice (R.S.) - both in Poland; the Cardiology Division, European Georges Pompidou Hospital, Paris (E.M.); the Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); the Hospital Clinic, Universtitat de Barcelona, Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, and Centro de Investigacion Biomedica en Red Cardiovascular, Madrid - all in Spain (L.M.); the Department of Cardiology, University Hospital Antwerp, Edegem, Belgium (A.S.); the Cardiology Clinic, St. Anna University Hospital Sofia, Sofia Medical University, Sofia, Bulgaria (V.V.); and the Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (D.W.)
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16
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Frausing MHJP, Van De Lande ME, Maass AH, Nguyen BO, Hemels MEW, Tieleman RG, Koldenhof T, De Melis M, Linz D, Schotten U, Weberndörfer V, Crijns HJGM, Van Gelder IC, Nielsen JC, Rienstra M. Brady- and tachyarrhythmias detected by continuous rhythm monitoring in paroxysmal atrial fibrillation. Heart 2023; 109:1286-1293. [PMID: 36948572 PMCID: PMC10423524 DOI: 10.1136/heartjnl-2022-322253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/18/2023] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) is associated with adverse events including conduction disturbances, ventricular arrhythmias and sudden death. The aim of this study was to examine brady- and tachyarrhythmias using continuous rhythm monitoring in patients with paroxysmal self-terminating AF (PAF). METHODS In this multicentre observational substudy to the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling and Vascular destabilisation in the progression of AF (RACE V), we included 392 patients with PAF and at least 2 years of continuous rhythm monitoring. All patients received an implantable loop recorder, and all detected episodes of tachycardia ≥182 beats per minute (BPM), bradycardia ≤30 BPM or pauses ≥5 s were adjudicated by three physicians. RESULTS Over 1272 patient-years of continuous rhythm monitoring, we adjudicated 1940 episodes in 175 patients (45%): 106 (27%) patients experienced rapid AF or atrial flutter (AFL), pauses ≥5 s or bradycardias ≤30 BPM occurred in 47 (12%) patients and in 22 (6%) patients, we observed both episode types. No sustained ventricular tachycardias occurred. In the multivariable analysis, age >70 years (HR 2.3, 95% CI 1.4 to 3.9), longer PR interval (HR 1.9, 1.1-3.1), CHA2DS2-VASc score ≥2 (HR 2.2, 1.1-4.5) and treatment with verapamil or diltiazem (HR 0.4, 0.2-1.0) were significantly associated with bradyarrhythmia episodes. Age >70 years was associated with lower rates of tachyarrhythmias. CONCLUSIONS In a cohort exclusive to patients with PAF, almost half experienced severe bradyarrhythmias or AF/AFL with rapid ventricular rates. Our data highlight a higher than anticipated bradyarrhythmia risk in PAF. TRIAL REGISTRATION NUMBER NCT02726698.
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Affiliation(s)
- Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Martijn E Van De Lande
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bao-Oanh Nguyen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Ziekenhuis Arnhem, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Tim Koldenhof
- Cardiology, Martini Hospital Groningen, Groningen, The Netherlands
| | - Mirko De Melis
- Medtronic Bakken Research Center BV, Maastricht, The Netherlands
| | - Dominik Linz
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
- Physiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vanessa Weberndörfer
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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17
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Rijks JHJ, Lankveld T, Manusama R, Broers B, Stipdonk AMWV, Chaldoupi SM, Bekke RMAT, Schotten U, Linz D, Luermans JGLM, Vernooy K. Left Bundle Branch Area Pacing and Atrioventricular Node Ablation in a Single-Procedure Approach for Elderly Patients with Symptomatic Atrial Fibrillation. J Clin Med 2023; 12:4028. [PMID: 37373721 DOI: 10.3390/jcm12124028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated. METHODS Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter. RESULTS 25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up. CONCLUSIONS LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF.
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Affiliation(s)
- Jesse H J Rijks
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Theo Lankveld
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
| | - Randolph Manusama
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
| | - Bernard Broers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Sevasti Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Rachel M A Ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, The University of Adelaide, Adelaide, SA 5005, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 1172 Copenhagen, Denmark
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands
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18
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Betz K, Verhaert DVM, Gawalko M, Hermans ANL, Habibi Z, Pluymaekers NAHA, van der Velden RMJ, Homberg M, Philippens S, Hereijgers MJM, Vorstermans B, Simons SO, den Uijl DW, Chaldoupi SM, Luermans JGLM, Westra SW, Lankveld T, van Steenwijk RP, Hol B, Schotten U, Vernooy K, Hendriks JM, Linz D. Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: insights from the Virtual-SAFARI study. Clin Res Cardiol 2023; 112:834-845. [PMID: 36773038 PMCID: PMC10241725 DOI: 10.1007/s00392-023-02157-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/10/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF. AIM We aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection. METHODS Consecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea-hypopnoea index (AHI) of ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening. RESULTS Of 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573-0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672-0.805) in the overall population. CONCLUSION AF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies. TRIAL REGISTRATION NUMBER ISOLATION was registered NCT04342312, 13-04-2020.
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Affiliation(s)
- Konstanze Betz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Internal Medicine, Eifelklinik St. Brigida GmbH & Co. KG, Kammerbruchstraße 8, 52152, Simmerath, Germany
| | - Dominique V M Verhaert
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center and Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Monika Gawalko
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- 1St Department of Cardiology, Doctoral School, Medical University of Warsaw, Żwirki i Wigury 61, 02-091, Warsaw, Poland
- Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, Forsthausweg 2, 47057, Duisburg, Germany
| | - Astrid N L Hermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Zarina Habibi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center and Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nikki A H A Pluymaekers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Rachel M J van der Velden
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Marloes Homberg
- Department of Anesthesiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Suzanne Philippens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Maartje J M Hereijgers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Bianca Vorstermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Sami O Simons
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Dennis W den Uijl
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Sevasti-Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Sjoerd W Westra
- Department of Cardiology, Radboud University Medical Center and Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Theo Lankveld
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | | | - Bernard Hol
- Netherland Sleep Institute, Computerweg 4, 3821 AB, Amersfoort, The Netherlands
| | - Ulrich Schotten
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center and Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Jeroen M Hendriks
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Port Rd, Adelaide, SA, 5000, Australia
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, Adelaide, SA, 5042, Australia
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- Department of Cardiology, Radboud University Medical Center and Radboud Institute for Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Port Rd, Adelaide, SA, 5000, Australia.
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, Adelaide, SA, 5042, Australia.
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Nørregade 10, 1165, Copenhagen, Denmark.
- Maastricht UMC+, Maastricht Heart+Vascular Center, 6202 AZ, Maastricht, The Netherlands.
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19
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Ganesan P, Deb B, Feng R, Rodrigo M, Ruiperez-Campillo S, Rogers AJ, Clopton P, Wang PJ, Zeemering S, Schotten U, Rappel WJ, Narayan SM. Quantifying a spectrum of clinical response in atrial tachyarrhythmias using spatiotemporal synchronization of electrograms. Europace 2023; 25:euad055. [PMID: 36932716 PMCID: PMC10227659 DOI: 10.1093/europace/euad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/19/2023] Open
Abstract
AIMS There is a clinical spectrum for atrial tachyarrhythmias wherein most patients with atrial tachycardia (AT) and some with atrial fibrillation (AF) respond to ablation, while others do not. It is undefined if this clinical spectrum has pathophysiological signatures. This study aims to test the hypothesis that the size of spatial regions showing repetitive synchronized electrogram (EGM) shapes over time reveals a spectrum from AT, to AF patients who respond acutely to ablation, to AF patients without acute response. METHODS AND RESULTS We studied n = 160 patients (35% women, 65.0 ± 10.4 years) of whom (i) n = 75 had AF terminated by ablation propensity matched to (ii) n = 75 without AF termination and (iii) n = 10 with AT. All patients had mapping by 64-pole baskets to identify areas of repetitive activity (REACT) to correlate unipolar EGMs in shape over time. Synchronized regions (REACT) were largest in AT, smaller in AF termination, and smallest in non-termination cohorts (0.63 ± 0.15, 0.37 ± 0.22, and 0.22 ± 0.18, P < 0.001). Area under the curve for predicting AF termination in hold-out cohorts was 0.72 ± 0.03. Simulations showed that lower REACT represented greater variability in clinical EGM timing and shape. Unsupervised machine learning of REACT and extensive (50) clinical variables yielded four clusters of increasing risk for AF termination (P < 0.01, χ2), which were more predictive than clinical profiles alone (P < 0.001). CONCLUSION The area of synchronized EGMs within the atrium reveals a spectrum of clinical response in atrial tachyarrhythmias. These fundamental EGM properties, which do not reflect any predetermined mechanism or mapping technology, predict outcome and offer a platform to compare mapping tools and mechanisms between AF patient groups.
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Affiliation(s)
- Prasanth Ganesan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Brototo Deb
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Ruibin Feng
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Miguel Rodrigo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
| | - Samuel Ruiperez-Campillo
- Electronic Engineering Department, Universitat de Valencia, Av. de Blasco Ibáñez, 13, 46010 València, Spain
- Department of Bioengineering, University of California, Berkeley, CA 94720, USA
| | - Albert J Rogers
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul Clopton
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
| | - Stef Zeemering
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University, 6211 LK Maastricht, 616 6200, Netherlands
| | - Wouter-Jan Rappel
- Department of Physics, University of California, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Sanjiv M Narayan
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, 453 Quarry Road, Palo Alto, CA 94304, USA
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20
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van de Lande ME, Rama RS, Koldenhof T, Arita VA, Nguyen BO, van Deutekom C, Weberndorfer V, Crijns HJGM, Hemels MEW, Tieleman RG, de Melis M, Schotten U, Linz D, Van Gelder IC, Rienstra M. Time of onset of atrial fibrillation and atrial fibrillation progression data from the RACE V study. Europace 2023; 25:euad058. [PMID: 36967470 PMCID: PMC10227656 DOI: 10.1093/europace/euad058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/05/2023] [Indexed: 08/24/2023] Open
Abstract
AIMS Atrial fibrillation (AF) progression is associated with adverse outcome, but the role of the circadian or diurnal pattern of AF onset remains unclear. We aim to assess the association between the time of onset of AF episodes with the clinical phenotype and AF progression in patients with self-terminating AF. METHODS AND RESULTS The Reappraisal of AF: Interaction Between Hypercoagulability, Electrical Remodelling, and Vascular Destabilization in the Progression of AF study included patients with self-terminating AF who underwent extensive phenotyping at baseline and continuous rhythm monitoring with an implantable loop recorder (ILR). In this subanalysis, ILR data were used to assess the development of AF progression and the diurnal pattern of AF onset: predominant (>80%) nocturnal AF, predominant daytime AF, or mixed AF without a predominant diurnal AF pattern. The median follow-up was 2.2 (1.6-2.8) years. The median age was 66 (59-71) years, and 117 (42%) were women. Predominant nocturnal (n = 40) and daytime (n = 43) AF onset patients had less comorbidities compared to that of mixed (n = 195) AF patients (median 2 vs. 2 vs. 3, respectively, P = 0.012). Diabetes was more common in the mixed group (12% vs. 5% vs. 0%, respectively, P = 0.031), whilst obesity was more frequent in the nocturnal group (38% vs. 12% vs. 27%, respectively, P = 0.028). Progression rates in the nocturnal vs. daytime vs. mixed groups were 5% vs. 5% vs. 24%, respectively (P = 0.013 nocturnal vs. mixed and P = 0.008 daytime vs. mixed group, respectively). CONCLUSION In self-terminating AF, patients with either predominant nocturnal or daytime onset of AF episodes had less associated comorbidities and less AF progression compared to that of patients with mixed onset of AF. CLINICAL TRIAL REGISTRATION NCT02726698.
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Affiliation(s)
- Martijn E van de Lande
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Rajiv S Rama
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Tim Koldenhof
- Department of Cardiology, Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Vicente Artola Arita
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Bao-Oanh Nguyen
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Colinda van Deutekom
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Vanessa Weberndorfer
- Department of Cardiology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 632, 6229 ER Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 632, 6229 ER Maastricht, The Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, Martini Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Mirko de Melis
- Medtronic Bakken Research Centre, Endepolsdomein 5, 6229 GW Maastricht, The Netherlands
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 632, 6229 ER Maastricht, The Netherlands
- Department of Physiology, University of Maastricht, Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre+, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 632, 6229 ER Maastricht, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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21
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van Mourik MJW, Linz D, Verwijs HJA, Bekkers SCAM, Weerts J, Schotten U, Rocca HBL, Lumens J, Crijns HJGM, Weijs B, Knackstedt C. Evaluating subclinical left ventricular and left atrial dysfunction in idiopathic atrial fibrillation: A speckle-tracking based strain-analysis. Int J Cardiol 2023:S0167-5273(23)00577-6. [PMID: 37088325 DOI: 10.1016/j.ijcard.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/20/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE A subset of patients with atrial fibrillation (AF) presents without established AF risk factors and normal left ventricular (LV) systolic function, called idiopathic AF (IAF). Traditionally, echocardiography derived LV dimensions and ejection fraction (EF) are used to exclude LV dysfunction in IAF, but their sensitivity is limited. Our objective is to evaluate the presence of subtle alterations in LV function despite normal LVEF in patients with IAF compared to healthy controls, using speckle-tracking echocardiography (STE) based global longitudinal strain (GLS). METHODS Standard transthoracic echocardiography was performed in 80 patients with IAF and 129 healthy controls. Patients with overt cardiac disease as well as known established AF risk factors were excluded. STE analysis was performed to assess GLS of the LV, and left atrial strain (LAS). RESULTS LVEF was normal and comparable between patients with IAF and healthy controls (63 ± 4% for both groups; p = 0.801). Mean GLS was within normal limits for both groups but statistically significantly more negative in patients with IAF (-20.6 ± 2.5% vs. -19.7 ± 2.5%; p = 0.016), however not when indexed for ventricular cycle length (p = 0.784). No differences in LA volume or non-indexed LAS were seen in patients with IAF compared to healthy controls. CONCLUSIONS In this selected group of IAF patients, STE did not detect any overt LV or LA dysfunction compared to healthy controls. Thus, IAF occurred in these patients not only in the absence of established AF risk factors but also without evidence of ventricular dysfunction.
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Affiliation(s)
- Manouk J W van Mourik
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands; Katholische Stiftung Marienhospital, Aachen, Germany
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Harm J A Verwijs
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands
| | - Sebastiaan C A M Bekkers
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Jerremy Weerts
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Ulrich Schotten
- CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Hanspeter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Bob Weijs
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Maastricht University Medical Center+, the Netherlands; CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, the Netherlands.
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22
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Özgül O, Hermans BJ, van Hunnik A, Verheule S, Schotten U, Bonizzi P, Zeemering S. High-density and high coverage composite mapping of repetitive atrial activation patterns. Comput Biol Med 2023; 159:106920. [PMID: 37119551 DOI: 10.1016/j.compbiomed.2023.106920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/18/2023] [Accepted: 04/13/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Repetitive atrial activation patterns (RAAPs) during atrial fibrillation (AF) may be associated with localized mechanisms that maintain AF. Current electro-anatomical mapping systems are unsuitable for analyzing RAAPs due to the trade-off between spatial coverage and electrode density in clinical catheters. This work proposes a technique to overcome this trade-off by constructing composite maps from spatially overlapping sequential recordings. METHODS High-density epicardial contact mapping was performed during open-chest surgery in goats (n=16, left and right atria) with 3 or 22 weeks of sustained AF (249-electrode array, electrode distance 2.4 mm). A dataset mimicking sequential recordings was generated by segmenting the grid into four spatially overlapping regions (each region 6.5 cm2, 48±10% overlap) without temporal overlap. RAAPs were detected in each region using recurrence plots of activation times. RAAPs in two different regions were joined in case of RAAP cross-recurrence between overlapping electrodes. We quantified the reconstruction success rate and quality of the composite maps. RESULTS Of 1021 RAAPs found in the full mapping array (32±13 per recording), 328 spatiotemporally stable RAAPs were analyzed. 247 composite maps were generated (75% success) with a quality of 0.86±0.21 (Pearson correlation). Success was significantly affected by the RAAP area. Quality was weakly correlated with the number of repetitions of RAAPs (r=0.13, p<0.05) and not affected by the atrial side (left or right) or AF duration (3 or 22 weeks of AF). CONCLUSIONS Constructing composite maps by combining spatially overlapping sequential recordings is feasible. Interpretation of these maps can play a central role in ablation planning.
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Affiliation(s)
- Ozan Özgül
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Ben Jm Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Arne van Hunnik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Sander Verheule
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.
| | - Pietro Bonizzi
- Department of Advanced Computing Sciences, Maastricht University, Maastricht, the Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
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23
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Young WJ, Haessler J, Benjamins JW, Repetto L, Yao J, Isaacs A, Harper AR, Ramirez J, Garnier S, van Duijvenboden S, Baldassari AR, Concas MP, Duong T, Foco L, Isaksen JL, Mei H, Noordam R, Nursyifa C, Richmond A, Santolalla ML, Sitlani CM, Soroush N, Thériault S, Trompet S, Aeschbacher S, Ahmadizar F, Alonso A, Brody JA, Campbell A, Correa A, Darbar D, De Luca A, Deleuze JF, Ellervik C, Fuchsberger C, Goel A, Grace C, Guo X, Hansen T, Heckbert SR, Jackson RD, Kors JA, Lima-Costa MF, Linneberg A, Macfarlane PW, Morrison AC, Navarro P, Porteous DJ, Pramstaller PP, Reiner AP, Risch L, Schotten U, Shen X, Sinagra G, Soliman EZ, Stoll M, Tarazona-Santos E, Tinker A, Trajanoska K, Villard E, Warren HR, Whitsel EA, Wiggins KL, Arking DE, Avery CL, Conen D, Girotto G, Grarup N, Hayward C, Jukema JW, Mook-Kanamori DO, Olesen MS, Padmanabhan S, Psaty BM, Pattaro C, Ribeiro ALP, Rotter JI, Stricker BH, van der Harst P, van Duijn CM, Verweij N, Wilson JG, Orini M, Charron P, Watkins H, Kooperberg C, Lin HJ, Wilson JF, Kanters JK, Sotoodehnia N, Mifsud B, Lambiase PD, Tereshchenko LG, Munroe PB. Genetic architecture of spatial electrical biomarkers for cardiac arrhythmia and relationship with cardiovascular disease. Nat Commun 2023; 14:1411. [PMID: 36918541 PMCID: PMC10015012 DOI: 10.1038/s41467-023-36997-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 02/26/2023] [Indexed: 03/15/2023] Open
Abstract
The 3-dimensional spatial and 2-dimensional frontal QRS-T angles are measures derived from the vectorcardiogram. They are independent risk predictors for arrhythmia, but the underlying biology is unknown. Using multi-ancestry genome-wide association studies we identify 61 (58 previously unreported) loci for the spatial QRS-T angle (N = 118,780) and 11 for the frontal QRS-T angle (N = 159,715). Seven out of the 61 spatial QRS-T angle loci have not been reported for other electrocardiographic measures. Enrichments are observed in pathways related to cardiac and vascular development, muscle contraction, and hypertrophy. Pairwise genome-wide association studies with classical ECG traits identify shared genetic influences with PR interval and QRS duration. Phenome-wide scanning indicate associations with atrial fibrillation, atrioventricular block and arterial embolism and genetically determined QRS-T angle measures are associated with fascicular and bundle branch block (and also atrioventricular block for the frontal QRS-T angle). We identify potential biology involved in the QRS-T angle and their genetic relationships with cardiovascular traits and diseases, may inform future research and risk prediction.
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Affiliation(s)
- William J Young
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
| | - Jeffrey Haessler
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jan-Walter Benjamins
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Linda Repetto
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Jie Yao
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Aaron Isaacs
- Dept. of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Maastricht Center for Systems Biology (MaCSBio), Maastricht University, Maastricht, the Netherlands
| | - Andrew R Harper
- Radcliffe Department of Medicine, University of Oxford, Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK
- Wellcome Centre for Human Genetics, Roosevelt Drive, Oxford, UK
| | - Julia Ramirez
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
- Aragon Institute of Engineering Research, University of Zaragoza, Zaragoza, Spain and Center of Biomedical Research Network, Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| | - Sophie Garnier
- Sorbonne Universite, INSERM, UMR-S1166, Research Unit on Cardiovascular Disorders, Metabolism and Nutrition, Team Genomics & Pathophysiology of Cardiovascular Disease, Paris, 75013, France
- ICAN Institute for Cardiometabolism and Nutrition, Paris, 75013, France
| | - Stefan van Duijvenboden
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Antoine R Baldassari
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Pina Concas
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - ThuyVy Duong
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Luisa Foco
- Eurac Research, Institute for Biomedicine (affiliated with the University of Lübeck), Bolzano, Italy
| | - Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hao Mei
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Raymond Noordam
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Casia Nursyifa
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Richmond
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - Meddly L Santolalla
- Department of Genetics, Ecology and Evolution, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Emerge, Emerging Diseases and Climate Change Research Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, 15152, Peru
| | - Colleen M Sitlani
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Negin Soroush
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Sébastien Thériault
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology, Université Laval, Quebec, QC, Canada
| | - Stella Trompet
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefanie Aeschbacher
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Fariba Ahmadizar
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
- Julius Global Health, University Utrecht Medical Center, Utrecht, the Netherlands
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jennifer A Brody
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Archie Campbell
- Usher Institute, University of Edinburgh, Nine, Edinburgh Bioquarter, 9 Little France Road, Edinburgh, UK
- Health Data Research UK, University of Edinburgh, Nine, Edinburgh Bioquarter, 9 Little France Road, Edinburgh, UK
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Adolfo Correa
- Departments of Medicine, Pediatrics and Population Health Science, University of Mississippi Medical Center, Jackson, MS, USA
| | - Dawood Darbar
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Antonio De Luca
- Cardiothoracovascular Department, Division of Cardiology, Azienda Sanitaria Universitaria Giuliano Isontina and University of Trieste, Trieste, Italy
| | - Jean-François Deleuze
- Université Paris-Saclay, CEA, Centre National de Recherche en Génomique Humaine (CNRGH), 91057, Evry, France
- Laboratory of Excellence GENMED (Medical Genomics), Paris, France
- Centre d'Etude du Polymorphisme Humain, Fondation Jean Dausset, Paris, France
| | - Christina Ellervik
- Department of Data and Data Support, Region Zealand, 4180, Sorø, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2100, Copenhagen, Denmark
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Christian Fuchsberger
- Eurac Research, Institute for Biomedicine (affiliated with the University of Lübeck), Bolzano, Italy
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Anuj Goel
- Radcliffe Department of Medicine, University of Oxford, Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK
- Wellcome Centre for Human Genetics, Roosevelt Drive, Oxford, UK
| | - Christopher Grace
- Radcliffe Department of Medicine, University of Oxford, Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK
- Wellcome Centre for Human Genetics, Roosevelt Drive, Oxford, UK
| | - Xiuqing Guo
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Susan R Heckbert
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rebecca D Jackson
- Center for Clinical and Translational Science, Ohio State Medical Center, Columbus, OH, USA
| | - Jan A Kors
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Allan Linneberg
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, København, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter W Macfarlane
- Institute of Health and Wellbeing, School of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Pau Navarro
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - David J Porteous
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Peter P Pramstaller
- Eurac Research, Institute for Biomedicine (affiliated with the University of Lübeck), Bolzano, Italy
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Alexander P Reiner
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | - Lorenz Risch
- Labormedizinisches zentrum Dr. Risch, Vaduz, Liechtenstein
- Faculty of Medical Sciences, Private University in the Principality of Liechtenstein, Triesen, Liechtenstein
- Center of Laboratory Medicine, University Institute of Clinical Chemistry, University of Bern, Inselspital, Bern, Switzerland
| | - Ulrich Schotten
- Dept. of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Xia Shen
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Greater Bay Area Institute of Precision Medicine (Guangzhou), Fudan University, Nansha District, Guangzhou, China
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Division of Cardiology, Azienda Sanitaria Universitaria Giuliano Isontina and University of Trieste, Trieste, Italy
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE), Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Monika Stoll
- Maastricht Center for Systems Biology (MaCSBio), Maastricht University, Maastricht, the Netherlands
- Dept. of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- Institute of Human Genetics, Genetic Epidemiology, University of Muenster, Muenster, Germany
| | - Eduardo Tarazona-Santos
- Department of Genetics, Ecology and Evolution, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Andrew Tinker
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katerina Trajanoska
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eric Villard
- Sorbonne Universite, INSERM, UMR-S1166, Research Unit on Cardiovascular Disorders, Metabolism and Nutrition, Team Genomics & Pathophysiology of Cardiovascular Disease, Paris, 75013, France
- ICAN Institute for Cardiometabolism and Nutrition, Paris, 75013, France
| | - Helen R Warren
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Eric A Whitsel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Kerri L Wiggins
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Dan E Arking
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christy L Avery
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Giorgia Girotto
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
- Department of Medical, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Niels Grarup
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Caroline Hayward
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
- Durrer Center for Cardiovascular Research, Amsterdam, the Netherlands
| | - Dennis O Mook-Kanamori
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands, Leiden, the Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands, Leiden, the Netherlands
| | | | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington, Seattte, WA, USA
| | - Cristian Pattaro
- Eurac Research, Institute for Biomedicine (affiliated with the University of Lübeck), Bolzano, Italy
| | - Antonio Luiz P Ribeiro
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Brazil, Belo Horizonte, Minas Gerais, Brazil
- Cardiology Service and Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil, Belo Horizonte, Minas Gerais, Brazil
| | - Jerome I Rotter
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
- Departments of Pediatrics and Human Genetics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
- Department of Cardiology, Heart and Lung Division, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cornelia M van Duijn
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Niek Verweij
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - James G Wilson
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michele Orini
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Philippe Charron
- Sorbonne Universite, INSERM, UMR-S1166, Research Unit on Cardiovascular Disorders, Metabolism and Nutrition, Team Genomics & Pathophysiology of Cardiovascular Disease, Paris, 75013, France
- ICAN Institute for Cardiometabolism and Nutrition, Paris, 75013, France
- APHP, Cardiology Department, Pitié-Salpêtrière Hospital, Paris, 75013, France
- APHP, Département de Génétique, Centre de Référence Maladies Cardiaques Héréditaires, Pitié-Salpêtrière Hospital, Paris, 75013, France
| | - Hugh Watkins
- Radcliffe Department of Medicine, University of Oxford, Division of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK
- Wellcome Centre for Human Genetics, Roosevelt Drive, Oxford, UK
| | - Charles Kooperberg
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Henry J Lin
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - James F Wilson
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, Scotland
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Borbala Mifsud
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Pier D Lambiase
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
- Department of Medicine, Cardiovascular Division, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.
| | - Patricia B Munroe
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK.
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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24
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Artola Arita V, Van De Lande ME, Khalilian Ekrami N, Nguyen BO, Van Melle JM, Geelhoed B, De With RR, Weberndörfer V, Erküner Ö, Hillege H, Linz D, Ten Cate H, Spronk HMH, Koldenhof T, Tieleman RG, Schotten U, Crijns HJGM, Van Gelder IC, Rienstra M. Clinical utility of the 4S-AF scheme in predicting progression of atrial fibrillation: data from the RACE V study. Europace 2023; 25:1323-1331. [PMID: 36857318 PMCID: PMC10105835 DOI: 10.1093/europace/euac268] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/23/2022] [Indexed: 03/02/2023] Open
Abstract
AIMS The recent 4S-AF (scheme proposed by the 2020 ESC AF guidelines to address stroke risk, symptom severity, severity of AF burden and substrate of AF to provide a structured phenotyping of AF patients in clinical practice to guide therapy and assess prognosis) scheme has been proposed as a structured scheme to characterize patients with atrial fibrillation (AF). We aimed to assess whether the 4S-AF scheme predicts AF progression in patients with self-terminating AF. METHODS AND RESULTS We analysed 341 patients with self-terminating AF included in the well-phenotyped Reappraisal of Atrial Fibrillation: Interaction between HyperCoagulability, Electrical remodelling, and Vascular Destabilization in the Progression of AF (RACE V) study. Patients had continuous monitoring with implantable loop recorders or pacemakers. AF progression was defined as progression to persistent or permanent AF or progression of self-terminating AF with >3% burden increase. Progression of AF was observed in 42 patients (12.3%, 5.9% per year). Patients were given a score based on the components of the 4S-AF scheme. Mean age was 65 [interquartile range (IQR) 58-71] years, 149 (44%) were women, 103 (49%) had heart failure, 276 (81%) had hypertension, and 38 (11%) had coronary artery disease. Median CHA2DS2-VASc (the CHA2DS2-VASc score assesses thromboembolic risk. C, congestive heart failure/left ventricular dysfunction; H, hypertension; A2, age ≥ 75 years; D, diabetes mellitus; S2, stroke/transient ischaemic attack/systemic embolism; V, vascular disease; A, age 65-74 years; Sc, sex category (female sex)) score was 2 (IQR 2-3), and median follow-up was 2.1 (1.5-2.6) years. The average score of the 4S-AF scheme was 4.6 ± 1.4. The score points from the 4S-AF scheme did not predict the risk of AF progression [odds ratio (OR) 1.1 95% CI 0.88-1.41, C-statistic 0.53]. However, excluding the symptoms domain, resulting in the 3S-AF (4S-AF scheme without the domain symptom severity, only including stroke risk, severity of AF burden and substrate of AF) scheme, predicted the risk of progression (OR 1.59 95% CI 1.15-2.27, C-statistic 0.62) even after adjusting for sex and age. CONCLUSIONS In self-terminating AF patients, the 4S-AF scheme does not predict AF progression. The 3S-AF scheme, excluding the symptom domain, may be a more appropriate score to predict AF progression. TRIAL REGISTRATION NUMBERS Clinicaltrials.gov NCT02726698 for RACE V.
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Affiliation(s)
- Vicente Artola Arita
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Martijn E Van De Lande
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Neda Khalilian Ekrami
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Bao-Oanh Nguyen
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Joost M Van Melle
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Ruben R De With
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Vanessa Weberndörfer
- Department of Cardiology, Maastricht University Medical Centre +, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Ömer Erküner
- Department of Cardiology, Maastricht University Medical Centre +, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Hans Hillege
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands.,Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Centre +, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Hugo Ten Cate
- Thrombosis Expertise Center (TEC) Maastricht, Departments of Biochemistry, Maastricht, The Netherlands.,Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Henri M H Spronk
- Thrombosis Expertise Center (TEC) Maastricht, Departments of Biochemistry, Maastricht, The Netherlands.,Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Tim Koldenhof
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands.,Department of Cardiology, Martini Hospital, Groningen, The Netherlands
| | - Robert G Tieleman
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands.,Department of Cardiology, Martini Hospital, Groningen, The Netherlands
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre +, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, The Netherlands
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25
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van der Velden J, Asselbergs FW, Bakkers J, Batkai S, Bertrand L, Bezzina CR, Bot I, Brundel BJJM, Carrier L, Chamuleau S, Ciccarelli M, Dawson D, Davidson SM, Dendorfer A, Duncker DJ, Eschenhagen T, Fabritz L, Falcão-Pires I, Ferdinandy P, Giacca M, Girao H, Gollmann-Tepeköylü C, Gyongyosi M, Guzik TJ, Hamdani N, Heymans S, Hilfiker A, Hilfiker-Kleiner D, Hoekstra AG, Hulot JS, Kuster DWD, van Laake LW, Lecour S, Leiner T, Linke WA, Lumens J, Lutgens E, Madonna R, Maegdefessel L, Mayr M, van der Meer P, Passier R, Perbellini F, Perrino C, Pesce M, Priori S, Remme CA, Rosenhahn B, Schotten U, Schulz R, Sipido KR, Sluijter JPG, van Steenbeek F, Steffens S, Terracciano CM, Tocchetti CG, Vlasman P, Yeung KK, Zacchigna S, Zwaagman D, Thum T. Animal models and animal-free innovations for cardiovascular research: current status and routes to be explored. Consensus document of the ESC Working Group on Myocardial Function and the ESC Working Group on Cellular Biology of the Heart. Cardiovasc Res 2022; 118:3016-3051. [PMID: 34999816 PMCID: PMC9732557 DOI: 10.1093/cvr/cvab370] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 01/05/2022] [Indexed: 01/09/2023] Open
Abstract
Cardiovascular diseases represent a major cause of morbidity and mortality, necessitating research to improve diagnostics, and to discover and test novel preventive and curative therapies, all of which warrant experimental models that recapitulate human disease. The translation of basic science results to clinical practice is a challenging task, in particular for complex conditions such as cardiovascular diseases, which often result from multiple risk factors and comorbidities. This difficulty might lead some individuals to question the value of animal research, citing the translational 'valley of death', which largely reflects the fact that studies in rodents are difficult to translate to humans. This is also influenced by the fact that new, human-derived in vitro models can recapitulate aspects of disease processes. However, it would be a mistake to think that animal models do not represent a vital step in the translational pathway as they do provide important pathophysiological insights into disease mechanisms particularly on an organ and systemic level. While stem cell-derived human models have the potential to become key in testing toxicity and effectiveness of new drugs, we need to be realistic, and carefully validate all new human-like disease models. In this position paper, we highlight recent advances in trying to reduce the number of animals for cardiovascular research ranging from stem cell-derived models to in situ modelling of heart properties, bioinformatic models based on large datasets, and state-of-the-art animal models, which show clinically relevant characteristics observed in patients with a cardiovascular disease. We aim to provide a guide to help researchers in their experimental design to translate bench findings to clinical routine taking the replacement, reduction, and refinement (3R) as a guiding concept.
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Grants
- R01 HL150359 NHLBI NIH HHS
- RG/16/14/32397 British Heart Foundation
- FS/18/37/33642 British Heart Foundation
- PG/17/64/33205 British Heart Foundation
- PG/15/88/31780 British Heart Foundation
- FS/RTF/20/30009, NH/19/1/34595, PG/18/35/33786, CS/17/4/32960, PG/15/88/31780, and PG/17/64/33205 British Heart Foundation
- NC/T001488/1 National Centre for the Replacement, Refinement and Reduction of Animals in Research
- PG/18/44/33790 British Heart Foundation
- CH/16/3/32406 British Heart Foundation
- FS/RTF/20/30009 British Heart Foundation
- NWO-ZonMW
- ZonMW and Heart Foundation for the translational research program
- Dutch Cardiovascular Alliance (DCVA)
- Leducq Foundation
- Dutch Research Council
- Association of Collaborating Health Foundations (SGF)
- UCL Hospitals NIHR Biomedical Research Centre, and the DCVA
- Netherlands CardioVascular Research Initiative CVON
- Stichting Hartekind and the Dutch Research Counsel (NWO) (OCENW.GROOT.2019.029)
- National Fund for Scientific Research, Belgium and Action de Recherche Concertée de la Communauté Wallonie-Bruxelles, Belgium
- Netherlands CardioVascular Research Initiative CVON (PREDICT2 and CONCOR-genes projects), the Leducq Foundation
- ERA PerMed (PROCEED study)
- Netherlands Cardiovascular Research Initiative
- Dutch Heart Foundation
- German Centre of Cardiovascular Research (DZHH)
- Chest Heart and Stroke Scotland
- Tenovus Scotland
- Friends of Anchor and Grampian NHS-Endowments
- National Institute for Health Research University College London Hospitals Biomedical Research Centre
- German Centre for Cardiovascular Research
- European Research Council (ERC-AG IndivuHeart), the Deutsche Forschungsgemeinschaft
- European Union Horizon 2020 (REANIMA and TRAINHEART)
- German Ministry of Education and Research (BMBF)
- Centre for Cardiovascular Research (DZHK)
- European Union Horizon 2020
- DFG
- National Research, Development and Innovation Office of Hungary
- Research Excellence Program—TKP; National Heart Program
- Austrian Science Fund
- European Union Commission’s Seventh Framework programme
- CVON2016-Early HFPEF
- CVON She-PREDICTS
- CVON Arena-PRIME
- European Union’s Horizon 2020 research and innovation programme
- Deutsche Forschungsgemeinschaft
- Volkswagenstiftung
- French National Research Agency
- ERA-Net-CVD
- Fédération Française de Cardiologie, the Fondation pour la Recherche Médicale
- French PIA Project
- University Research Federation against heart failure
- Netherlands Heart Foundation
- Dekker Senior Clinical Scientist
- Health Holland TKI-LSH
- TUe/UMCU/UU Alliance Fund
- south African National Foundation
- Cancer Association of South Africa and Winetech
- Netherlands Heart Foundation/Applied & Engineering Sciences
- Dutch Technology Foundation
- Pie Medical Imaging
- Netherlands Organisation for Scientific Research
- Dr. Dekker Program
- Netherlands CardioVascular Research Initiative: the Dutch Heart Foundation
- Dutch Federation of University Medical Centres
- Netherlands Organization for Health Research and Development and the Royal Netherlands Academy of Sciences for the GENIUS-II project
- Netherlands Organization for Scientific Research (NWO) (VICI grant); the European Research Council
- Incyte s.r.l. and from Ministero dell’Istruzione, Università e Ricerca Scientifica
- German Center for Cardiovascular Research (Junior Research Group & Translational Research Project), the European Research Council (ERC Starting Grant NORVAS),
- Swedish Heart-Lung-Foundation
- Swedish Research Council
- National Institutes of Health
- Bavarian State Ministry of Health and Care through the research project DigiMed Bayern
- ERC
- ERA-CVD
- Dutch Heart Foundation, ZonMw
- the NWO Gravitation project
- Ministero dell'Istruzione, Università e Ricerca Scientifica
- Regione Lombardia
- Netherlands Organisation for Health Research and Development
- ITN Network Personalize AF: Personalized Therapies for Atrial Fibrillation: a translational network
- MAESTRIA: Machine Learning Artificial Intelligence Early Detection Stroke Atrial Fibrillation
- REPAIR: Restoring cardiac mechanical function by polymeric artificial muscular tissue
- Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)
- European Union H2020 program to the project TECHNOBEAT
- EVICARE
- BRAV3
- ZonMw
- German Centre for Cardiovascular Research (DZHK)
- British Heart Foundation Centre for Cardiac Regeneration
- British Heart Foundation studentship
- NC3Rs
- Interreg ITA-AUS project InCARDIO
- Italian Association for Cancer Research
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Affiliation(s)
- Jolanda van der Velden
- Amsterdam UMC, Vrije Universiteit, Physiology, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Faculty of Population Health Sciences, Institute of Cardiovascular Science and Institute of Health Informatics, University College London, London, UK
| | - Jeroen Bakkers
- Hubrecht Institute-KNAW and University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sandor Batkai
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | - Luc Bertrand
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | - Connie R Bezzina
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pole of Cardiovascular Research, Brussels, Belgium
| | - Ilze Bot
- Heart Center, Department of Experimental Cardiology, Amsterdam UMC, Location Academic Medical Center, Amsterdam Cardiovascular Sciences, University of Amsterdam, Amsterdam, The Netherlands
- Division of BioTherapeutics, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Bianca J J M Brundel
- Amsterdam UMC, Vrije Universiteit, Physiology, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
| | - Lucie Carrier
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Steven Chamuleau
- Amsterdam UMC, Heart Center, Cardiology, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
| | - Michele Ciccarelli
- Department of Medicine, Surgery and Odontology, University of Salerno, Fisciano (SA), Italy
| | - Dana Dawson
- Department of Cardiology, Aberdeen Cardiovascular and Diabetes Centre, Aberdeen Royal Infirmary and University of Aberdeen, Aberdeen, UK
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London WC1E 6HX, UK
| | - Andreas Dendorfer
- Walter-Brendel-Centre of Experimental Medicine, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Thoraxcenter, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thomas Eschenhagen
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Larissa Fabritz
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Center of Cardiovascular Sciences and Department of Cardiology, University Heart Center Hamburg, Germany and Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Ines Falcão-Pires
- UnIC - Cardiovascular Research and Development Centre, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Portugal
| | - Péter Ferdinandy
- Cardiometabolic Research Group and MTA-SE System Pharmacology Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Mauro Giacca
- Department of Medicine, Surgery and Health Sciences and Cardiovascular Department, Centre for Translational Cardiology, Azienda Sanitaria Universitaria Integrata Trieste, Trieste, Italy
- International Center for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
- King’s British Heart Foundation Centre, King’s College London, London, UK
| | - Henrique Girao
- Univ Coimbra, Center for Innovative Biomedicine and Biotechnology, Faculty of Medicine, Coimbra, Portugal
- Clinical Academic Centre of Coimbra, Coimbra, Portugal
| | | | - Mariann Gyongyosi
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Tomasz J Guzik
- Instutute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Jagiellonian University, Collegium Medicum, Kraków, Poland
| | - Nazha Hamdani
- Division Cardiology, Molecular and Experimental Cardiology, Ruhr University Bochum, Bochum, Germany
- Institute of Physiology, Ruhr University Bochum, Bochum, Germany
| | - Stephane Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Andres Hilfiker
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Denise Hilfiker-Kleiner
- Department for Cardiology and Angiology, Hannover Medical School, Hannover, Germany
- Department of Cardiovascular Complications in Pregnancy and in Oncologic Therapies, Comprehensive Cancer Centre, Philipps-Universität Marburg, Germany
| | - Alfons G Hoekstra
- Computational Science Lab, Informatics Institute, Faculty of Science, University of Amsterdam, Amsterdam, the Netherlands
| | - Jean-Sébastien Hulot
- Université de Paris, INSERM, PARCC, F-75015 Paris, France
- CIC1418 and DMU CARTE, AP-HP, Hôpital Européen Georges-Pompidou, F-75015 Paris, France
| | - Diederik W D Kuster
- Amsterdam UMC, Vrije Universiteit, Physiology, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
| | - Linda W van Laake
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Sandrine Lecour
- Department of Medicine, Hatter Institute for Cardiovascular Research in Africa and Cape Heart Institute, University of Cape Town, Cape Town, South Africa
| | - Tim Leiner
- Department of Radiology, Utrecht University Medical Center, Utrecht, the Netherlands
| | - Wolfgang A Linke
- Institute of Physiology II, University of Muenster, Robert-Koch-Str. 27B, 48149 Muenster, Germany
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Esther Lutgens
- Experimental Vascular Biology Division, Department of Medical Biochemistry, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- DZHK, Partner Site Munich Heart Alliance, Munich, Germany
| | - Rosalinda Madonna
- Department of Pathology, Cardiology Division, University of Pisa, 56124 Pisa, Italy
- Department of Internal Medicine, Cardiology Division, University of Texas Medical School in Houston, Houston, TX, USA
| | - Lars Maegdefessel
- DZHK, Partner Site Munich Heart Alliance, Munich, Germany
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Manuel Mayr
- King’s British Heart Foundation Centre, King’s College London, London, UK
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robert Passier
- Department of Applied Stem Cell Technologies, TechMed Centre, University of Twente, 7500AE Enschede, The Netherlands
- Department of Anatomy and Embryology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Filippo Perbellini
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | - Cinzia Perrino
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Maurizio Pesce
- Unità di Ingegneria Tissutale Cardiovascolare, Centro cardiologico Monzino, IRCCS, Milan, Italy
| | - Silvia Priori
- Molecular Cardiology, Istituti Clinici Scientifici Maugeri, Pavia, Italy
- University of Pavia, Pavia, Italy
| | - Carol Ann Remme
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pole of Cardiovascular Research, Brussels, Belgium
| | - Bodo Rosenhahn
- Institute for information Processing, Leibniz University of Hanover, 30167 Hannover, Germany
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Rainer Schulz
- Institute of Physiology, Justus Liebig University Giessen, Giessen, Germany
| | - Karin R Sipido
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Joost P G Sluijter
- Experimental Cardiology Laboratory, Department of Cardiology, Regenerative Medicine Center Utrecht, Circulatory Health Laboratory, Utrecht University, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank van Steenbeek
- Division Heart & Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Sabine Steffens
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität München (LMU), Munich, Germany
- DZHK, Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Carlo Gabriele Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center for Clinical and Translational Research (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Patricia Vlasman
- Amsterdam UMC, Vrije Universiteit, Physiology, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
| | - Kak Khee Yeung
- Amsterdam UMC, Vrije Universiteit, Surgery, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
| | - Serena Zacchigna
- Department of Medicine, Surgery and Health Sciences and Cardiovascular Department, Centre for Translational Cardiology, Azienda Sanitaria Universitaria Integrata Trieste, Trieste, Italy
- International Center for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Dayenne Zwaagman
- Amsterdam UMC, Heart Center, Cardiology, Amsterdam Cardiovascular Science, Amsterdam, The Netherlands
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
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26
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Zeemering S, Isaacs A, Winters J, Maesen B, Bidar E, Dimopoulou C, Guasch E, Batlle M, Haase D, Hatem SN, Kara M, Kääb S, Mont L, Sinner MF, Wakili R, Maessen J, Crijns HJGM, Fabritz L, Kirchhof P, Stoll M, Schotten U. Atrial fibrillation in the presence and absence of heart failure enhances expression of genes involved in cardiomyocyte structure, conduction properties, fibrosis, inflammation, and endothelial dysfunction. Heart Rhythm 2022; 19:2115-2124. [PMID: 36007727 DOI: 10.1016/j.hrthm.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 07/29/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Little is known about genome-wide changes in the atrial transcriptome as a cause or consequence of atrial fibrillation (AF), and the effect of its common and clinically relevant comorbidity-heart failure (HF). OBJECTIVE The purpose of this study was to explore candidate disease processes for AF by investigating gene expression changes in atrial tissue samples from patients with and without AF, stratified by HF. METHODS RNA sequencing was performed in right and left atrial appendage tissue in 195 patients undergoing open heart surgery from centers participating in the CATCH-ME consortium (no history of AF, n = 91; paroxysmal AF, n = 53; persistent/permanent AF, n = 51). Analyses were stratified into patients with/without HF (n = 75/120) and adjusted for age, sex, atrial side, and a combination of clinical characteristics. RESULTS We identified 35 genes associated with persistent AF compared to patients without a history of AF, both in the presence or absence of HF (false discovery rate <0.05). These were mostly novel associations, including 13 long noncoding RNAs. Genes were involved in regulation of cardiomyocyte structure, conduction properties, fibrosis, inflammation, and endothelial dysfunction. Gene set enrichment analysis identified mainly inflammatory gene sets to be enriched in AF patients without HF, and gene sets involved in cellular respiration in AF patients with HF. CONCLUSION Analysis of atrial gene expression profiles identified numerous novel genes associated with persistent AF, in the presence or absence of HF. Interestingly, no consistent transcriptional changes were associated with paroxysmal AF, suggesting that AF-induced changes in gene expression predominate other changes.
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Affiliation(s)
- Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, the Netherlands
| | - Aaron Isaacs
- Department of Physiology, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, the Netherlands; Maastricht Centre for Systems Biology, Maastricht University, Maastricht, the Netherlands
| | - Joris Winters
- Department of Physiology, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, the Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, University Maastricht, Maastricht, the Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, University Maastricht, Maastricht, the Netherlands
| | | | - Eduard Guasch
- Cardiovascular Institute, Hospital Clinic Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; CIBERCV, Madrid, Spain
| | - Montserrat Batlle
- Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; CIBERCV, Madrid, Spain
| | | | - Stéphane N Hatem
- INSERM UMRS1166, Institute of CardioMetabolism and Nutrition, Sorbonne Université, Paris, France; Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Mansour Kara
- Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Stefan Kääb
- Department of Medicine I, University Hospital, Munich, Germany; German Centre for Cardiovascular Research, partner site Munich Heart, Munich, Germany
| | - Lluis Mont
- European Society of Cardiology, Sophia Antipolis, France; Cardiovascular Institute, Hospital Clinic Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; CIBERCV, Madrid, Spain
| | - Moritz F Sinner
- Department of Medicine I, University Hospital, Munich, Germany; German Centre for Cardiovascular Research, partner site Munich Heart, Munich, Germany
| | - Reza Wakili
- German Centre for Cardiovascular Research, partner site Munich Heart, Munich, Germany; Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Essen, Germany
| | - Jos Maessen
- Maastricht Centre for Systems Biology, Maastricht University, Maastricht, the Netherlands
| | - Harry J G M Crijns
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Larissa Fabritz
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; Department of Cardiology, UHB and SWBH NHS Trusts, Birmingham, United Kingdom
| | - Paulus Kirchhof
- INSERM UMRS1166, Institute of CardioMetabolism and Nutrition, Sorbonne Université, Paris, France; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; University Heart and Vascular Center UKE Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, partner site Hamburg/Kiel/Lübeck, Germany
| | - Monika Stoll
- Maastricht Centre for Systems Biology, Maastricht University, Maastricht, the Netherlands; Institute of Human Genetics, University of Muenster, Muenster, Germany
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, University Maastricht, Maastricht, the Netherlands; INSERM UMRS1166, Institute of CardioMetabolism and Nutrition, Sorbonne Université, Paris, France.
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27
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Fabritz L, Connolly DL, Czarnecki E, Dudek D, Guasch E, Haase D, Huebner T, Zlahoda-Huzior A, Jolly K, Kirchhof P, Obergassel J, Schotten U, Vettorazzi E, Winkelmann SJ, Zapf A, Schnabel RB. Smartphone and wearable detected atrial arrhythmias in Older Adults: Results of a fully digital European Case finding study. Eur Heart J Digit Health 2022; 3:610-625. [PMID: 36710894 PMCID: PMC9779806 DOI: 10.1093/ehjdh/ztac067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/24/2022] [Indexed: 11/23/2022]
Abstract
Aims Simplified detection of atrial arrhythmias via consumer-electronics would enable earlier therapy in at-risk populations. Whether this is feasible and effective in older populations is not known. Methods and results The fully remote, investigator-initiated Smartphone and wearable detected atrial arrhythmia in Older Adults Case finding study (Smart in OAC-AFNET 9) digitally enrolled participants ≥65 years without known atrial fibrillation, not receiving oral anticoagulation in Germany, Poland, and Spain for 8 weeks. Participants were invited by media communications and direct contacts. Study procedures adhered to European data protection. Consenting participants received a wristband with a photoplethysmography sensor to be coupled to their smartphone. The primary outcome was the detection of atrial arrhythmias lasting 6 min or longer in the first 4 weeks of monitoring. Eight hundred and eighty-two older persons (age 71 ± 5 years, range 65-90, 500 (57%) women, 414 (47%) hypertension, and 97 (11%) diabetes) recorded signals. Most participants (72%) responded to adverts or word of mouth, leaflets (11%) or general practitioners (9%). Participation was completely remote in 469/882 persons (53%). During the first 4 weeks, participants transmitted PPG signals for 533/696 h (77% of the maximum possible time). Atrial arrhythmias were detected in 44 participants (5%) within 28 days, and in 53 (6%) within 8 weeks. Detection was highest in the first monitoring week [incidence rates: 1st week: 3.4% (95% confidence interval 2.4-4.9); 2nd-4th week: 0.55% (0.33-0.93)]. Conclusion Remote, digitally supported consumer-electronics-based screening is feasible in older European adults and identifies atrial arrhythmias in 5% of participants within 4 weeks of monitoring (NCT04579159).
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Affiliation(s)
- L Fabritz
- Corresponding author. Tel. +4940741057980,
| | - D L Connolly
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston Wolfson Drive, B15 2TT Birmingham, UK,Department of Cardiology and R&D, Birmingham City Hospital, Sandwell and West Birmingham Trust, Dudley Road, B18 7QH Birmingham, UK
| | - E Czarnecki
- Atrial Fibrillation NETwork (AFNET), Mendelstr 11, 48149 Münster, Germany
| | - D Dudek
- Jagiellonian University Medical College, Center for Digital Medicine and Robotics, Ul. Kopernika 7E, 33-332 Kraków, Poland,Maria Cecilia Hospital, Via Corriera, 1, 48033 Cotignola RA, Italy
| | - E Guasch
- Institut Clínic Cardio-Vascular, Hospital Clínic, University of Barcelona, Carrer de Villaroel, 170, 08036 Barcelona, CA, Spain, Spain,IDIBAPS, Rosselló 149-153, 08036 Barcelona, CA, Spain,CIBERCV, Monforte de Lemos 3-5, Pabellon 11, Planta 0, 28029 Madrid, Spain
| | - D Haase
- Atrial Fibrillation NETwork (AFNET), Mendelstr 11, 48149 Münster, Germany
| | - T Huebner
- Preventicus GmbH, Ernst-Abbe-Straße 15, 07743 Jena, Germany
| | - A Zlahoda-Huzior
- Department of Measurement and Electronics, AGH University of Science and Technology, Al. Mickiewicza 30, 30-059 Kraków, Poland
| | - K Jolly
- Institute of Applied Health Research, University of Birmingham, Edgbaston, B15 2TT Birmingham, UK
| | - P Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251 Hamburg, Germany,DZHK German Center for Cardiovascular Research, partner site Hamburg/Luebeck/Kiel, Germany,Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston Wolfson Drive, B15 2TT Birmingham, UK,Atrial Fibrillation NETwork (AFNET), Mendelstr 11, 48149 Münster, Germany
| | - J Obergassel
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251 Hamburg, Germany,Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251 Hamburg, Germany,DZHK German Center for Cardiovascular Research, partner site Hamburg/Luebeck/Kiel, Germany
| | - U Schotten
- Atrial Fibrillation NETwork (AFNET), Mendelstr 11, 48149 Münster, Germany,Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center +, Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - E Vettorazzi
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Christoph-Probst-Weg 1, 20246 Hamburg, Germany
| | - S J Winkelmann
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251 Hamburg, Germany,Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251 Hamburg, Germany
| | - A Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Christoph-Probst-Weg 1, 20246 Hamburg, Germany
| | - R B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistr. 52, 20251 Hamburg, Germany,DZHK German Center for Cardiovascular Research, partner site Hamburg/Luebeck/Kiel, Germany,Atrial Fibrillation NETwork (AFNET), Mendelstr 11, 48149 Münster, Germany
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28
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Verhaert DVM, Linz D, Wassink GF, Weijs B, Philippens S, Luermans JGLM, Westra SW, Schotten U, Vernooy K, den Uijl DW. A new efficient and integrated pathway for patient evaluation prior to atrial fibrillation ablation. Eur J Cardiovasc Nurs 2022:6756528. [PMID: 36218087 DOI: 10.1093/eurjcn/zvac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022]
Abstract
AIM In this quality improvement project, a care pathway for patients considered for atrial fibrillation (AF) ablation was optimized with the goals to improve the patient journey and simultaneously integrate prospective data collection into the clinical process. METHODS AND RESULTS The Lean Six Sigma approach was used to map the pre-existing process, identify constraints and formulate countermeasures. The percentage of patients going through the full pre-ablation preparation that eventually underwent AF ablation, number of hospital visits and consultations, pathway compliance, and completeness of scientific data were measured before and after pathway optimisation. Constraints in the process were (1) lack of standardized processes, (2) inefficient use of resources, (3) lack of multidisciplinary integration, (4) lack of research integration, and (5) suboptimal communication. The impact of the corresponding countermeasures (defining a uniform process, incorporating 'go/no-go' moment, introducing a 'one-stop-shop', integrating prospective data collection, and improving communication) was studied for 33 patients before and 26 patients after pathway optimisation. After optimisation, the percentage of patients receiving a full pre-ablation preparation that eventually underwent AF ablation increased from 59% to 94% (p < 0.01). Fewer hospital visits (3.2 ± 1.2 versus 2.3 ± 0.8, p = 0.01) and electrophysiologist consultations (1.8 ± 0.7 versus 1.0 ± 0.3, p < 0.01) were required after pathway optimisation. Pathway compliance and complete collection of scientific data increased significantly (3% versus 73%, p < 0.01 and 15% versus 73%, p < 0.01, respectively). CONCLUSION The optimisation project resulted in a more efficient evaluation of patients considered for AF ablation. The new more efficient process includes prospective data collection and facilitates easy conduct of research studies focused on improvements of patient outcomes.
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Affiliation(s)
- Dominique V M Verhaert
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands.,Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Geert F Wassink
- Integrated Health Solutions, Medtronic plc, Eindhoven, The Netherlands
| | - Bob Weijs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology and Electrophysiology, Katholische Stiftung Marienhospital Aachen, Aachen. Germany
| | - Suzanne Philippens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Sjoerd W Westra
- Department of Cardiology, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Dennis W den Uijl
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
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29
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Verhaert DVM, Knackstedt C, Lankveld TAR, Den Uijl DW, Habibi Z, Westra SW, Hermans ANL, Betz K, Van Der Velden RMJ, Gawalko MM, Schotten U, Linz DK, Vernooy K. We all know A and B, but what about C? Exploring the management of modifiable risk factors in patients with atrial fibrillation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) advise to treat AF according to the ABC pathway: A, anticoagulation, B, better symptom control, and C, comorbidities and cardiovascular risk factor management. Optimal treatment of comorbidities and risk factors slows AF progression and improves success rates of rhythm interventions for AF. However, several studies report underdiagnosis and therefore possible undertreatment for common cardiovascular comorbidities.
Purpose
This study aims to evaluate how common modifiable cardiovascular risk factors are managed in AF patients referred for catheter ablation.
Methods
This is a substudy of the ISOLATION study, a prospective cohort study including consecutive patients with paroxysmal or persistent AF referred for AF ablation. Screening for common modifiable risk factors for AF is structurally embedded in the work-up for AF ablation in the two participating centres. In the present study the prevalence of the following risk factors at this screening moment was assessed: (1) body mass index (BMI) above the target BMI for ablation (≥27 kg/m2), (2) hypertension, defined as on-site systolic blood pressure >130 mmHg and/or diastolic blood pressure >80 mmHg, (3) decreased glucose tolerance or diabetes mellitus, defined as HbA1c ≥6.5%, (4) dyslipidaemia, defined as low-density lipoprotein (LDL) ≥2.5 mmol/l, (5) regular alcohol consumption, defined as self-reported consumption of >15 standardized units/week, and (6) sleep disordered breathing (SDB), defined as apnoea-hypopnoea index (AHI) ≥15 assessed with home sleep tests (subset of patients).
Results
Among the 981 patients studied (median age 65 [59–71] years old, 64% male, 69% paroxysmal AF), previously diagnosed comorbidities were common (46% hypertension, 7% diabetes, 22% dyslipidaemia, 10% SDB), and a large proportion of patients received targeted treatment (Table 1). However, non-optimally managed risk factors remained significant (Figure 1). BMI ≥27 kg/m2 was present in 56% of patients. High systolic and diastolic blood pressure were present in 62% and 51% of patients, respectively, and any form of high blood pressure (either systolic or diastolic) was seen in 72% of patients. HbA1c was found to be above target ranges in 9% patients and LDL in 56%. A weekly alcohol consumption of ≥15 units was reported by 4% of patients. Screening for SDB was performed in a subset of patients (n=287), for whom AHI was ≥15 in 52%. Overall, 9% of patients had 4 or more non-optimally controlled modifiable risk factors, whereas the median number of modifiable risk factors was 2 [1–3].
Conclusions
Structural screening revealed a high prevalence of non-optimally controlled modifiable cardiovascular risk factors in patients referred for AF catheter ablation. According to recent ESC guidelines, improving treatment of comorbidities may improve AF ablation success rates and even reduce mortality.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- D V M Verhaert
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
| | - C Knackstedt
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - T A R Lankveld
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - D W Den Uijl
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - Z Habibi
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
| | - S W Westra
- Radboud University Medical Center , Nijmegen , The Netherlands
| | - A N L Hermans
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - K Betz
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - R M J Van Der Velden
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - M M Gawalko
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht , The Netherlands
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Department of physiology , Maastricht , The Netherlands
| | - D K Linz
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
| | - K Vernooy
- Maastricht University Medical Center and Radboud University Medical Center, Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht/Nijmegen , The Netherlands
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Bijvoet GP, Hermans BJM, Holtackers RJ, Luermans JGLM, Linz D, Maesen B, Mihl C, Nijveldt R, Vernooy K, Wildberger JE, Schotten U, Chaldoupi SM. The use of novel 3D dark-blood late gadolinium enhancement MRI to determine the optimal threshold for atrial scar after pulmonary vein isolation ablation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Dark-blood late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) is proved to be superior to bright-blood LGE MRI in localising subtle subendocardial scar in the ventricles, because of improved contrast between myocardial scar and blood. However, dark-blood LGE MRI has not yet been applied to identify atrial scar in the left atrium (LA) and therefore its threshold to determine scar is unknown.
Purpose
To determine the optimal intensity threshold for 3D dark-blood LGE MRI for atrial ablation scar after pulmonary vein isolation (PVI)
Methods
Twelve re-do PVI patients with symptomatic atrial fibrillation (AF) who underwent pre-procedural 3D dark-blood LGE MRI were included. The image intensity ratio (IIR = myocardial intensity normalized to the blood pool) from the LGE MRI were calculated using ADAS-AF. High-density bipolar voltages (BiV) maps were recorded during sinus rhythm prior to ablation. All BiV locations ≤5 mm from the ADAS LA anatomy were compared with the corresponding IIR, using custom-made software in MATLAB. To achieve an equal ratio between scar (BiV ≤0.15 mV) and non-scar (BiV >0.15 mV) for each patient, non-scar pairs were randomly resampled to the same number as scar pairs. This was repeated 10 times and for every random selection, receiver operating characteristics (ROC) analysis was performed to determine the optimal IIR threshold (provided by the Youden's index) for scar defined as BiV <0.15 mV (Figure 1). All IIR thresholds and areas under the curve were averaged to determine the overall performance and optimal IIR threshold.
Results
Of the 12 included patients, 8 had prior cryo PVI, 2 radiofrequency PVI, and 2 surgical/hybrid AF ablation. ROC curve analysis estimated the average optimal threshold for predicting BiV <0.15 mV to be an IIR of 1.106, with a mean area under the curve (AUC) of 0.73 (Figure 1). Figure 2 shows two examples of the IIR map (A), BiV map (B), and the correspondence map (C) providing information on spatial agreement between IIR and BiV. This individual qualitative assessment provides insight into the spatial variation between techniques and may facilitate future studies on the pathophysiological understanding of atrial ablation scarring.
Conclusion
This is the first study to use the novel 3D dark-blood whole heart LGE MRI to evaluate LA ablation scar after PVI. Based on the ROC analyses, an IIR of 1.106 is the optimal threshold for atrial ablation scar, defined as high density bipolar voltage <0.15 mV.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- G P Bijvoet
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - B J M Hermans
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - R J Holtackers
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - J G L M Luermans
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - D Linz
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - B Maesen
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - C Mihl
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - R Nijveldt
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - K Vernooy
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - J E Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
| | - S M Chaldoupi
- Cardiovascular Research Institute Maastricht (CARIM), Department of Physiology , Maastricht , The Netherlands
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Kawczynski MJ, Van De Walle S, Maesen B, Isaacs A, Zeemering S, Hermans B, Vernooy K, Maessen JG, Schotten U, Bidar E. Preoperative P-wave parameters and risk of atrial fibrillation after cardiac surgery: a meta-analysis of 20 201 patients. Interact Cardiovasc Thorac Surg 2022; 35:6673150. [PMID: 35993895 PMCID: PMC9492265 DOI: 10.1093/icvts/ivac220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
To evaluate the role of P-wave parameters, as defined on preprocedural electrocardiography (ECG), in predicting atrial fibrillation after cardiac surgery [postoperative atrial fibrillation (POAF)].
METHODS
PubMed, Cochrane library and Embase were searched for studies reporting on P-wave parameters and risk of POAF. Meta-analysis of P-wave parameters reported by at least 5 different publications was performed. In case of receiver operator characteristics (ROC-curve) analysis in the original publications, an ROC meta-analysis was performed to summarize the sensitivity and specificity.
RESULTS
Thirty-two publications, with a total of 20 201 patients, contributed to the meta-analysis. Increased P-wave duration, measured on conventional 12-lead ECG (22 studies, Cohen’s d = 0.4, 95% confidence interval: 0.3–0.5, P < 0.0001) and signal-averaged ECG (12 studies, Cohen’s d = 0.8, 95% confidence interval: 0.5–1.2, P < 0.0001), was a predictor of POAF independently from left atrial size. ROC meta-analysis for signal-averaged ECG P-wave duration showed an overall sensitivity of 72% (95% confidence interval: 65–78%) and specificity of 68% (95% confidence interval: 58–77%). Summary ROC curve had a moderate discriminative power with an area under the curve of 0.76. There was substantial heterogeneity in the meta-analyses for P-wave dispersion and PR-interval.
CONCLUSIONS
This meta-analysis shows that increased P-wave duration, measured on conventional 12-lead ECG and signal-averaged ECG, predicted POAF in patients undergoing cardiac surgery.
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Affiliation(s)
- Michal J Kawczynski
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Sophie Van De Walle
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Aaron Isaacs
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Stef Zeemering
- Department of Physiology, Maastricht University , Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Ben Hermans
- Department of Physiology, Maastricht University , Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
- Department of Cardiology, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
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32
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Young WJ, Lahrouchi N, Isaacs A, Duong T, Foco L, Ahmed F, Brody JA, Salman R, Noordam R, Benjamins JW, Haessler J, Lyytikäinen LP, Repetto L, Concas MP, van den Berg ME, Weiss S, Baldassari AR, Bartz TM, Cook JP, Evans DS, Freudling R, Hines O, Isaksen JL, Lin H, Mei H, Moscati A, Müller-Nurasyid M, Nursyifa C, Qian Y, Richmond A, Roselli C, Ryan KA, Tarazona-Santos E, Thériault S, van Duijvenboden S, Warren HR, Yao J, Raza D, Aeschbacher S, Ahlberg G, Alonso A, Andreasen L, Bis JC, Boerwinkle E, Campbell A, Catamo E, Cocca M, Cutler MJ, Darbar D, De Grandi A, De Luca A, Ding J, Ellervik C, Ellinor PT, Felix SB, Froguel P, Fuchsberger C, Gögele M, Graff C, Graff M, Guo X, Hansen T, Heckbert SR, Huang PL, Huikuri HV, Hutri-Kähönen N, Ikram MA, Jackson RD, Junttila J, Kavousi M, Kors JA, Leal TP, Lemaitre RN, Lin HJ, Lind L, Linneberg A, Liu S, MacFarlane PW, Mangino M, Meitinger T, Mezzavilla M, Mishra PP, Mitchell RN, Mononen N, Montasser ME, Morrison AC, Nauck M, Nauffal V, Navarro P, Nikus K, Pare G, Patton KK, Pelliccione G, Pittman A, Porteous DJ, Pramstaller PP, Preuss MH, Raitakari OT, Reiner AP, Ribeiro ALP, Rice KM, Risch L, Schlessinger D, Schotten U, Schurmann C, Shen X, Shoemaker MB, Sinagra G, Sinner MF, Soliman EZ, Stoll M, Strauch K, Tarasov K, Taylor KD, Tinker A, Trompet S, Uitterlinden A, Völker U, Völzke H, Waldenberger M, Weng LC, Whitsel EA, Wilson JG, Avery CL, Conen D, Correa A, Cucca F, Dörr M, Gharib SA, Girotto G, Grarup N, Hayward C, Jamshidi Y, Järvelin MR, Jukema JW, Kääb S, Kähönen M, Kanters JK, Kooperberg C, Lehtimäki T, Lima-Costa MF, Liu Y, Loos RJF, Lubitz SA, Mook-Kanamori DO, Morris AP, O'Connell JR, Olesen MS, Orini M, Padmanabhan S, Pattaro C, Peters A, Psaty BM, Rotter JI, Stricker B, van der Harst P, van Duijn CM, Verweij N, Wilson JF, Arking DE, Ramirez J, Lambiase PD, Sotoodehnia N, Mifsud B, Newton-Cheh C, Munroe PB. Genetic analyses of the electrocardiographic QT interval and its components identify additional loci and pathways. Nat Commun 2022; 13:5144. [PMID: 36050321 PMCID: PMC9436946 DOI: 10.1038/s41467-022-32821-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 08/17/2022] [Indexed: 11/10/2022] Open
Abstract
The QT interval is an electrocardiographic measure representing the sum of ventricular depolarization and repolarization, estimated by QRS duration and JT interval, respectively. QT interval abnormalities are associated with potentially fatal ventricular arrhythmia. Using genome-wide multi-ancestry analyses (>250,000 individuals) we identify 177, 156 and 121 independent loci for QT, JT and QRS, respectively, including a male-specific X-chromosome locus. Using gene-based rare-variant methods, we identify associations with Mendelian disease genes. Enrichments are observed in established pathways for QT and JT, and previously unreported genes indicated in insulin-receptor signalling and cardiac energy metabolism. In contrast for QRS, connective tissue components and processes for cell growth and extracellular matrix interactions are significantly enriched. We demonstrate polygenic risk score associations with atrial fibrillation, conduction disease and sudden cardiac death. Prioritization of druggable genes highlight potential therapeutic targets for arrhythmia. Together, these results substantially advance our understanding of the genetic architecture of ventricular depolarization and repolarization.
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Affiliation(s)
- William J Young
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
| | - Najim Lahrouchi
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge, MA, USA
- Cardiovascular Research Center, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Aaron Isaacs
- Deptartment of Physiology, Cardiovascular Research Institute Maastricht CARIM, Maastricht University, Maastricht, The Netherlands
- Maastricht Center for Systems Biology MaCSBio, Maastricht University, Maastricht, The Netherlands
| | - ThuyVy Duong
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Luisa Foco
- Eurac Research, Institute for Biomedicine affiliated with the University of Lübeck, Bolzano, Italy
| | - Farah Ahmed
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
| | - Jennifer A Brody
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Reem Salman
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
| | - Raymond Noordam
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan-Walter Benjamins
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Jeffrey Haessler
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Leo-Pekka Lyytikäinen
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
- Department of Clinical Chemistry, Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Linda Repetto
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Maria Pina Concas
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Marten E van den Berg
- Department of Epidemiology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Stefan Weiss
- DZHK German Centre for Cardiovascular Research; partner site Greifswald, Greifswald, Germany
- Interfaculty Institute for Genetics and Functional Genomics; Department of Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Antoine R Baldassari
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Traci M Bartz
- Cardiovascular Health Research Unit, Departments of Biostatistics and Medicine, University of Washington, Seattle, WA, USA
| | - James P Cook
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Daniel S Evans
- California Pacific Medical Center, Research Institute, San Francisco, CA, USA
| | - Rebecca Freudling
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany
- Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Oliver Hines
- Genetics Research Centre, St George's University of London, London, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Jonas L Isaksen
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Honghuang Lin
- National Heart Lung and Blood Institute's and Boston University's Framingham Heart Study, Framingham, MA, USA
- Section of Computational Biomedicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Hao Mei
- Department of Data Science, University of Mississippi Medical Center, Jackson, USA
| | - Arden Moscati
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Martina Müller-Nurasyid
- Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- IBE, Faculty of Medicine, LMU Munich, Munich, Germany
- Institute of Medical Biostatistics, Epidemiology and Informatics IMBEI, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Casia Nursyifa
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Yong Qian
- Translational Gerontology Branch, National Institute on Aging, National Institute of Health, Baltimore, US
| | - Anne Richmond
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Carolina Roselli
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
| | - Kathleen A Ryan
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
- Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eduardo Tarazona-Santos
- Department of Genetics, Ecology and Evolution, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte/Minas Gerais, Brazil
| | - Sébastien Thériault
- Population Health Research Institute, McMaster University, Hamilton, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology, Université Laval, Quebec, Canada
| | - Stefan van Duijvenboden
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Helen R Warren
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jie Yao
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Dania Raza
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - Stefanie Aeschbacher
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gustav Ahlberg
- Laboratory for Molecular Cardiology, The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Laura Andreasen
- Laboratory for Molecular Cardiology, The Heart Centre, Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Joshua C Bis
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Eric Boerwinkle
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX, USA
| | - Archie Campbell
- Usher Institute, University of Edinburgh, Nine, Edinburgh Bioquarter, 9 Little France Road, Edinburgh, UK
- Health Data Research UK, University of Edinburgh, Nine, Edinburgh Bioquarter, 9 Little France Road, Edinburgh, UK
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Eulalia Catamo
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Massimiliano Cocca
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Michael J Cutler
- Intermountain Heart Institute, Intermountain Medical Center, Murray, UT, USA
| | - Dawood Darbar
- Department of Medicine, University of Illinois at Chicago, Chicago, USA
| | - Alessandro De Grandi
- Eurac Research, Institute for Biomedicine affiliated with the University of Lübeck, Bolzano, Italy
| | - Antonio De Luca
- Cardiothoracovascular Department, ASUGI, University of Trieste, Trieste, Italy
| | - Jun Ding
- Translational Gerontology Branch, National Institute on Aging, National Institute of Health, Baltimore, US
| | - Christina Ellervik
- Department of Data and Data Support, Region Zealand, 4180, Sorø, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2100, Copenhagen, Denmark
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Demoulas Center for Cardiac Arrhythmias and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Stephan B Felix
- DZHK German Centre for Cardiovascular Research; partner site Greifswald, Greifswald, Germany
- Department of Internal Medicine B - Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine; University Medicine Greifswald, Greifswald, Germany
| | - Philippe Froguel
- Department of Epidemiology and Biostatistics, MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
- University of Lille Nord de France, Lille, France
- CNRS UMR8199, Institut Pasteur de Lille, Lille, France
| | - Christian Fuchsberger
- Eurac Research, Institute for Biomedicine affiliated with the University of Lübeck, Bolzano, Italy
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, USA
- Center for Statistical Genetics, University of Michigan School of Public Health, Ann Arbor, USA
| | - Martin Gögele
- Eurac Research, Institute for Biomedicine affiliated with the University of Lübeck, Bolzano, Italy
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Mariaelisa Graff
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xiuqing Guo
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Susan R Heckbert
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology/University of Washington, Seattle, WA, USA
| | - Paul L Huang
- Cardiology Division and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and University Hospital of Oulu, Oulu, Finland
| | - Nina Hutri-Kähönen
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
- Department of Pediatrics, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Tampere Centre for Skills Training and Simulation, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Rebecca D Jackson
- Center for Clinical and Translational Science, Ohio State Medical Center, Columbus, OH, USA
| | - Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and University Hospital of Oulu, Oulu, Finland
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Jan A Kors
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, NL, The Netherlands
| | - Thiago P Leal
- Department of Genetics, Ecology and Evolution, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte/Minas Gerais, Brazil
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rozenn N Lemaitre
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Henry J Lin
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lars Lind
- Deptartment of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Allan Linneberg
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Simin Liu
- Center for Global Cardiometabolic Health, Departments of Epidemiology, Medicine and Surgery, Brown University, Providence, USA
| | - Peter W MacFarlane
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Massimo Mangino
- Department of Twin Research and Genetic Epidemiology, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Foundation Trust, London, UK
| | - Thomas Meitinger
- Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- Institute of Human Genetics, Technical University of Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany
| | - Massimo Mezzavilla
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Pashupati P Mishra
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
- Department of Clinical Chemistry, Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Rebecca N Mitchell
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nina Mononen
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
- Department of Clinical Chemistry, Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - May E Montasser
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
- Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Matthias Nauck
- DZHK German Centre for Cardiovascular Research; partner site Greifswald, Greifswald, Germany
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Victor Nauffal
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Pau Navarro
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - Kjell Nikus
- Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
- Department of Cardiology, Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Guillaume Pare
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Kristen K Patton
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Giulia Pelliccione
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Alan Pittman
- Genetics Research Centre, St George's University of London, London, UK
| | - David J Porteous
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, UK
| | - Peter P Pramstaller
- Eurac Research, Institute for Biomedicine affiliated with the University of Lübeck, Bolzano, Italy
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Michael H Preuss
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Olli T Raitakari
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland
- Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
| | - Alexander P Reiner
- Department of Epidemiology/University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | - Antonio Luiz P Ribeiro
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Brazil, Belo Horizonte, Minas Gerais, Brazil
- Cardiology Service and Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil, Belo Horizonte, Minas Gerais, Brazil
| | - Kenneth M Rice
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Lorenz Risch
- Labormedizinisches zentrum Dr. Risch, Vaduz, Liechtenstein
- Faculty of Medical Sciences, Private University in the Principality of Liechtenstein, Triesen, Liechtenstein
- Center of Laboratory Medicine, University Institute of Clinical Chemistry, University of Bern, Inselspital, Bern, Switzerland
| | - David Schlessinger
- Laboratory of Genetics and Genomics, National Institute on Aging, National Institute of Health, Baltimore, US
| | - Ulrich Schotten
- Deptartment of Physiology, Cardiovascular Research Institute Maastricht CARIM, Maastricht University, Maastricht, The Netherlands
| | - Claudia Schurmann
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Digital Health Center, Hasso Plattner Institute, University of Potsdam, Potsdam, Germany
- Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xia Shen
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Greater Bay Area Institute of Precision Medicine Guangzhou, Fudan University, Nansha District, Guangzhou, China
| | - M Benjamin Shoemaker
- Department of Medicine, Division of Cardiovascular Medicine, Arrhythmia Section, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, ASUGI, University of Trieste, Trieste, Italy
| | - Moritz F Sinner
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center EPICARE, Wake Forest School of Medicine, Winston Salem, USA
| | - Monika Stoll
- Maastricht Center for Systems Biology MaCSBio, Maastricht University, Maastricht, The Netherlands
- Dept. of Biochemistry, Cardiovascular Research Institute Maastricht CARIM, Maastricht University, Maastricht, NL, The Netherlands
- Institute of Human Genetics, Genetic Epidemiology, University of Muenster, Muenster, Germany
| | - Konstantin Strauch
- Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- IBE, Faculty of Medicine, LMU Munich, Munich, Germany
- Institute of Medical Biostatistics, Epidemiology and Informatics IMBEI, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Kirill Tarasov
- Laboratory of Cardiovascular Sciences, National Institute on Aging, National Institute of Health, Baltimore, US
| | - Kent D Taylor
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Andrew Tinker
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stella Trompet
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Uwe Völker
- DZHK German Centre for Cardiovascular Research; partner site Greifswald, Greifswald, Germany
- Interfaculty Institute for Genetics and Functional Genomics; Department of Functional Genomics, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- DZHK German Centre for Cardiovascular Research; partner site Greifswald, Greifswald, Germany
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Melanie Waldenberger
- DZHK (German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany
- Research Unit Molecular Epidemiology, Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Lu-Chen Weng
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Eric A Whitsel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - James G Wilson
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, USA
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, USA
| | - Christy L Avery
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Adolfo Correa
- Departments of Medicine, Pediatrics and Population Health Science, University of Mississippi Medical Center, Jackson, USA
| | - Francesco Cucca
- Institute of Genetic and Biomedical Rsearch, Italian National Research Council, Monserrato, Italy
| | - Marcus Dörr
- DZHK German Centre for Cardiovascular Research; partner site Greifswald, Greifswald, Germany
- Department of Internal Medicine B - Cardiology, Pneumology, Infectious Diseases, Intensive Care Medicine; University Medicine Greifswald, Greifswald, Germany
| | - Sina A Gharib
- Center for Lung Biology, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Giorgia Girotto
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
- Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Niels Grarup
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Caroline Hayward
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Yalda Jamshidi
- Genetics Research Centre, St George's University of London, London, UK
| | - Marjo-Riitta Järvelin
- Center for Life Course Health Research, Faculty of Medicine, University of Oulu, Oulu, Finland
- Unit of Primary Health Care, Oulu University Hospital, Oulu, Finland
- Department of Epidemiology and Biostatistics, MRC PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
- Department of Life Sciences, College of Health and Life Sciences, Brunel University London, London, UK
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Stefan Kääb
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany
- DZHK (German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany
| | - Mika Kähönen
- Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland
- Department of Clinical Physiology, Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Charles Kooperberg
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories, Tampere, Finland
- Department of Clinical Chemistry, Finnish Cardiovascular Research Center - Tampere, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Yongmei Liu
- Department of Medicine, Duke University, Durham, NC, USA
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven A Lubitz
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, MA, USA
- Demoulas Center for Cardiac Arrhythmias and Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Dennis O Mook-Kanamori
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew P Morris
- Department of Health Data Science, University of Liverpool, Liverpool, UK
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, The University of Manchester, Manchester, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Jeffrey R O'Connell
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
- Program for Personalized and Genomic Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Michele Orini
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Cristian Pattaro
- Eurac Research, Institute for Biomedicine affiliated with the University of Lübeck, Bolzano, Italy
| | - Annette Peters
- Institute of Genetic Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
- DZHK (German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology/University of Washington, Seattle, WA, USA
- Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Jerome I Rotter
- Institute for Translational Genomics and Population Sciences/The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
- Department of Pediatrics/Harbor-UCLA Medical Center, Torrance, CA, USA
- Departments of Pediatrics and Human Genetics/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Bruno Stricker
- Department of Epidemiology, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
- Department of Cardiology, Heart and Lung Division, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cornelia M van Duijn
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Niek Verweij
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - James F Wilson
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, Scotland
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, Scotland
| | - Dan E Arking
- McKusick-Nathans Institute, Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia Ramirez
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Pier D Lambiase
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS trust, London, UK
- Institute of Cardiovascular Sciences, University of College London, London, UK
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Borbala Mifsud
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK
- Genomics and Translational Biomedicine, College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Christopher Newton-Cheh
- Program in Medical and Population Genetics, Broad Institute of Harvard and MIT, Cambridge, MA, USA.
- Cardiovascular Research Center, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Patricia B Munroe
- William Harvey Research Institute, Clinical Pharmacology, Queen Mary University of London, London, UK.
- NIHR Barts Cardiovascular Biomedical Research Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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van Mourik MJW, Artola Arita V, Lyon A, Lumens J, De With RR, van Melle JP, Schotten U, Bekkers SCAM, Crijns HJGM, Van Gelder IC, Rienstra M, Linz DK. Association between comorbidities and left and right atrial dysfunction in patients with paroxysmal atrial fibrillation: Analysis of AF-RISK. Int J Cardiol 2022; 360:29-35. [PMID: 35618104 DOI: 10.1016/j.ijcard.2022.05.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND To identify the association between comorbidities and left atrial (LA) and right atrial (RA) function in patients with paroxysmal atrial fibrillation (AF). METHODS This is a cross-sectional study. Speckle-tracking echocardiography was performed in 344 patients with paroxysmal AF at baseline, and available in 298 patients after 1-year follow-up. The number of comorbidities (hypertension, diabetes mellitus, coronary artery disease, body mass index > 25 kg/m2, age > 65 years, moderate to severe mitral valve regurgitation and kidney dysfunction (estimated glomerular filtration rate < 60 ml/min/1.73 m2)) was determined and the association with atrial strain was tested. RESULTS Mean age of the patients was 58 (SD 12) years and 137 patients were women (40%). Patients with a higher number of comorbidities had larger LA volumes (p for trend <0.001), and had a decrease in all strain phases from the LA and RA, except for the RA contraction phase (p for trend 0.47). A higher number of comorbidities was associated with LA reservoir and conduit strain decrease independently of LA volume (p < 0.001, p < 0.001 respectively). Patients with 1-2 comorbidities, but not patients with 3 or more comorbidities, showed a further progression of impaired LA and RA function in almost all atrial strain phases at 14 [13-17] months follow-up. CONCLUSIONS In patients with paroxysmal AF, individual and combined comorbidities are related to lower LA and RA strain. In patients with few comorbidities, impairment in atrial function progresses during one year of follow-up. Whether comorbidity management prevents or reverses decrease in atrial function warrants further study.
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Affiliation(s)
- Manouk J W van Mourik
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiology, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Vicente Artola Arita
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Aurore Lyon
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Biomedical Engineering, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Biomedical Engineering, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Ruben R De With
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ulrich Schotten
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sebastiaan C A M Bekkers
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiology, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Harry J G M Crijns
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiology, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Isabelle C Van Gelder
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dominik K Linz
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiology, Maastricht University, Maastricht University Medical Center, Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands; Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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34
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Schnabel RB, Marinelli EA, Arbelo E, Boriani G, Boveda S, Buckley CM, Camm AJ, Casadei B, Chua W, Dagres N, de Melis M, Desteghe L, Diederichsen SZ, Duncker D, Eckardt L, Eisert C, Engler D, Fabritz L, Freedman B, Gillet L, Goette A, Guasch E, Svendsen JH, Hatem SN, Haeusler KG, Healey JS, Heidbuchel H, Hindricks G, Hobbs FDR, Hübner T, Kotecha D, Krekler M, Leclercq C, Lewalter T, Lin H, Linz D, Lip GYH, Løchen ML, Lucassen W, Malaczynska-Rajpold K, Massberg S, Merino JL, Meyer R, Mont L, Myers MC, Neubeck L, Niiranen T, Oeff M, Oldgren J, Potpara TS, Psaroudakis G, Pürerfellner H, Ravens U, Rienstra M, Rivard L, Scherr D, Schotten U, Shah D, Sinner MF, Smolnik R, Steinbeck G, Steven D, Svennberg E, Thomas D, True Hills M, van Gelder IC, Vardar B, Palà E, Wakili R, Wegscheider K, Wieloch M, Willems S, Witt H, Ziegler A, Daniel Zink M, Kirchhof P. Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference. Europace 2022; 25:6-27. [PMID: 35894842 PMCID: PMC9907557 DOI: 10.1093/europace/euac062] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.
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Affiliation(s)
- Renate B Schnabel
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Serge Boveda
- Cardiology—Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France,Universiteit Ziekenhuis, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Barbara Casadei
- RDM, Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mirko de Melis
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Lien Desteghe
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Division of Electrophysiology, Department of Cardiology and Angiology, Münster, Germany
| | | | - Daniel Engler
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Larissa Fabritz
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,University Center of Cardiovascular Science Hamburg, Hamburg, Germany
| | - Ben Freedman
- Heart Research Institute, The University of Sydney, Sydney, Australia
| | | | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Muenster, Germany,St Vincenz Hospital, Paderborn, Germany
| | - Eduard Guasch
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl Georg Haeusler
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Jeff S Healey
- Population Health Research Institute, McMaster University Hamilton, ON, Canada
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Gerhard Hindricks
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - Dipak Kotecha
- University of Birmingham & University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Hospital Munich South, Department of Cardiology, Munich, Germany,Department of Cardiology, University of Bonn, Bonn, Germany
| | - Honghuang Lin
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maja Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Wim Lucassen
- Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands
| | | | - Steffen Massberg
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | | | - Lluıs Mont
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Lis Neubeck
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | - Teemu Niiranen
- Medtronic, Dublin, Ireland,Centre for Cardiovascular Health Edinburgh Napier University, Edinburgh, UK
| | - Michael Oeff
- Atrial Fibrillation Network (AFNET), Muenster, Germany
| | - Jonas Oldgren
- University of Turku and Turku University Hospital, Turku, Finland
| | | | - George Psaroudakis
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Helmut Pürerfellner
- School of Medicine, Belgrade University, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ursula Ravens
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Bayer AG, Leverkusen, Germany
| | - Michiel Rienstra
- Ordensklinikum Linz, Elisabethinen, Cardiological Department, Linz, Austria
| | - Lena Rivard
- Institute of Experimental Cardiovascular Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Daniel Scherr
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ulrich Schotten
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Dipen Shah
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Moritz F Sinner
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands,Royal Brompton Hospital, London, UK
| | | | - Gerhard Steinbeck
- Atrial Fibrillation Network (AFNET), Muenster, Germany,MUMC+, Maastricht, The Netherlands
| | - Daniel Steven
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital of Geneva, Cardiac Electrophysiology Unit, Geneva, Switzerland
| | - Emma Svennberg
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Dierk Thomas
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital Cologne, Heart Center, Department of Electrophysiology, Cologne, Germany,Karolinska Institutet, Department of Medicine Huddinge, Karolinska University Hospital, Stockholm, Sweden,Department of Cardiology, Medical University Hospital, Heidelberg, Germany
| | - Mellanie True Hills
- HCR (Heidelberg Center for Heart Rhythm Disorders), Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Isabelle C van Gelder
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Burcu Vardar
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elena Palà
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX, USA
| | - Reza Wakili
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Karl Wegscheider
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Mattias Wieloch
- Department of Cardiology and Vascular Medicine, Westgerman Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Department of Coagulation Disorders, Skane University Hospital, Lund University, Malmö, Sweden
| | | | | | - Matthias Daniel Zink
- Asklepios Hospital St Georg, Department of Cardiology and Internal Intensive Care Medicine, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Corresponding author. Tel: +49 40 7410 52438; Fax: +49 40 7410 55862. E-mail address:
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Nguyen BO, Weberndorfer V, Crijns HJ, Geelhoed B, Ten Cate H, Spronk H, Kroon A, De With R, Al-Jazairi M, Maass AH, Blaauw Y, Tieleman RG, Hemels MEW, Luermans J, de Groot J, Allaart CP, Elvan A, De Melis M, Scheerder C, van Zonneveld AJ, Schotten U, Linz D, Van Gelder I, Rienstra M. Prevalence and determinants of atrial fibrillation progression in paroxysmal atrial fibrillation. Heart 2022; 109:heartjnl-2022-321027. [PMID: 35858774 PMCID: PMC9872250 DOI: 10.1136/heartjnl-2022-321027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/24/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Atrial fibrillation (AF) often progresses from paroxysmal AF (PAF) to more permanent forms. To improve personalised medicine, we aim to develop a new AF progression risk prediction model in patients with PAF. METHODS In this interim-analysis of the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF study, patients with PAF undergoing extensive phenotyping at baseline and continuous rhythm monitoring during follow-up of ≥1 year were analysed. AF progression was defined as (1) progression to persistent or permanent AF or (2) progression of PAF with >3% burden increase. Multivariable analysis was done to identify predictors of AF progression. RESULTS Mean age was 65 (58-71) years, 179 (43%) were female. Follow-up was 2.2 (1.6-2.8) years, 51 of 417 patients (5.5%/year) showed AF progression. Multivariable analysis identified, PR interval, impaired left atrial function, mitral valve regurgitation and waist circumference to be associated with AF progression. Adding blood biomarkers improved the model (C-statistic from 0.709 to 0.830) and showed male sex, lower levels of factor XIIa:C1-esterase inhibitor and tissue factor pathway inhibitor, and higher levels of N-terminal pro-brain natriuretic peptide, proprotein convertase subtilisin/kexin type 9 and peptidoglycan recognition protein 1 were associated with AF progression. CONCLUSION In patients with PAF, AF progression occurred in 5.5%/year. Predictors for progression included markers for atrial remodelling, sex, mitral valve regurgitation, waist circumference and biomarkers associated with coagulation, inflammation, cardiomyocyte stretch and atherosclerosis. These prediction models may help to determine risk of AF progression and treatment targets, but validation is needed. TRIAL REGISTRATION NUMBER NCT02726698.
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Affiliation(s)
- Bao-Oanh Nguyen
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Vanessa Weberndorfer
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Harry Jgm Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Bastiaan Geelhoed
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Henri Spronk
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Abraham Kroon
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Ruben De With
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Meelad Al-Jazairi
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Alexander H Maass
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Yuri Blaauw
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | | | - Martin E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Justin Luermans
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Joris de Groot
- Department of Cardiology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Arif Elvan
- Cardiology, Isala Zwolle, Zwolle, The Netherlands
| | - Mirko De Melis
- Medtronic Bakken Research Centre, Maastricht, The Netherlands
| | - Coert Scheerder
- Medtronic Bakken Research Centre, Maastricht, The Netherlands
| | - Anton Jan van Zonneveld
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Experimental Vascular Medicine, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Ulrich Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
- Physiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Dominik Linz
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Isabelle Van Gelder
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
| | - Michiel Rienstra
- Cardiology, University Medical Centre Groningen Thoraxcentre, Groningen, The Netherlands
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36
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Verhaert DVM, Linz D, Chaldoupi SM, Westra SW, den Uijl DW, Philippens S, Kerperien M, Habibi Z, Vorstermans B, ter Bekke RMA, Beukema RJ, Evertz R, Hemels MEW, Luermans JGLM, Manusama R, Lankveld TAR, van der Heijden CAJ, Bidar E, Hermans BJM, Zeemering S, Bijvoet GP, Habets J, Holtackers RJ, Mihl C, Nijveldt R, van Empel VPM, Knackstedt C, Simons SO, Buhre WFFA, Tijssen JGP, Isaacs A, Crijns HJGM, Maesen B, Vernooy K, Schotten U. Rationale and Design of the ISOLATION Study: A Multicenter Prospective Cohort Study Identifying Predictors for Successful Atrial Fibrillation Ablation in an Integrated Clinical Care and Research Pathway. Front Cardiovasc Med 2022; 9:879139. [PMID: 35879962 PMCID: PMC9307503 DOI: 10.3389/fcvm.2022.879139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Continuous progress in atrial fibrillation (AF) ablation techniques has led to an increasing number of procedures with improved outcome. However, about 30-50% of patients still experience recurrences within 1 year after their ablation. Comprehensive translational research approaches integrated in clinical care pathways may improve our understanding of the complex pathophysiology of AF and improve patient selection for AF ablation. Objectives Within the "IntenSive mOlecular and eLectropathological chAracterization of patienTs undergoIng atrial fibrillatiOn ablatioN" (ISOLATION) study, we aim to identify predictors of successful AF ablation in the following domains: (1) clinical factors, (2) AF patterns, (3) anatomical characteristics, (4) electrophysiological characteristics, (5) circulating biomarkers, and (6) genetic background. Herein, the design of the ISOLATION study and the integration of all study procedures into a standardized pathway for patients undergoing AF ablation are described. Methods ISOLATION (NCT04342312) is a two-center prospective cohort study including 650 patients undergoing AF ablation. Clinical characteristics and routine clinical test results will be collected, as well as results from the following additional diagnostics: determination of body composition, pre-procedural rhythm monitoring, extended surface electrocardiogram, biomarker testing, genetic analysis, and questionnaires. A multimodality model including a combination of established predictors and novel techniques will be developed to predict ablation success. Discussion In this study, several domains will be examined to identify predictors of successful AF ablation. The results may be used to improve patient selection for invasive AF management and to tailor treatment decisions to individual patients.
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Affiliation(s)
- Dominique V. M. Verhaert
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Dominik Linz
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, The University of Adelaide, Adelaide, SA, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sevasti Maria Chaldoupi
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sjoerd W. Westra
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Dennis W. den Uijl
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Suzanne Philippens
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mijke Kerperien
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Zarina Habibi
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bianca Vorstermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rachel M. A. ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Rypko J. Beukema
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Reinder Evertz
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Martin E. W. Hemels
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Justin G. L. M. Luermans
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Randolph Manusama
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Theo A. R. Lankveld
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Claudia A. J. van der Heijden
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Ben J. M. Hermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Geertruida P. Bijvoet
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jesse Habets
- Department of Medical Imaging, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Robert J. Holtackers
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Casper Mihl
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robin Nijveldt
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Vanessa P. M. van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sami O. Simons
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | | | - Jan G. P. Tijssen
- Department of Cardiology, Amsterdam University Medical Center (UMC), Amsterdam, Netherlands
| | - Aaron Isaacs
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Harry J. G. M. Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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Zeemering S, Isaacs A, Winters J, Gilbers M, Kawczynksi M, Chua W, Guasch E, Kaab S, Crijns H, Mont L, Hatem S, Fabritz L, Kirchhof P, Stoll M, Schotten U. Replicated gene expression changes in patients with atrial fibrillation. Europace 2022. [DOI: 10.1093/europace/euac053.615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union Horizon 2020 CATCH ME; Cardiovascular Research Netherlands RACE V
Background
Little is known about changes in the atrial transcriptome associated with paroxysmal and persistent atrial fibrillation (AF).
Purpose
To identify major molecular mechanisms in AF, we determined consistent differential expression (DE) between atrial tissue samples from well-characterized patients with paroxysmal or persistent AF and patients without a history of AF (no AF) in two independent patient cohorts.
Methods
Poly-A tailed RNA from left and right atrial appendage tissue samples from independent discovery and replication cohorts CATCH ME (n=192) and RACE V (n=122) was sequenced and analyzed according to patient AF history. Analyses were performed stratified by atrial side, adjusting for age, sex, heart failure and a combination of clinical characteristics determined by principal component analysis. Transcripts were considered DE in CATCH ME if their fold change reached transcriptome-wide significance (false discovery rate (FDR) < 0.05). DE transcripts in each rhythm comparison were replicated in RACE V if we observed a concordant direction of effect and a within-set FDR < 0.05 in the same comparison.
Results
Persistent AF compared to no AF was associated with 184 left atrial DE transcripts in CATCH ME of which 85 (46%) were replicated in RACE V, and with 208 right atrial DE transcripts in CATCH ME of which 86 (41%) were replicated in RACE V. Overall, 26 transcripts were discovered and replicated in both atria. Discovered but non-replicated transcripts often did exhibit concordant direction of effect (left: 78%, right: 83%). Replicated transcripts consisted of protein coding genes, antisense and non-coding RNAs. Protein coding genes showed involvement in pathways linking persistent AF to cardiomyocyte structure, conduction properties, fibrosis, inflammation, molecule trafficking, and endothelial dysfunction. Interestingly, paroxysmal AF was not consistently associated with DE transcripts in any comparison. Principal component analysis of the expression of the 26 transcripts strongly associated with persistent AF did however reveal a distinct paroxysmal AF expression profile in-between no AF and persistent AF patients in the first principal component scores (Figure 1).
Conclusion
RNA sequencing of human atrial tissue samples identified many transcripts associated with persistent AF in left and/or right atria, discovered and replicated using two independent cohorts. These consistent findings of AF-induced changes provide a starting point for targeted proteomic analysis and single-nucleus sequencing to further unravel the molecular mechanisms underlying AF progression to persistent AF, and biomarker development to quantify AF progression and enable precision medicine in individual patients.
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Affiliation(s)
- S Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - A Isaacs
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - J Winters
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - M Gilbers
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - M Kawczynksi
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - W Chua
- University of Birmingham, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - E Guasch
- Institute of Biomedical Research August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - S Kaab
- University Hospital of Munich, Department of Medicine I, Munich, Germany
| | - H Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - L Mont
- Hospital Clinic of Barcelona, Cardiovascular Institute, Barcelona, Spain
| | - S Hatem
- University Pierre & Marie Curie Paris VI, Paris, France
| | - L Fabritz
- University of Birmingham, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - P Kirchhof
- University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - M Stoll
- University of Münster, Institute of Human Genetics, Münster, Germany
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
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38
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Van De Lande ME, Rajiv RS, Koldenhof T, Artola Arita V, Nguyen LBO, Weberndorfer V, Crijns HJGM, Elvan A, Hemels MEW, Tieleman RG, De Melis M, Schotten U, Linz D, Van Gelder IC, Rienstra M. The role of the autonomous nervous system in atrial fibrillation progression. Data from the RACE V study. Europace 2022. [DOI: 10.1093/europace/euac053.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): We acknowledge the support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF (RACE V). Unrestricted grant support from Medtronic Trading NL B.V.
Background
Atrial fibrillation (AF) progression is associated with adverse outcome.
The autonomic nervous system plays a yet unsettled role in initiation and progression of AF.
Purpose
To assess in patients with paroxysmal selfterminating AF differences in phenotype and AF progression depending on the role of the autonomic nervous system in triggering AF episodes.
Methods
Patients with paroxysmal AF included in the Reappraisal of AF: Interaction Between HyperCoagulability, Electrical Remodelling, and Vascular Destabilisation in the Progression of AF (RACE V) study were analysed. Patients were extensively phenotyped at baseline and received continuous rhythm monitoring with an implantable loop recorder (ILR).To adequately define the role of the autonomic nervous system in triggering AF only patients with at least 3 selfterminating AF episodes were included. ILR data were used to assess whether AF was mainly vagally induced (>80% of episodes starting during night time) or mainly adrenergically induced (>80% starting during daytime), and to assess the development of AF progression. If a patient could not be identified as either vagal or adrenergic, they were classified as mixed AF. Primary outcome were differences in AF progression between the three groups. AF progression was defined as (1) progression to persistent or permanent AF, or (2) progression of PAF with >3% burden increase. Follow-up was 2.2 (1.6-2.8) years.
Results
278 patients were included, median was age 66 (59-71) years, 117 (42%) were women (Table 1). Patients with vagally or adrenergically induced AF had less comorbidities compared to mixed AF patients (median 2 versus 2 versus 3, respectively, p=0.012). In the mixed group, compared to either the vagal or adrenergic group the estimated glomerular filtration rate was slightly worse (median 78 versus 84 versus 82 mL/min*1.73m2 in the mixed versus vagal and adrenergic group, respectively, p=0.018), diabetes was more common (12% versus 5% versus 0%, respectively, p=0.031). Obesity was most often present in the vagal group (38% versus 12% versus 27%, in the vagal versus adrenergic versus mixed group, respectively p=0.028). Progression rates in the vagal versus adrenergic versus mixed groups were 5% versus 5% versus 24%, respectively (p=0.013 vagal versus mixed and p=0.008 adrenergic versus mixed group, respectively)(Figure).
Conclusion
Important differences exist between AF patients depending on their autonomic nervous system associated triggering mechanisms. Patients with either vagally or adrenergically induced AF have less comorbidities as compared to those with a mixed initiation type of AF and showed lower AF progression rates.
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Affiliation(s)
- ME Van De Lande
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - RS Rajiv
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - T Koldenhof
- Martini Hospital, Cardiology, Groningen, Netherlands (The)
| | - V Artola Arita
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - LBO Nguyen
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - V Weberndorfer
- Academic Hospital Maastricht, Cardiology, Maastricht, Netherlands (The)
| | - HJGM Crijns
- Academic Hospital Maastricht, Cardiology, Maastricht, Netherlands (The)
| | - A Elvan
- Isala Hospital, Cardiology, Zwolle, Netherlands (The)
| | - MEW Hemels
- Rijnstate Hospital, Cardiology, Arnhem, Netherlands (The)
| | - RG Tieleman
- Martini Hospital, Cardiology, Groningen, Netherlands (The)
| | - M De Melis
- Bakken Research Center, Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - D Linz
- Academic Hospital Maastricht, Cardiology, Maastricht, Netherlands (The)
| | - IC Van Gelder
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - M Rienstra
- University Medical Center Groningen, Groningen, Netherlands (The)
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39
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Verhaert D, Betz K, Gawalko M, Hermans ANL, Van Der Velden RMJ, Westra SW, Schotten U, Hendriks JM, Vernooy K, Linz D. The impact of a structured polygraphy screening incorporated in a novel remote mobile health pathway on sleep apnoea prevalence in patients with atrial fibrillation. Europace 2022. [DOI: 10.1093/europace/euac053.585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Untreated obstructive sleep apnoea (OSA) contributes to progression of atrial fibrillation (AF) and reduces the success rate of heart rhythm control strategies. OSA remains one of the most frequently underdiagnosed modifiable risk factors in AF patients due to a lack of standardized screening methods and low awareness.
Purpose
To assess the impact of implementation of a structured remote OSA screening and management pathway on the prevalence of OSA in AF patients scheduled for AF ablation procedures.
Methods
In October 2020, a novel remote OSA screening and management pathway (VIRTUAL-SAFARI) was introduced in two AF outpatient clinics in the Netherlands. Consecutive patients scheduled for AF ablation were offered OSA screening consisting of sending a portable home sleep test to patients’ homes to perform a remote sleep recording for one night, analysis by a sleep physician, discussion of results with the patient, and initiation of treatment (when applicable). The impact of this structural screening strategy was assessed by comparing the prevalence of concomitant OSA (defined as apnoea-hypopnoea index ≥5) for patients scheduled for AF ablation in the year before and after introduction of the OSA management pathway.
Results
A total of 733 patients was studied, 308 in the year before (Oct ’19 - Sep ’20) and 425 in the year after (Oct ’20 - Sep ’21) introduction of the VIRTUAL-SAFARI pathway. Median age was 65 [58-71], 64% was male and median body mass index (BMI) was 27 [25-30] kg/m2. Baseline characteristics were comparable for the groups before and after introduction of the pathway (Table 1).
In the cohort before pathway introduction, OSA had been diagnosed in 26 patients (8%, Figure 1) and was treated with positive airway pressure in 10 cases (3%).
In the cohort after pathway introduction, OSA had previously been diagnosed in 53 patients (12%). Eighty-eight percent of patients without previous OSA screening was referred via the remote pathway. Results of the sleep recordings were available for 213 (59%) at the time of this analysis. Previously unknown OSA was diagnosed in 184 patients (86% of available recordings), increasing the prevalence of confirmed OSA to 237 (55%). For 22% of patients, results of sleep recordings are pending. Absence of OSA was confirmed in 9%, and 13% of patients had not been screened (e.g. because of patient preference or logistical reasons). After pathway introduction, 82 patients (19%) were treated or received advice to start treatment with positive airway pressure. Treatment decisions are pending for 9% of the cohort.
Conclusion
After the implementation of structured remote OSA screening in a well characterized cohort of consecutive patients scheduled for AF ablation, the prevalence of diagnosed OSA increased from 8% to 55%. Whether appropriate risk factor management, including treatment of OSA identified by structured screening, will improve AF outcomes needs to be tested in future studies.
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Affiliation(s)
- D Verhaert
- Radboud University Medical Center, Department of cardiology, Radboud Institute of Health Sciences (RIHS), Nijmegen, Netherlands (The)
| | - K Betz
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - M Gawalko
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - ANL Hermans
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - RMJ Van Der Velden
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - SW Westra
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - U Schotten
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - JM Hendriks
- Royal Adelaide Hospital, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - D Linz
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
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40
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Artola V, Geelhoed B, Van Lande M, Khalilian Ekrami N, De With R, Weberndorfer V, Linz D, Ten Cate H, Spronk H, Koldenhof T, Tieleman RG, Schotten U, Crijns HJG, Van Gelder I, Rienstra M. The 3S-AF scheme, rather than the 4S-AF scheme, predicts progression in patients with paroxysmal atrial fibrillation: data from RACE V study. Europace 2022. [DOI: 10.1093/europace/euac053.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF (RACE V).
Purpose
To assess whether the 4S-AF scheme predicts AF progression, cardiovascular hospitalizations and mortality in patients with self-terminating paroxysmal AF.
Methods
We analysed well-phenotyped patients with paroxysmal AF from the Reappraisal of Atrial Fibrillation: Interaction between HyperCoagulability, Electrical remodelling, and Vascular Destabilisation in the Progression of AF (RACE V study). From the 417 patients included in RACE V, 341 (82%) had echocardiography available. Patient had continuous monitoring with implantable loop recorders or pacemakers. Primary endpoint of RACE V was AF progression, defined as (1) progression to persistent or permanent AF, or (2) progression of PAF with >3% burden increase. Median follow-up was 2.2 (1.6-2.8) years. Patients were given a score based on the components of the 4S-AF scheme (St, stroke=1; Sy, symptoms=2; Sb, Severity of burden=2; Su, Substrate=5) to a total maximum of 10 points (table 1). Left atrial fibrosis was not evaluated in our patients and therefore not included into the score. A score of zero (0) in the AF burden domain was given to all patients due to the presence of paroxysmal AF in all. A modified 4S-AF scheme was designed by eliminating the symptom domain, resulting in a 3S-AF scheme. Logistic regression was performed to assess AF progression and the composite endpoint of cardiovascular hospitalizations and mortality, C-statistic to assess prediction of the score, for both using the 4S-AF and the modified 3S-AF scheme.
Results
Mean age was 65 (IQR 58-71) years, 149 (44%) were women, 103 (48%) had heart failure (HFrEF 6 [2%]; HFpEF 97 [46%]), 276 (81%) had hypertension, 38(11%) had coronary artery disease and 162(48%) atherosclerosis (Table 2, Panel A). Based on the 4S-AF scheme, patients had an average score of 4.5±1.3, the majority had a score under 5 (n=272, 80%), 20% of the score was explained by the S1 domain (stroke), 16% of the score was explained by the Sy domain (symptoms), and 64% of the score was explained by the Su domain (substrate). The score points from the 4S-AF scheme did not predict the risk of AF progression (OR 1.08 95%CI 0.84 – 1.39, C-statistic 0.53) nor the composite endpoint (OR 0.79 95%CI 0.53 – 1.20, C-statistic 0.42, Table 2, Panel B). However, when excluding the Sy domain (symptoms) from the scheme, the 3S-AF scheme, it predicted the risk of progression (OR 1.54 95%CI 1.12 – 2.18, C-statistic 0.61, Table 2, Panel B).
Conclusion
In paroxysmal AF patients the 4S-AF scheme does not predict AF progression nor the composite endpoint cardiovascular hospitalizations and mortality. Although symptoms are important for choosing the treatment strategy, they may be less relevant to determine AF progression, cardiovascular hospitalization and mortality. To assess progression, the 3S-AF scheme may be more appropriate.
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Affiliation(s)
- V Artola
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - B Geelhoed
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - M Van Lande
- University Medical Center Groningen, Groningen, Netherlands (The)
| | | | - R De With
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - V Weberndorfer
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - D Linz
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - H Ten Cate
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - H Spronk
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - T Koldenhof
- Martini Hospital, Groningen, Netherlands (The)
| | - RG Tieleman
- Martini Hospital, Groningen, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - HJG Crijns
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - I Van Gelder
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - M Rienstra
- University Medical Center Groningen, Groningen, Netherlands (The)
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D’ Alessandro E, Scaf B, Sobota V, Van Hunnik A, Kuiper M, Winters J, Van Oerle R, Spronk HMH, Van Nieuwenhoven FA, Ten Cate H, Verheule S, Schotten U. Atrial fibrillation and age synergistically increase clotting potential and promote atrial structural remodeling in goats. Europace 2022. [DOI: 10.1093/europace/euac053.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Other. Main funding source(s): Netherlands Heart Foundation, European Union
Background
Age is a risk factor for atrial fibrillation (AF) as well as for stroke in patients with AF. However, the effect of ageing on AF mechanisms and on coagulation activity is not well understood.
Purpose
To evaluate the effect of age and AF on coagulation activity, AF characteristics, and atrial structural remodeling.
Methods
Four groups of female goats were investigated: Young sham (Y-Sh: sinus rhythm, <3 years old, n=9), Young AF (Y-AF: 4 weeks of AF, <3 years old, n=7), Old sham (O-Sh: sinus rhythm, >8 years old, n=6), and Old AF (O-AF, 4 weeks of AF, >8 years old, n=8). Groups were matched for body weight. AF was maintained using implantable pacemakers in both AF groups. Clotting potential, expressed as the ability of activated plasma to generate thrombin, was measured using tissue factor-induced thrombin generation assays at baseline and 4 weeks (final). A terminal experiment was performed with atrial contact mapping to study electrophysiological AF properties and to collect atrial tissue for histological analysis.
Results
Thrombin generation analysis showed that 4 weeks of AF induced a significant increase in clotting potential in old, but not in young goats. AF complexity and hemodynamics were not affected by age alone. AF, however, significantly increased the right atrial pressure in old (O-Sh: 6.4±1.9 vs. O-AF: 11.4±3.1 mmHg, p=0.02), but not in young goats. AF induced atrial myocyte hypertrophy and left atrial epicardial endomysial fibrosis in old goats, while this was not the case in young goats.
Conclusion
Four weeks of AF and advanced age synergistically enhanced coagulation potential and promoted atrial structural remodeling in goats. Complexity of atrial conduction was affected by AF, but not by age.
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Affiliation(s)
- E D’ Alessandro
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | - B Scaf
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | | | - A Van Hunnik
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | - M Kuiper
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | - J Winters
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | - R Van Oerle
- Faculty of Health, Medicine and Life Sciences Maastricht University, Biochemistry, Maastricht, Netherlands (The)
| | - HMH Spronk
- Faculty of Health, Medicine and Life Sciences Maastricht University, Biochemistry and Internal medicine, Maastricht, Netherlands (The)
| | - FA Van Nieuwenhoven
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | - H Ten Cate
- Faculty of Health, Medicine and Life Sciences Maastricht University, Biochemistry and Internal medicine, Maastricht, Netherlands (The)
| | - S Verheule
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
| | - U Schotten
- Faculty of Health, Medicine and Life Sciences Maastricht University, Physiology, Maastricht, Netherlands (The)
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Verhaert D, Linz D, Wassink GW, Weijs B, Philippens S, Luermans JGLM, Westra SW, Schotten U, Vernooy K, Den Uijl DW. Optimization of a care pathway before atrial fibrillation ablation with the integration of translational research into routine clinical care. Europace 2022. [DOI: 10.1093/europace/euac053.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
The diagnostic work-up for atrial fibrillation (AF) catheter ablation is often complex and expensive. Improving the organization of this work-up may help to streamline patient journeys and to reduce administrative burden and costs. Additionally, reorganizing the existing work-up provides the opportunity to integrate (translational) research into routine clinical care, hereby contributing to improved patient selection and improved care for future patients.
Purpose
The aim of this project was to optimize a care pathway for patients considered for AF ablation, with the goals to improve the patient journey and simultaneously integrate research into the clinical process.
Methods
The Lean Six Sigma approach was used to map the pre-existing process, identify constraints in the process and formulate countermeasures. The impact of this pathway optimization was evaluated using four outcome measures: (1) efficient use of medical resources, defined as the percentage of patients receiving the pre-ablation work-up and eventually undergoing AF ablation, (2) number of hospital visits and consultations with a cardiologist, (3) pathway compliance, defined as the percentage of patients that completed the work-up with a maximum of 2 outpatient hospital visits, a maximum of 1 cardiologist consultation, laboratory results available, and a complete echocardiogram available, and (4) completeness of scientific data, defined as the availability of a predefined set of relevant variables (clinical indicators, medication, laboratory results and echocardiography derived data).
Results
Five root causes for constraints in the pre-existing work-up were identified and corresponding countermeasures were formulated (Figure 1). The impact of the countermeasures was studied for 33 patients before and 26 patients after pathway optimization. After optimization, efficient use of resources increased from 44% to 95% (p<0.01). The project resulted in fewer hospital visits per patient (3.2 ±1.2 versus 2.3 ±0.8, p=0.01) and fewer cardiologist consultations (1.8 ±0.7 versus 1.0 ±0.3, p<0.01). Pathway compliance increased significantly (3% versus 73%, p<0.01), an increase that was reflected in all separate components of overall pathway compliance (Figure 2, panel A). The percentage of available data for scientific research increased from 80% to 94% (p<0.01), resulting in a complete dataset in 73% of patients after, compared to only 15% of patients prior to the optimization project (p<0.01, Figure 2, panel B).
Conclusions
This optimization project resulted in a more efficient care pathway for patients considered for AF ablation. The structural integration of research into the care pathway may lay the foundations for further improvements of AF care in the future.
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Affiliation(s)
- D Verhaert
- Radboud University Medical Center, Nijmegen, Netherlands (The)
| | - D Linz
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - GW Wassink
- Medtronic plc, Integrated Health Solutions, Eindhoven, Netherlands (The)
| | - B Weijs
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - S Philippens
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - JGLM Luermans
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - SW Westra
- Radboud University Medical Center, Nijmegen, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Department of physiology, Maastricht, Netherlands (The)
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - DW Den Uijl
- Maastricht University Medical Centre (MUMC), Department of cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
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Ozgul O, Hermans BJM, Van Hunnik A, Verheule S, Schotten U, Bonizzi P, Zeemering S. High-density sequential mapping of repetitive atrial conduction patterns during atrial fibrillation. Europace 2022. [DOI: 10.1093/europace/euac053.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by PersonalizeAF project. This project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 860974.
Background
Localized AF drivers are considered candidate ablation targets for patients with persistent atrial fibrillation (AF). These drivers are expected to be associated with repetitive atrial conduction patterns during AF. Thus, tools that localize atrial sites with repetitive electrical activity might be instrumental in guiding ablation.
Purpose
High-density mapping catheters cover only a small portion of the atria. Combining sequential recordings from those catheters could provide a more complete picture of repetitive conduction patterns, and enable AF driver localization. We hypothesize that the repetitive activity generated by local AF drivers can be detected by means of high-coverage composite activation maps generated from spatially overlapping sequential recordings.
Methods
Repetitive conduction patterns were detected in a goat model of AF (249-electrode epicardial mapping array, 2.4mm inter-electrode distance, n=16) by exploiting recurrence plots (Fig 1A-C). Cross-recurrences of repetitive patterns in sequential recordings were detected in spatially overlapping recording locations. Using this information, local activation maps were aligned and combined into larger composite average activation maps (Fig. 1D-F). The proposed algorithm was tested on a dataset formed by segmenting the epicardial mapping area into four spatially overlapping regions. The proposed algorithm was then used to merge these segmented regions back together to reconstruct the original mapping area. Reconstruction accuracy was measured as the correlation between original and reconstructed average activation patterns (Fig. 2.). Statistical analyses were performed to investigate a possible relation between reconstruction accuracy and pattern properties such as duration, size, complexity, and cycle length. Patterns were classified as single peripheral, multiple waves, focal source, or re-entry based on the preferential conduction velocity directions.
Results
Among 1021 detected repetitive patterns, 328 spatiotemporally stable- patterns were present in all four artificially segmented recordings. In 32% of these, repetitiveness was associated with a local driver-either focal or re-entrant. Composite maps could be generated in 75% of the cases, and mainly in case of larger patterns (p<0.01). The average correlation between the actual activation maps and the composite maps was 0.86 ±0.16. Only pattern duration showed a statistically significant low correlation with reconstruction accuracy of composite maps (r=0.126, p<0.05). There was no significant difference in the reconstruction accuracy for multiple waves, focal sources and re-entries.
Conclusion(s)
The proposed framework could align sequentially recorded repetitive epicardial patterns over different atrial regions, to produce high-fidelity composite maps. The performance was minimally affected by pattern properties, thus suggesting potential use with a diverse range of AF patterns.
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Affiliation(s)
- O Ozgul
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - BJM Hermans
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - A Van Hunnik
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - S Verheule
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - P Bonizzi
- Maastricht University, Department of Data Science and Knowledge Engineering, Maastricht, Netherlands (The)
| | - S Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
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Winters J, Isaacs A, Zeemering S, Casadei B, Fabritz L, Guasch E, Mont L, Hatem S, Kirchhof P, Verheule S, Schotten U. Atrial endomysial fibrosis is associated with sex, atrial fibrillation, heart failure and age in cardiac surgery patients: results from the Catch-Me consortium. Europace 2022. [DOI: 10.1093/europace/euac053.609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020
Background
Risk factors for atrial fibrillation (AF), such as ageing, heart failure and AF itself, enhance AF propensity partly by inducing atrial fibrosis. Atrial endomysial fibrosis, a type of reactive fibrosis occurring between cardiomyocytes, impairs transverse conduction in rapid atrial pacing animal models. The factors underlying transcriptional regulation of endomysial fibrosis are largely unknown.
Objective
To examine the contributions of age, sex, AF and heart failure to the development of endomysial fibrosis in the context of concurrent pathologies. To study genome-wide transcriptional changes associated with endomysial fibrosis in human left and right atrial appendage biopsies (LAA, n=95; RAA, n=76).
Methods
An algorithm for automated quantification of endomysial fibrosis following staining with wheat germ agglutinin (WGA) was employed. Linear mixed models were constructed to determine endomysial fibrosis quantity as a function of AF, heart failure, sex, age and four principal components that accounted for potential confounding effects of other clinical characteristics. RNA sequencing was used to study expression changes in the atrial transcriptome associated with endomysial fibrosis.
Results
Sex, persistent AF, heart failure and age were independently associated with endomysial fibrosis. We identified hundreds (LAA: 386, RAA: 311) of RNA transcripts associated with endomysial fibrosis. None of these associations were independent from the clinical phenotypes. However, explorative gene set enrichment analysis identified association of endomysial fibrosis with gene sets involved in extracellular matrix organization, immune response, cell motility, developmental processes, cardiac muscle contraction and proteostasis in LAA while in RAA only gene sets regulating contractile function were enriched.
Conclusion
Besides AF, female sex, age and heart failure are associated with endomysial fibrosis in the atria. While abundance of none of the differential genes were independently associated with endomysial fibrosis, gene set enrichment analysis suggests an involvement of extracellular matrix organization, immune response, cell motility, developmental processes and cardiac muscle contraction in endomysial fibrosis.
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Affiliation(s)
- J Winters
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - A Isaacs
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - S Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - B Casadei
- John Radcliffe Hospital, Oxford, United Kingdom of Great Britain & Northern Ireland
| | - L Fabritz
- Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - E Guasch
- Barcelona Hospital Clinic, Barcelona, Spain
| | - L Mont
- Barcelona Hospital Clinic, Barcelona, Spain
| | - S Hatem
- University Pierre & Marie Curie Paris VI, Paris, France
| | - P Kirchhof
- Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - S Verheule
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
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Betz K, Verhaert DVM, Gawalko M, Hermans ANL, Van Der Velden RMJ, Schotten U, Vernooy K, Hendriks J, Linz D. Performance of STOP-BANG questionnaire as sleep apnoea screening tool and development of a novel pre-selection model in patients with atrial fibrillation - insights from the Virtual-SAFARI study. Europace 2022. [DOI: 10.1093/europace/euac053.584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Sleep-disordered breathing (SDB) is highly prevalent in patients with atrial fibrillation (AF) and its screening is recommended in this population. The STOP-BANG questionnaire is widely used as SDB screening tool, but the subjective assessment of some of its parameters might limit its validity to detect SDB in AF patients.
Purpose
We assessed the performance of the STOP-BANG questionnaire to detect SDB with the use of a mobile health-based portable home sleep test given as reference in a cohort of AF patients. Moreover, we explored options to improve pre-selection for SDB screening in this cohort.
Methods
Consecutive AF patients who were referred for AF catheter ablation in two AF outpatient clinics and without previous history of SDB and/or SDB screening, were included prospectively. Patients characteristics together with STOP-BANG questionnaire were assessed at baseline visitation. STOP-BANG scores of 3-4 and 5-8 were interpreted as intermediate and high risk for SDB, respectively. All patients were digitally referred to a virtual SDB management pathway, independent of STOP-BANG score. Patients received a portable home sleep test to detect SDB, which patients used for one night at home after instructions. Sleep recordings were accessed by sleep physicians via a secured cloud and sleep reports were discussed with patients and referring physicians. Apnoea-hypopnoea-indexes (AHI) of >=15 and of >= 30 were interpreted as moderate-to-severe and severe SDB, respectively. Results of the STOP-BANG and the home sleep test were compared and performance of the STOP-BANG questionnaire was assessed. Uni- and multivariable logistic regression analyses based on patient characteristics were used to construct a nomogram to improve pre-selection for SDB screening in this cohort.
Results
A total of 156 patients (median age 65 years, 63.8% male) were included. According to results from the home sleep test, 53% of patients were diagnosed with moderate-to-severe SDB, including 16% with severe SDB. STOP-BANG questionnaire performed poorly with an area under the receiver operating characteristic curve (AUROC) of 0.661 and 0.684 in predicting moderate-to-severe and severe SDB, respectively. On multivariable logistic analysis, independent predictors for moderate-to-severe SDB were body-mass-index (BMI), age and apnoeas. A nomogram was built on this variables (Fig. 1), which performed good with an AUROC of 0.728 in predicting moderate-to-severe SDB.
Conclusion
In a cohort of AF patients scheduled for AF catheter ablation, SDB was highly prevalent. STOP-BANG questionnaire had poor value for the prediction of moderate-to-severe and severe SDB compared to a systematical SDB screening via home sleep test. Using STOP-BANG questionnaire as a pre-selection tool might lead to frequently undetected and untreated SDB. Whether the nomogram based on our analyses improves pre-selection for SDB screening in AF patients will be validated in a future cohort.
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Affiliation(s)
- K Betz
- Cardiovascular Research Institute Maastricht (CARIM), Department of Cardiology, Maastricht, Netherlands (The)
| | - DVM Verhaert
- Cardiovascular Research Institute Maastricht (CARIM), Department of Cardiology, Maastricht, Netherlands (The)
| | - M Gawalko
- Cardiovascular Research Institute Maastricht (CARIM), Department of Cardiology, Maastricht, Netherlands (The)
| | - ANL Hermans
- Cardiovascular Research Institute Maastricht (CARIM), Department of Cardiology, Maastricht, Netherlands (The)
| | - RMJ Van Der Velden
- Cardiovascular Research Institute Maastricht (CARIM), Department of Cardiology, Maastricht, Netherlands (The)
| | - U Schotten
- Maastricht University Medical Centre (MUMC), Department of Cardiology, Maastricht, Netherlands (The)
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Department of Cardiology, Maastricht, Netherlands (The)
| | - J Hendriks
- Royal Adelaide Hospital, Centre for Heart Rhythm Disorders, Adelaide, Australia
| | - D Linz
- Maastricht University Medical Centre (MUMC), Department of Cardiology, Maastricht, Netherlands (The)
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Weberndoerfer V, Van De Lande ME, Artola Arita VA, Nguyen BO, Elvan A, Hemels MEW, Tieleman RG, De Melis M, Mihl C, Schotten U, Van Gelder IC, Rienstra M, Linz D, Crijns HJGM, Kroon AA. Advanced vascular aging in patients with paroxysmal atrial fibrillation - Data from RACE V. Europace 2022. [DOI: 10.1093/europace/euac053.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation, Medtronic
Background
The incidence of atrial fibrillation (AF) increases exponentially with age. To which extend vascular aging is part of this process is unknown. Pulse wave velocity and carotid intima-media thickness are established markers for vascular aging and have been combined in a vascular aging index as published before(1).
Purpose
We aim to investigate if vascular age exceeds chronological age in our cohort with paroxysmal AF and if yes to which extend.
Methods
In this substudy from RACE V we included 295 patients with paroxysmal AF in which carotid-femoral pulse wave velocity (cfPWV) and carotid intima-media thickness (IMT) were measured. To calculate vascular aging we used a logarithmic formula derived from the Malmö-Cancer-and-Diet study which yields a vascular age index derived from cfPWV, cIMT and chronological age. This vascular aging index (VAI) is a strong predictor of cardiovascular events. (1). All patients underwent cardiac echocardiography and had a native cardiac CT scan in which fat around the heart and coronary calcium were quantified. In 121 patients Agatston scores from the ascending aortic artery were also measured.
Results
Patients in this study had a mean chronological age of 63.8 ± 10.1 years and a vascular age of 71.4 ± 11.7 years. Vascular age was on average 9.3 ± 10.2 years higher than chronological age. Vascular age correlated significantly with markers for diastolic dysfunction, vascular calcification in the coronary arteries as well as the aorta and the amount of epicardial and pericardial fat (table 1).
Conclusions
In patients with PAF vascular age was on average 9.3 years higher than chronological age in our cohort. Advanced vascular age is represented by vascular and myocardial remodeling related to fibrosis, calcification and fat accumulation. The results suggest that in patients with AF enhanced inflammation is leading to fibrosis and calcification. Whether AF is a marker, a mechanism or both in advanced vascular aging warrants further study.
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Affiliation(s)
- V Weberndoerfer
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - ME Van De Lande
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - VA Artola Arita
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - BO Nguyen
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - A Elvan
- Isala Hospital, Cardiology, Zwolle, Netherlands (The)
| | - MEW Hemels
- Rijnstate Hospital, Cardiology, Arnhem, Netherlands (The)
| | - RG Tieleman
- Martini Hospital, Cardiology, Groningen, Netherlands (The)
| | - M De Melis
- Bakken Research Center, Maastricht, Netherlands (The)
| | - C Mihl
- Maastricht University Medical Centre (MUMC), Radiology, Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - IC Van Gelder
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - M Rienstra
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - D Linz
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - HJGM Crijns
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - AA Kroon
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
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47
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Weberndoerfer V, Van De Lande ME, Artola Arita VA, Nguyen BA, Elvan A, Hemels MEW, Thieleman RG, De Melis M, Schotten U, Van Gelder IC, Rienstra M, Crijns HJGM, Mihl C, Linz D. The impact of different fat depots in the body on the progression of atrial fibrillation - data from RACE V. Europace 2022. [DOI: 10.1093/europace/euac053.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Dutch Heart Foundation, Medtronic
Background
Paroxysmal atrial fibrillation (PAF) progression is associated with cardiovascular complications and worse outcome. Obesity is independently associated with AF prevalence and progression. The association between different fat depots in the body with AF is unclear.
Aim
We aim to systematically investigate the association of different fat depots in the body with AF.
Methods
417 patients with PAF and continuous rhythm monitoring (implantable loop recorder or pacemaker) were included in the prospective RACE V study. In addition to extensive phenotyping at baseline including calculating BMI and measuring waist circumference (WC) epicardial and pericardial fat were measured on non-contrast enhanced cardiac CT scans by tracing the pericardium manually on every slice and afterwards fat automatically summed between -50 and -150 HU. Epicardial fat was defined as fat within the pericardium, pericardial fat as fat inside the pericardium and adjacent to the pericardium and thoracic fat as adjacent fat outside the pericardium. AF progression was defined as (1) progression to persistent or permanent AF, or (2) progression of PAF with >3% burden increase within 2.2years of follow-up. Multivariable logistic regression analysis was used to analyse the association of different fat pads with AF progression.
Results
Six percent of patients per year showed AF progression (51/417) after a median follow-up of 2.2 (1.6-2.8) years. Multivariate analysis identified WC (odds ratio [OR] 1.03, 95% confidence intervals [CI] 1.01-1.06, p=.014) to be associated with AF progression. Epicardial fat (OR 1.00, 95%CI .99-1.01, p=.407), pericardial fat (OR 1.00, 95%CI .99-1.01, p=.311), thoracic fat (OR 1.00, 95%CI .99-1.01, p=.372), and BMI (OR 1.03, 95%CI .97-1.10, p=.328) showed no relation with AF progression.
Conclusion
AF progression occurred in 6% per year in patients with PAF. In contrast to epicardial, pericardial and thoracic fat measured in a semiautomatic way, WC was the only fat depot associated with AF progression. Whether a more different assessment of obesity and epicardial fat may demonstrate an association with AF progression warrants further study.
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Affiliation(s)
- V Weberndoerfer
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - ME Van De Lande
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - VA Artola Arita
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - BA Nguyen
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - A Elvan
- Isala Hospital, Cardiology, Zwolle, Netherlands (The)
| | - MEW Hemels
- Rijnstate Hospital, Cardiology, Arnhem, Netherlands (The)
| | - RG Thieleman
- Martini Hospital, Cardiology, Groningen, Netherlands (The)
| | - M De Melis
- Bakken Research Center, Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands (The)
| | - IC Van Gelder
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - M Rienstra
- University Medical Center Groningen, Cardiology, Groningen, Netherlands (The)
| | - HJGM Crijns
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - C Mihl
- Maastricht University Medical Centre (MUMC), Radiology, Maastricht, Netherlands (The)
| | - D Linz
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
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48
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Zink MD, Hermans B, Gramlich M, Philippens SAM, Vernooy K, Van Hunnik A, Linz DK, Zeemering S, Schotten U. BMP10 level helps to stratify risk of atrial fibrillation recurrence within one year after catheter ablation. Europace 2022. [DOI: 10.1093/europace/euac053.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): DGK Electrophysiology grant
Background
Freedom of atrial fibrillation (AF) is the main purpose of catheter ablation. However, AF recurrence is commonly seen after catheter ablation. Cardiovascular biomarkers may help to identify patients at risk for AF recurrence.
Purpose
We investigated the association of preprocedural known and novel cardiovascular biomarker level with AF recurrence within one year after catheter ablation.
Methods
In 187 patients of the AFAB registry (University Maastricht, the Netherlands) clinical recurrence of AF after catheter ablation was investigated using Holter ECGs at 3- and 12-months follow-up. Blood samples taken before AF catheter ablation were analyzed for prediction of AF recurrence by known or novel cardiovascular biomarkers (FGF23, BMP10, Ang2, IGFBP7, CA125, NT-proBNP, TNT_hs, sFlt_1, ESM1_7F89A5, DKK3). Recurrence of AF was defined as any symptomatic, or ECG documented episode of AF within one year after catheter ablation. A logistic regression model adjusted for typical risk factors of AF recurrence (Sex, age, type of AF (paroxysmal or persistent), ongoing rhythm, LA diameter, heart failure, body mass index and hypertension) was calculated and receiver-operating analysis was performed for prediction of AF recurrence.
Results
AF recurrence was found in 86 patients within one year after catheter ablation. Elevated biomarker level in patients with AF recurrence were found for BMP10, Ang2, and NT-proBNP in univariate analysis (table 1). In the logistic regression BMP10 (Odds ratio 2.94, 95%CI 1.089-7.939, P=0.033) indicated a high probability of AF recurrence within one year. A model including factors of AF recurrence showed a predictability for AF recurrence of an area under the curve (AUC) of 0.68 (sensitivity 60%, specificity 64%). By adding each of the univariate significant biomarker the predictability of the model increases further Ang2 (AUC 0.69, sensitivity 69%, specificity 60%), NT-proBNP (AUC 0.69, sensitivity 65%, specificity 60%), and BMP10 (AUC 0.71, sensitivity 60%, specificity 73%).
Conclusions
Based on our data, Ang2, BMP10, NT-proBNP showed elevated values for patients with recurrence of AF within one year before catheter ablation. BMP10, which is likely associated with trabeculation of the heart, outperformed the other investigated known and novel biomarker indicating a higher probability of AF recurrence within one year after ablation.
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Affiliation(s)
- MD Zink
- RWTH University Hospital Aachen, Internal Medicine I, Cardiology, Pulmonology & Vascular Medicine, Aachen, Germany
| | - B Hermans
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
| | - M Gramlich
- RWTH University Hospital Aachen, Internal Medicine I, Cardiology, Pulmonology & Vascular Medicine, Aachen, Germany
| | - SAM Philippens
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - A Van Hunnik
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
| | - DK Linz
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
| | - S Zeemering
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
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49
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Hermans BJM, Bijvoet GP, Holtackers RJ, Mihl C, Luermans JGLM, Vernooy K, Linz D, Chaldoupi SM, Schotten U. Development and validation of a fully automatic algorithm to align 3D MRI and electro-anatomical mapping anatomies of the left atrium. Europace 2022. [DOI: 10.1093/europace/euac053.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
The role of pre-procedural cardiac imaging in the guidance and planning of ablation procedures is becoming increasingly important. Emerging non-invasive techniques such as late gadolinium enhancement magnetic resonance imaging (LGE MRI) and electrocardiographic imaging (ECGi) can potentially help to locate ablation targets prior to the ablation procedure. To be able to integrate LGE MRI and ECGi information into targeted ablation procedures, a reliable alignment between cardiac imaging and electro-anatomical mapping (EAM) is required.
Purpose
To develop and evaluate a fully automatic technique to align pre-procedural MRI anatomies with EAM anatomies of the left atrium (LA).
Methods
Twenty-one patients scheduled for a (re-do) pulmonary vein (PV) isolation with a 3D pre-procedural LGE MRI were enrolled in this study. LA anatomy was segmented from the MRI dataset using ADAS-AF. During the ablation procedure LA anatomy was recorded with an HD-grid (Ensite) or Pentaray catheter (CARTO). The MRI segmentation and EAM were performed by different cardiologists blinded for each other’s results. Anatomies of both MRI and EAM were aligned using an iterative closest point-to-plane algorithm in custom-made software in Matlab 2021a. With this algorithm, the distance between MRI anatomy voxels (=points) and the surface of the EAM anatomy (=plane) is minimized by translating and rotating the MRI anatomy until the total residual distance is minimized. The result of the alignment is quantified by calculating the Euclidian distance between the aligned anatomies after excluding PVs and the mitral anulus.
Results
The algorithm was successfully applied in 18/21 patients (n=11 CARTO, n=7 Ensite). In the remaining 3 patients, the algorithm could not align the anatomies because of a large difference in LA volume or PV anatomy between the two techniques. In the analysed patients, the average distance between anatomies was 2.7±0.77mm. The top of Figure 1 shows the alignment of the anatomies with the smallest (patient A) and the largest (patient B) residual distances as well as the distances between these anatomies for both patients (right) with purple ≤2.5mm and red ≥5.0mm. The distributions of distances (bottom left) show that, after alignment most of the MRI anatomy is closer than 5mm from the EAM anatomy in every patient. On average, 87.6±10.4% of the atrial surfaces showed distances below 5.0mm between the two anatomies and 55.1±13.2% of the surfaces was within 2.5mm from each other. Results did not differ between Ensite and CARTO anatomies.
Conclusion
LA anatomy obtained from 3D LGE MRI can automatically and reliably be aligned with LA anatomy recorded during an ablation procedure with an EAM system using an iterative closest point-to-plane algorithm.
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Affiliation(s)
- BJM Hermans
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
| | - GP Bijvoet
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - RJ Holtackers
- Maastricht University Medical Centre (MUMC), Radiology, Maastricht, Netherlands (The)
| | - C Mihl
- Maastricht University Medical Centre (MUMC), Radiology, Maastricht, Netherlands (The)
| | - JGLM Luermans
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - K Vernooy
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - D Linz
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - SM Chaldoupi
- Maastricht University Medical Centre (MUMC), Cardiology, Maastricht, Netherlands (The)
| | - U Schotten
- Cardiovascular Research Institute Maastricht (CARIM), Physiology, Maastricht, Netherlands (The)
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50
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Zeemering S, Isaacs A, Winters J, Isaacs A, Kawczynski M, Rivero MH, Ghalawinji A, Witten A, Chua W, Kaab S, Wakili R, Sinner MF, Mont L, Guasch E, Hatem S, Crijns HJ, Fabritz L, Kirchhof P, Stoll M, Schotten U. BS-515-04 REPLICATED GENE EXPRESSION CHANGES IN PATIENTS WITH PERSISTENT ATRIAL FIBRILLATION. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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