Perioperative Management in Patients with Atrial Fibrillation Treated with Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Minor Bleeding Risk Procedure: Rationale and Protocol for the PERIXa Study

Background

While treatment interruption of non-vitamin K antagonist oral anticoagulants (NOACs) for elective surgery or procedures among patients with atrial fibrillation (AF) is becoming more prevalent, there remains insufficient evidence regarding the optimal perioperative management of NOACs, particularly procedures with minor bleeding risks.

Objective

This study aims to evaluate the safety and effectiveness of a simplified, standardized protocol for perioperative management of direct factor Xa inhibitors in patients, with AF undergoing procedures associated with minor bleeding risk.

Methods

This multicenter, prospective single-arm registry study plans to enroll patients undergoing procedures with minor bleeding risk who were prescribed direct factor Xa inhibitors for AF. The procedures with minor bleeding risk will include gastrointestinal endoscopy for diagnostic purposes, selected dental procedures, and ocular surgery for cataracts or glaucoma. For apixaban, patients will withhold the last evening dose and resume either from the evening dose of the procedure day or the following morning, depending on the bleeding risk of the patient. For edoxaban or rivaroxaban, patients will withhold only a single dose on the procedure day. The primary outcome is the occurrence of major bleeding events within 30 days. Secondary outcomes include systemic thromboembolism, all-cause mortality, and a composite of major and clinically relevant non-major bleeding events.

Conclusion

This study has the potential to generate evidence regarding the safety of perioperative management for patients, with AF undergoing procedures associated with minor bleeding risk.

Trial Registration

Clinicaltrials.gov: NCT05801068.

Correction: Three-Day Monitoring of Adhesive Single-Lead Electrocardiogram Patch for Premature Ventricular Complex: Prospective Study for Diagnosis Validation and Evaluation of Burden Fluctuation

[This corrects the article DOI: 10.2196/46098.].

Association between types of antihypertensive medication and the risk of atrial fibrillation: a nationwide population study

Background

Patients with hypertension are at a high risk of atrial fibrillation (AF). Recent research has indicated the varying effects of antihypertensive medications on developing AF.

Objectives

We investigated the relationship between different types of antihypertensive medications and the risk of AF occurrence.

Methods

We analyzed data from 113,582 subjects with national health screening examinations between 2009 and 2014. The study population was categorized according to antihypertensive medication type. The primary outcome was the incidence of AF.

Results

Among 113,582 subjects (mean age 59.4 ± 12.0 years, 46.7% men), 93,557 received monotherapy [angiotensin receptor blockers (ARB), angiotensin-converting enzyme inhibitors (ACEi), beta-blockers, calcium channel blockers (CCB), or diuretics], while 34,590 received combination therapy (ARB/beta-blockers, ARB/CCB, ARB/diuretics, or ARB/CCB/diuretics). During a mean follow-up duration of 7.6 ± 2.1 years, 3.9% of patients were newly diagnosed with AF. In monotherapy, ACEi and CCB had similar AF risks as ARB, while beta-blockers and diuretics showed higher AF risks than ARB. In combination therapy, ARBs/CCBs and ARBs/diuretics had the lowest AF risk, whereas ARBs/beta-blockers had the highest compared to ARB/CCB. Among the specific ARBs, the AF risk varied insignificantly, except for telmisartan and candesartan.

Conclusions

In hypertensive patients receiving monotherapy, ACEi and CCB showed a similar AF risk as ARBs, while beta-blockers and diuretics were associated with a higher risk. Among those receiving combination therapy, ARBs/CCBs and ARBs/diuretics had the lowest AF risk, whereas ARBs/beta-blockers showed the highest risk. Various types of ARBs have different associations with AF risk.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Alcohol is neither a risk factor nor a protective factor for sudden cardiac death and/or fatal ventricular arrhythmia: A population-based study with genetic traits and alcohol consumption in the UK Biobank

BACKGROUND

The association between alcohol consumption and the risk of sudden cardiac death and/or fatal ventricular arrhythmia remains controversial.

OBJECTIVE

We analyzed the association between alcohol consumption, genetic traits for alcohol metabolism, and the risk of sudden cardiac death and/or fatal ventricular arrhythmia.

METHODS

We identified 397,164 individuals enrolled between 2006 and 2010 from the UK Biobank database and followed them until 2021. Alcohol consumption was categorized as current nondrinkers (nondrinkers and ex-drinkers), mild drinkers, moderate drinkers, or heavy drinkers. Genetic traits of alcohol metabolism were stratified according to the polygenic risk score tertiles. The primary and secondary outcomes were a composite of sudden cardiac death and fatal ventricular arrhythmia as well as their individual components.

RESULTS

During follow-up (median 12.5 years), 3543 cases of clinical outcomes occurred. Although mild, moderate, and heavy drinkers showed deceased risks of outcomes compared with current nondrinkers, there was no prognostic difference among nondrinkers, mild drinkers, moderate drinkers, and heavy drinkers. Ex-drinkers showed an increased risk in univariate analysis, but the significance was attenuated after adjusting covariates (hazard ratio 1.19; 95% confidence interval 0.94-1.50). As a continuous variable, alcohol consumption was not associated with clinical outcomes (hazard ratio 1.01; 95% confidence interval 0.99-1.02). Consistent with these findings, there was no association between genetic traits for alcohol metabolism and the risk of clinical outcomes.

CONCLUSION

Alcohol consumption was neither a protective factor nor a risk factor for sudden cardiac death or fatal ventricular arrhythmia. Genetic traits of alcohol metabolism were not associated with the clinical prognosis.

Accelerometer-derived physical activity and the risk of death, heart failure, and stroke in patients with atrial fibrillation: a prospective study from UK Biobank

OBJECTIVE

Data on cardiovascular outcomes according to objectively measured physical activity (PA) in patients with atrial fibrillation (AF) are scarce. This study explored the associations between PA derived from wrist-worn accelerometers and the risk of death, incident heart failure (HF), and incident stroke in patients with AF.

METHODS

From 37 990 patients with AF in UK Biobank, 2324 patients with accelerometer data were included. Weekly moderate-to-vigorous PA (MVPA) duration was computed from accelerometer data. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular mortality, incident HF, and incident stroke. Restricted cubic splines estimated the dose-response associations between MVPA duration and the outcomes. The adjusted HRs (aHRs) of the outcomes according to adherence to PA standard guidelines (performing MVPA≥150 min/week) were also evaluated.

RESULTS

The mean age was 66.9±6.2 years and 64.9% were male. During a median follow-up of 6.7 years, there were 181 all-cause deaths, 62 cardiovascular deaths, 225 cases of incident HF, and 91 cases of incident stroke; the overall incidence rate per 1000 patient-years was 11.76, 4.03, 15.16 and 5.99, respectively. There was a linear inverse dose-response relationship between MVPA (≥108 min/week) and all-cause mortality. Performing MVPA for 105-590 min/week was associated with a lower risk of HF than those with no measurable MVPA. The risk of stroke and cardiovascular mortality was not associated with MVPA. Performing guideline-adherent MVPA was related to a 30% lower risk of all-cause mortality (aHR: 0.70 (0.50-0.98), p=0.04) and 33% lower risk of HF (aHR 0.67 (0.49-0.93), p=0.02).

CONCLUSION

In patients with AF, accelerometer-derived PA data supports lower risks of all-cause mortality and HF according to a greater level of MVPA and adherence to PA guidelines. Regular MVPA should be encouraged in patients with AF as a part of integrated management.

Effect of physical activity on incident atrial fibrillation in individuals with varying duration of diabetes: a nationwide population study

BACKGROUND

Diabetes mellitus (DM) duration affects incident atrial fibrillation (AF) risk; the effect of physical activity on mitigating AF risk related to varying DM duration remains unknown. We assessed the effect of physical activity on incident AF in patients with DM with respect to known DM duration.

METHODS

Patients with type 2 DM who underwent the Korean National Health Insurance Service health examination in 2015-2016 were grouped by DM duration: new onset and < 5, 5-9, and ≥ 10 years. Physical activity was classified into four levels: 0, < 500, 500-999, 1,000-1,499, and ≥ 1,500 metabolic equivalent task (MET)-min/week, with the primary outcome being new-onset AF.

RESULTS

The study enrolled 2,392,486 patients (aged 59.3 ± 12.0 years, 39.8% female) with an average follow-up of 3.9 ± 0.8 years and mean DM duration of 5.3 ± 5.1 years. Greater physical activity was associated with a lower AF risk. Lowering of incident AF risk varied with different amounts of physical activity in relation to known DM duration. Among patients with new-onset DM, DM duration < 5 years and 5-9 years and 1,000-1,499 MET-min/week exhibited the lowest AF risk. Physical activity ≥ 1,500 MET-min/week was associated with the lowest incident AF risk in patients with DM duration ≥ 10 years (by 15%), followed DM duration of 5-9 years (12%) and < 5 years (9%) (p-for-interaction = 0.002).

CONCLUSIONS

Longer DM duration was associated with a high risk of incident AF, while increased physical activity generally reduced AF risk. Engaging in > 1,500 MET-min/week was associated with the greatest AF risk reduction in patients with longer DM duration, highlighting the potential benefits of higher activity levels for AF prevention.

Three-Day Monitoring of Adhesive Single-Lead Electrocardiogram Patch for Premature Ventricular Complex: Prospective Study for Diagnosis Validation and Evaluation of Burden Fluctuation

BACKGROUND

Wearable electrocardiogram (ECG) monitoring devices are used worldwide. However, data on the diagnostic yield of an adhesive single-lead ECG patch (SEP) to detect premature ventricular complex (PVC) and the optimal duration of wearing an SEP for PVC burden assessment are limited.

OBJECTIVE

We aimed to validate the diagnostic yield of an SEP (mobiCARE MC-100, Seers Technology) for PVC detection and evaluate the PVC burden variation recorded by the SEP over a 3-day monitoring period.

METHODS

This is a prospective study of patients with documented PVC on a 12-lead ECG. Patients underwent simultaneous ECG monitoring with the 24-hour Holter monitor and SEP on the first day. On the subsequent second and third days, ECG monitoring was continued using only SEP, and a 3-day extended monitoring was completed. The diagnostic yield of SEP for PVC detection was evaluated by comparison with the results obtained on the first day of Holter monitoring. The PVC burden monitored by SEP for 3 days was used to assess the daily and 6-hour PVC burden variations. The number of patients additionally identified to reach PVC thresholds of 10%, 15%, and 20% during the 3-day extended monitoring by SEP and the clinical factors associated with the higher PVC burden variations were explored.

RESULTS

The recruited data of 134 monitored patients (mean age, 54.6 years; males, 45/134, 33.6%) were analyzed. The median daily PVC burden of these patients was 2.4% (IQR 0.2%-10.9%), as measured by the Holter monitor, and 3.3% (IQR 0.3%-11.7%), as measured in the 3-day monitoring by SEP. The daily PVC burden detected on the first day of SEP was in agreement with that of the Holter monitor: the mean difference was -0.07%, with 95% limits of agreement of -1.44% to 1.30%. A higher PVC burden on the first day was correlated with a higher daily (R2=0.34) and 6-hour burden variation (R2=0.48). Three-day monitoring by SEP identified 29% (12/42), 18% (10/56), and 7% (4/60) more patients reaching 10%, 15%, and 20% of daily PVC burden, respectively. Younger age was additionally associated with the identification of clinically significant PVC burden during the extended monitoring period (P=.02).

CONCLUSIONS

We found that the mobiCARE MC-100 SEP accurately detects PVC with comparable diagnostic yield to the 24-hour Holter monitor. Performing 3-day PVC monitoring with SEP, especially among younger patients, may offer a pragmatic alternative for identifying more individuals exceeding the clinically significant PVC burden threshold.

Clonal haematopoiesis of indeterminate potential and atrial fibrillation: an east Asian cohort study

BACKGROUND AND AIMS

Both clonal haematopoiesis of indeterminate potential (CHIP) and atrial fibrillation (AF) are age-related conditions. This study investigated the potential role of CHIP in the development and progression of AF.

METHODS

Deep-targeted sequencing of 24 CHIP mutations (a mean depth of coverage = 1000×) was performed in 1004 patients with AF and 3341 non-AF healthy subjects. Variant allele fraction ≥ 2.0% indicated the presence of CHIP mutations. The association between CHIP and AF was evaluated by the comparison of (i) the prevalence of CHIP mutations between AF and non-AF subjects and (ii) clinical characteristics discriminated by CHIP mutations within AF patients. Furthermore, the risk of clinical outcomes-the composite of heart failure, ischaemic stroke, or death-according to the presence of CHIP mutations in AF was investigated from the UK Biobank cohort.

RESULTS

The mean age was 67.6 ± 6.9 vs. 58.5 ± 6.5 years in AF (paroxysmal, 39.0%; persistent, 61.0%) and non-AF cohorts, respectively. CHIP mutations with a variant allele fraction of ≥2.0% were found in 237 (23.6%) AF patients (DNMT3A, 13.5%; TET2, 6.6%; and ASXL1, 1.5%) and were more prevalent than non-AF subjects [356 (10.7%); P < .001] across the age. After multivariable adjustment (age, sex, smoking, body mass index, diabetes, and hypertension), CHIP mutations were 1.4-fold higher in AF [adjusted odds ratio (OR) 1.38; 95% confidence interval 1.10-1.74, P < .01]. The ORs of CHIP mutations were the highest in the long-standing persistent AF (adjusted OR 1.50; 95% confidence interval 1.14-1.99, P = .004) followed by persistent (adjusted OR 1.44) and paroxysmal (adjusted OR 1.33) AF. In gene-specific analyses, TET2 somatic mutation presented the highest association with AF (adjusted OR 1.65; 95% confidence interval 1.05-2.60, P = .030). AF patients with CHIP mutations were older and had a higher prevalence of diabetes, a longer AF duration, a higher E/E', and a more severely enlarged left atrium than those without CHIP mutations (all P < .05). In UK Biobank analysis of 21 286 AF subjects (1297 with CHIP and 19 989 without CHIP), the CHIP mutation in AF is associated with a 1.32-fold higher risk of a composite clinical event (heart failure, ischaemic stroke, or death).

CONCLUSIONS

CHIP mutations, primarily DNMT3A or TET2, are more prevalent in patients with AF than non-AF subjects whilst their presence is associated with a more progressive nature of AF and unfavourable clinical outcomes.

Association between antithrombotic therapy after stroke in patients with atrial fibrillation and the risk of net clinical outcome: an observational cohort study

AIMS

Data on the optimal use of antithrombotic drugs and associated clinical outcomes in patients with atrial fibrillation (AF) and acute ischaemic stroke (IS) are limited. We investigated the prescription patterns of antithrombotics in community practice and long-term clinical prognosis according to early post-stroke antithrombotic therapy in patients with AF and acute IS.

METHODS AND RESULTS

Patients with AF who were admitted for acute IS at a single tertiary hospital in 2010-2020 were retrospectively reviewed. Clinical profiles including the aetiology of stroke and prescription patterns of antithrombotics were identified. The net clinical outcome (NCO)-the composite of recurrent stroke, any bleeding, hospitalization or emergency department visits for cardiovascular (CV) events, and death-was compared according to the antithrombotic therapy at the first outpatient clinic visit [oral anticoagulation (OAC) alone vs. antiplatelet (APT) alone vs. OAC/APT(s)] following discharge. A total of 918 patients with AF and acute IS (mean age, 72.6 years; male, 59.3%; mean CHA₂DS₂-VASc score 3.3) were analysed. One-third (33.9%, n = 310) of patients were simultaneously diagnosed with AF and IS. The most common aetiology of IS was cardioembolism (71.2%), followed by undetermined aetiology (19.8%) and large artery atherosclerosis (6.0%). OAC, APT(s), and concomitant OAC and APT(s) were prescribed in 33.4%, 11.1%, and 53.4% of patients during admission that changed to 67.0%, 9.1%, and 21.7% at the first outpatient clinic, and were mostly continued up to one year after IS. Non-prescription of OAC was observed in 11.3% of post-stroke patients with AF. During a median follow-up of 2.1 years, the overall incidence rate of NCO per 100 patient-year (PY) was 20.14. APT(s) monotherapy presented the highest cumulative risk of NCO (adjusted hazard ratio 1.47, 95% confidence interval 1.08-2.00, P = 0.015; with reference to OAC monotherapy) mainly driven by the highest rates of recurrent stroke and any bleeding. OAC/APT(s) combination therapy was associated with a 1.62-fold significantly higher risk of recurrent stroke (P = 0.040) and marginally higher risk of any bleeding than OAC monotherapy.

CONCLUSION

Approximately one-third of acute IS in AF have a distinctive mechanism from cardioembolism. Although APT was frequently prescribed in post-stroke patients with AF, no additive clinical benefit was observed. Adherence to OAC treatment is essential to prevent further CV adverse events in patients with AF and IS.

Neuroticism and the Risk of Atrial Fibrillation: An Observational Epidemiologic and Mendelian Randomization Study

Background

The association between neuroticism and atrial fibrillation (AF) remains unknown.

Objectives

This study aimed to assess the epidemiological and causal relationships between neuroticism and AF.

Methods

Individuals without AF history were selected From the UK Biobank nationwide prospective cohort study. Participants were divided into 2 groups (high and low) based on the median summary score from a self-questionnaire of 12 neurotic behavior domains. The 10-year AF risk was compared between the neuroticism score groups using inverse probability of treatment weighting. The causal relationship between neuroticism and AF was evaluated using a 2-sample summary-level Mendelian randomization with the inverse variance-weighted method.

Results

Of 394,834 participants (mean age 56.3 ± 8.1 years, 45.9% male), AF occurred in 23,509 (6.0%) during a 10-year follow-up. The risk of incident AF significantly increased in the high neuroticism score group (score ≥4) (inverse probability of treatment weighting-adjusted HR: 1.05; 95% CI: 1.02-1.09; P = 0.005) compared with the low neuroticism group. In the subgroup analysis, younger age, lower body mass index, or nonsmoker/ex-smoker participants were particularly susceptible to increased AF risk due to high neuroticism scores. A Mendelian randomization analysis showed a significant causal relationship between an increase in neuroticism score and increased risk of AF (OR by inverse variance-weighted method 1.06; 95% CI: 1.02-1.11; P = 0.007) without evidence of reverse causality.

Conclusions

There was a significant longitudinal and causal relationship between neuroticism and AF. An integrated care including active mental health screening and management may benefit in high-risk populations.

Reduction of Upper Gastrointestinal Bleeding Risk With Proton Pump Inhibitor Therapy in Asian Patients With Atrial Fibrillation Receiving Direct Oral Anticoagulant: A Nationwide Population-based Cohort Study

BACKGROUND & AIMS

In patients with atrial fibrillation (AF) receiving direct oral anticoagulant (DOAC), upper gastrointestinal bleeding (UGIB) is a serious complication. There are limited data on the benefit of preventive proton pump inhibitor (PPI) use to reduce the risk of UGIB in DOAC users.

METHODS

We included patients with AF receiving DOAC from 2015 to 2020 based on the Korean Health Insurance Review and Assessment database. The propensity score (PS) weighting method was used to compare patients with PPI use and those without PPI use. The primary outcome was hospitalization for UGIB. Weighted hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were evaluated using the Cox proportional hazards regression model.

RESULTS

A total of 165,624 patients were included (mean age: 72.2 ± 10.8 years; mean CHA2DS2-VASc score: 4.3 ± 1.8; mean HAS-BLED score: 3.3 ± 1.2). Among them, 99,868 and 65,756 were in the non-PPI group and PPI group, respectively. During a median follow-up of 1.5 years, the PPI group was associated with lower risks of hospitalization for UGIB and UGIB requiring red blood cell transfusion than non-PPI group (weighted HR, 0.825; 95% CI, 0.761-0.894 and 0.798; 95% CI, 0.717-0.887, respectively, both P < .001). The benefits of PPI on the risk of hospitalization for UGIB were greater in those with older age (≥75 years), higher HAS-BLED score (≥3), prior GIB history, and concomitant use of antiplatelet agent (all P-for-interaction < .1). Low-dose PPI was consistently associated with a lower risk of significant UGIB by 43.6-49.3% (P < .001).

CONCLUSIONS

In this large Asian cohort of patients with AF on DOAC, PPI co-therapy is beneficial for reducing the risk of hospitalization for UGIB, particularly in high-risk patients.

Impact of Unhealthy Lifestyles on Patients with Atrial Fibrillation at Low Risk of Stroke: A Nationwide Cohort Study

BACKGROUND

The impact of unhealthy lifestyles on clinical outcomes among patients with atrial fibrillation (AF) who are at low risk of stroke remains uncertain. The study objective was to evaluate the association between unhealthy lifestyles and clinical outcomes among low-risk AF patients with 0-1 non-sex risk factor of the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack [TIA], Vascular disease, Age 65-74 years, female Sex;) score.

METHODS

A total of 52,451 low-risk AF patients (mean age 51.6 ± 10.4 years) were evaluated with the National Health Insurance Service of the Republic of Korea database between 2009 and 2016. Using the survey on health habits, an unhealthy lifestyle score (ULS) was calculated by adding one point each if a respondent had a sedentary lifestyle, drinking, or smoking. The primary outcome was the composite of myocardial infarction, ischemic stroke, heart failure, and all-cause death. Multivariable Cox regression analysis was used to estimate the risk of the study outcome according to the ULS.

RESULTS

There was a total of 12,792 (24.4%), 24,785 (47.3%), 11,602 (22.1%), and 3272 (6.2%) low-risk AF patients with 0 to 3 points of the ULS, respectively. The median follow-up period was 4.1 (2.1-6.1) years. Compared with the healthiest-lifestyle group (ULS 0), the other groups were associated with significantly higher risks of the primary outcome, with a gradually increasing trend according to the ULS (adjusted hazard ratio [95% confidence interval] =1.17 [1.05-1.31], 1.37 [1.21-1.56], 1.82 [1.53-2.17], for the groups with ULS 1, 2, and 3, respectively).

CONCLUSION

Unhealthy lifestyles, including a sedentary lifestyle, drinking, and smoking, may synergistically impact poor clinical outcomes in AF patients who are deemed to be at low risk of stroke.

Risk of newly developed atrial fibrillation by alcohol consumption differs according to genetic predisposition to alcohol metabolism: a large-scale cohort study with UK Biobank

BACKGROUND

The predictive relationship between mild-to-moderate alcohol consumption and the risk of incident atrial fibrillation (AF) remains controversial.

OBJECTIVE

We investigated whether the relationship between alcohol consumption and the risk of incident AF could be associated with the genetic predisposition to alcohol metabolism.

METHODS

A total of 399,329 subjects with genetic data from the UK Biobank database, enrolled between 2006 and 2010, were identified and followed for incident AF until 2021. Genetic predisposition to alcohol metabolism was stratified according to the polygenic risk score (PRS) tertiles. Alcohol consumption was categorized as non-drinkers, mild-to-moderate drinkers (< 30 g/day), and heavy drinkers (≥ 30 g/day).

RESULTS

During the follow-up (median 12.2 years), 19,237 cases of AF occurred. When stratified by PRS tertiles, there was a significant relationship between genetic predisposition to alcohol metabolism and actual alcohol consumption habits (P < 0.001). Mild-to-moderate drinkers showed a decreased risk of AF (HR 0.96, 95% CI 0.92-0.99), and heavy drinkers showed an increased risk of AF (HR 1.06, 95% CI 1.02-1.10) compared to non-drinkers. When stratified according to PRS tertiles for genetic predisposition to alcohol metabolism, mild-to-moderate drinkers had equivalent AF risks, and heavy drinkers showed increased AF risk in the low PRS tertile group. However, mild-to-moderate drinkers had decreased AF risks and heavy drinkers showed similar risks of AF in the middle/high PRS tertile groups.

CONCLUSIONS

Differential associations between alcohol consumption habits and incident AF across genetic predisposition to alcohol metabolism were observed; individuals with genetic predisposition to low alcohol metabolism were more susceptible to AF.

Metabolic syndrome and ischaemic stroke in non-anticoagulated atrial fibrillation with low CHA2DS2-VASc scores

OBJECTIVE

Conflicting results have been reported on whether metabolic syndrome (MetS) confers an increased risk of ischaemic stroke in atrial fibrillation (AF). We investigated the risk of ischaemic stroke according to MetS in patients with AF who are not indicated for oral anticoagulants.

METHODS

A total of 76 015 oral anticoagulant-naïve patients with AF with low Congestive Heart Failure, Hypertension, Age ≥75 years (Doubled), Diabetes Mellitus, Stroke (Doubled), Vascular Disease, Age 65-74 years, Sex Category (Female) (CHA2DS2-VASc) score (0 and 1) were included from the National Health Information Database. The risk of ischaemic stroke was evaluated according to MetS, the number of MetS components (metabolic burden), and individual metabolic components defined by health examination data within 2 years of AF diagnosis.

RESULTS

MetS was prevalent among 21 570 (28.4%) of the entire study population (mean age 49.8±11.1 years, mean CHA2DS2-VASc score 0.7±0.5). During a mean follow-up of 5.1 years, ischaemic stroke occurred in 1395 (1.84%) patients. MetS was associated with a higher risk of ischaemic stroke (adjusted HR (aHR) 1.19, 95% CI 1.06 to 1.33, p=0.002). Patients with the highest number of MetS components (4 or 5) showed the greatest aHR of 1.38 (95% CI 1.13 to 1.69), whereas those with a single component had a marginal risk of ischaemic stroke (aHR 1.17, 95% CI 0.97 to 1.40). Elevated blood pressure and increased waist circumference were independent components associated with 1.48-fold and 1.15-fold higher risks of ischaemic stroke, respectively.

CONCLUSION

Among AF patients with CHA2DS2-VASc scores of 0 and 1 with no anticoagulation, MetS is associated with an increased risk of ischaemic stroke. Given the linear incremental association between metabolic burden and ischaemic stroke, the integrated management of metabolic derangements in AF is required.

Association Between Atrial Fibrillation and Diabetes-Related Complications: A Nationwide Cohort Study

OBJECTIVE

This study aimed to investigate the associations between concurrent atrial fibrillation and diabetes-related complications among patients with diabetes.

RESEARCH DESIGN AND METHODS

This nationwide observational cohort study used the health checkup database from the Korean National Health Insurance Service. Patients diagnosed with diabetes who underwent health checkups between 2009 and 2012 were investigated. The patients with atrial fibrillation were matched in a 1:5 ratio with those without atrial fibrillation using propensity scores. Study outcomes included macrovascular, microvascular (diabetic retinopathy and diabetic nephropathy), and diabetic foot complications. The risks of clinical outcomes were measured using hazard ratios (HRs) with 95% CIs.

RESULTS

A total of 65,760 patients with diabetes were analyzed (54,800 without atrial fibrillation and 10,960 with atrial fibrillation). After well-balanced propensity score matching, atrial fibrillation was associated with significantly higher risks of macrovascular complications (HR 1.12, 95% CI 1.09-1.16), diabetic nephropathy (HR 1.23, 95% CI 1.16-1.30), and diabetic foot complications (HR 1.13, 95% CI 1.09-1.17) compared with no atrial fibrillation, while the risk of diabetic retinopathy was comparable (HR 0.99, 95% CI 0.96-1.03). Patients with atrial fibrillation had a significantly higher risk of diabetic foot amputation (HR 4.12, 95% CI 1.98-8.56).

CONCLUSIONS

Among patients with diabetes, concurrent atrial fibrillation was associated with increased risks for diabetes-related macrovascular complications, diabetic nephropathy, and diabetic foot. Such patients require holistic management to reduce the risk of adverse outcomes.

Early rhythm control on diabetes-related complications and mortality in patients with type 2 diabetes mellitus and atrial fibrillation

AIMS

We evaluated the impact of early rhythm control (ERC) on diabetes-related complications and mortality in subjects with type 2 diabetes mellitus (T2DM) and atrial fibrillation (AF).

METHODS

This observational cohort study based on the Korean National Health Insurance Service claims database from 2009 to 2016, divided newly diagnosed AF patients with T2DM into ERC or usual care groups based on receiving rhythm control treatment within 1 year of AF diagnosis. The primary outcome was ischemic stroke, and the secondary outcomes were macro/microvascular complications, and all-cause death.

RESULTS

Among 47,509 subjects (mean age 66.7 ± 10.5 years; 61.8 % men; mean CHA2DS2-VASc score 4.6 ± 1.8; mean follow-up 4.3 ± 2.3 years; mean DM duration 5.6 ± 4.7 years), 23.1 % received ERC, and 76.9 % did not (usual care group). ERC was associated with lower risks of ischemic stroke, macrovascular and microvascular complications, and all-cause death compared to usual care (adjusted hazard ratios [95 % confidence interval]: 0.77 [0.70-0.85], 0.79 [0.73-0.86], 0.86 [0.82-0.90], and 0.92 [0.87-0.98], p < 0.001, <0.001, <0.001, and 0.012, respectively).

CONCLUSIONS

Early rhythm control was associated with reduced risks of diabetes-related complications and mortality in subjects with T2DM and AF. Rhythm control within 1 year of AF diagnosis with proper anticoagulation should be considered to prevent adverse outcomes.

Novel laparoscopic renal denervation immediately reduces atrial fibrillation inducibility: a swine model study

Catheter-based approaches may have inherent limitations in achieving effective renal denervation (RDN) and treatment of atrial fibrillation (AF). This study aimed to investigate the acute effects of novel laparoscopic RDN on modulating AF inducibility using a swine model. Four and five swine were randomly allocated to the sham and RDN groups, respectively. Each swine underwent measurement of the atrial effective refractory period (AERP) and AF induction tests using burst atrial pacing before and immediately after sham or RDN procedures with and without vagal nerve stimulation (VNS). A laparoscopic RDN procedure circumferentially ablated the renal nerves round the renal arteries using radiofrequency energy. There was no significant difference in the baseline AERP between the two groups (p > 0.05). Under VNS, AERP was significantly increased by 20 ms after laparoscopic RDN (95% CI = 0-30, p = 0.004). Compared to the sham group, the RDN group showed significantly reduced AF inducibility [OR (95% CI) = 0.32 (0.13-0.76) and 0.24 (0.11-0.57) with and without VNS, respectively]. After laparoscopic RDN, the duration of inducible AF episodes was significantly shortened from 28 (10-77) s to 7 (3-11) s (p < 0.001). The novel laparoscopic RDN can immediately reduce AF inducibility in a swine model.

Increased cardiovascular events in young patients with mental disorders: a nationwide cohort study

AIMS

It remains unclear whether young patients with mental disorders have a higher risk of cardiovascular diseases than does the general population. Using a nationwide database, we investigated the prognostic association between the risks of myocardial infarction (MI), ischaemic stroke (IS), and mental disorders in young patients.

METHODS AND RESULTS

Young patients aged between 20 and 39 years old who underwent nationwide health examinations between 2009 and 2012 were screened. A total of 6 557 727 individuals were identified and subsequently classified according to mental disorders including depressive disorder, bipolar disorder, schizophrenia, insomnia, anxiety disorder, post-traumatic stress disorder, personality disorder, somatoform disorder, eating disorder, and substance use disorder. Patients were then followed up for MI and IS until December 2018. Patients with mental disorders did not show unfavourable lifestyle behaviours or worse metabolic profiles than their counterparts. During the follow-up period (median, 7.6 years; interquartile range, 6.5-8.3), 16 133 cases of MI and 10 509 cases of IS occurred. Patients with mental disorders had higher risks of MI (log-rank P = 0.033 in eating disorder and log-rank P < 0.001 in all other mental disorders). Patients with mental disorders had higher risks of IS except post-traumatic stress disorder (log-rank P = 0.119) and eating disorder (log-rank P = 0.828). After adjusting for covariates, the overall diagnosis and each mental disorder were independently associated with increased cardiovascular endpoints.

CONCLUSION

Mental disorders in young patients may have deleterious effects which increase the incidence of MI and IS. Prevention efforts are needed to prevent MI and IS in young patients with mental disorders.

Impact of components of metabolic syndrome on the risk of adverse renal outcomes in patients with atrial fibrillation: a nationwide cohort study

Background

The renal effect of metabolic syndrome components is unclear in patients with atrial fibrillation. This study aimed to investigate the association between metabolic syndrome components and incident end-stage renal disease among patients with atrial fibrillation.

Methods

A total of 202,434 atrial fibrillation patients without prevalent end-stage renal disease were identified from the National Health Insurance Service database between 2009 and 2016. We defined the metabolic score range from 0 to 5 points such that a patient received every 1 point if the patient met each component listed in the diagnostic criteria of metabolic syndrome. The population was divided into 6 groups: MS0-MS5 for a metabolic score of 0-5, respectively. Multivariate Cox regression analysis was used to estimate the risks of end-stage renal disease.

Results

There were 12,747, 31,059, 40,361, 48,068, 46,630, and 23,569 patients for MS0-MS5, respectively. Compared with MS0, MS5 had a higher CHA2DS2-VASc score (3.8 vs. 1.0) (P < .001). During a median follow-up of 3.5 years, compared with MS0, MS1-MS5 were associated with a gradually increasing incidence of end-stage renal disease, in relation to an increase in the metabolic score, (log-rank P < .001). After multivariate adjustment, a higher metabolic score was associated with a greater risk of incident end-stage renal disease: adjusted hazard ratio [95% confidence interval] = 1.60 [0.78-3.48], 2.08 [1.01-4.31], 2.94 [1.43-6.06], 3.71 [1.80-7.66], and 4.82 [2.29-10.15], for MS1-MS5, respectively.

Conclusions

Metabolic syndrome components additively impacts the risk of incident end-stage renal disease among patients with atrial fibrillation.

Machine Learning Prediction for the Recurrence After Electrical Cardioversion of Patients With Persistent Atrial Fibrillation

BACKGROUND AND OBJECTIVES

There is limited evidence regarding machine-learning prediction for the recurrence of atrial fibrillation (AF) after electrical cardioversion (ECV). This study aimed to predict the recurrence of AF after ECV using machine learning of clinical features and electrocardiograms (ECGs) in persistent AF patients.

METHODS

We analyzed patients who underwent successful ECV for persistent AF. Machine learning was designed to predict patients with 1-month recurrence. Individual 12-lead ECGs were collected before and after ECV. Various clinical features were collected and trained the extreme gradient boost (XGBoost)-based model. Ten-fold cross-validation was used to evaluate the performance of the model. The performance was compared to the C-statistics of the selected clinical features.

RESULTS

Among 718 patients (mean age 63.5±9.3 years, men 78.8%), AF recurred in 435 (60.6%) patients after 1 month. With the XGBoost-based model, the areas under the receiver operating characteristic curves (AUROCs) were 0.57, 0.60, and 0.63 if the model was trained by clinical features, ECGs, and both (the final model), respectively. For the final model, the sensitivity, specificity, and F1-score were 84.7%, 28.2%, and 0.73, respectively. Although the AF duration showed the best predictive performance (AUROC, 0.58) among the clinical features, it was significantly lower than that of the final machine-learning model (p<0.001). Additional training of extended monitoring data of 15-minute single-lead ECG and photoplethysmography in available patients (n=261) did not significantly improve the model's performance.

CONCLUSIONS

Machine learning showed modest performance in predicting AF recurrence after ECV in persistent AF patients, warranting further validation studies.

Prediction of post-stroke cognitive impairment after acute ischemic stroke using machine learning

BACKGROUND AND OBJECTIVES

Post-stroke cognitive impairment (PSCI) occurs in up to 50% of patients with acute ischemic stroke (AIS). Thus, the prediction of cognitive outcomes in AIS may be useful for treatment decisions. This PSCI cohort study aimed to determine the applicability of a machine learning approach for predicting PSCI after stroke.

METHODS

This retrospective study used a prospective PSCI cohort of patients with AIS. Demographic features, clinical characteristics, and brain imaging variables previously known to be associated with PSCI were included in the analysis. The primary outcome was PSCI at 3-6 months, defined as an adjusted z-score of less than - 2.0 standard deviation in at least one of the four cognitive domains (memory, executive/frontal, visuospatial, and language), using the Korean version of the Vascular Cognitive Impairment Harmonization Standards-Neuropsychological Protocol (VCIHS-NP). We developed four machine learning models (logistic regression, support vector machine, extreme gradient boost, and artificial neural network) and compared their accuracies for outcome variables.

RESULTS

A total of 951 patients (mean age 65.7 ± 11.9; male 61.5%) with AIS were included in this study. The area under the curve for the extreme gradient boost and the artificial neural network was the highest (0.7919 and 0.7365, respectively) among the four models for predicting PSCI according to the VCIHS-NP definition. The most important features for predicting PSCI include the presence of cortical infarcts, mesial temporal lobe atrophy, initial stroke severity, stroke history, and strategic lesion infarcts.

CONCLUSION

Our findings indicate that machine-learning algorithms, particularly the extreme gradient boost and the artificial neural network models, can best predict cognitive outcomes after ischemic stroke.

Neuroticism and sudden cardiac death: a prospective cohort study from UK biobank

OBJECTIVE

There is a paucity of evidence on the risk of sudden cardiac death (SCD) according to the degree of neuroticism. We sought to evaluate the association between neuroticism and the long-term risk of SCD.

METHODS

From the UK Biobank nationwide prospective cohort, participants free from previous SCD, ventricular arrhythmias, implantable cardioverter-defibrillator (ICD) insertion, depression, schizophrenia, and bipolar disorder were selected. The 12-item scale of neuroticism measurement (neuroticism score) was categorized into high (≥ 3) and low (< 3) groups. The primary outcome was SCD including ventricular fibrillation (VF) at median 12.6 years of follow-up. The outcomes were compared between the groups using multivariable Cox regression and inverse probability of treatment weighting (IPTW).

RESULTS

A total of 377,563 participants (aged 56.5 ± 8.1, 53.1% women) were analyzed. The high neuroticism score group had a significantly lower risk of SCD (adjusted hazard ratio [aHR] = 0.87, 95% confidence interval [CI] 0.79-0.96, P = 0.007; IPTW-adjusted HR [IPTW-HR] 0.87 [0.77-0.97], P = 0.016) than the low neuroticism score group. The effect of a high neuroticism score on the decreased risk of SCD was more prominent in women (IPTW-HR 0.71 [0.56-0.89], P = 0.003) than in men (IPTW-HR 0.93 [0.82-1.07], P = 0.305, P-for-interaction = 0.043). Sex differences were observed among independent predictors for incident SCD, emphasizing the protective role of a high neuroticism score and moderate-to-vigorous physical activity only in women.

CONCLUSIONS

A high neuroticism score was significantly associated with a lower risk of SCD, particularly in women. Efforts to unveil the causal and mechanistic relationship between personality phenotypes and the risk of SCD should be continued.

The effect of non-optimal lipids on the progression of coronary artery calcification in statin-naïve young adults: results from KOICA registry

Background

Despite the importance of attaining optimal lipid levels from a young age to secure long-term cardiovascular health, the detailed impact of non-optimal lipid levels in young adults on coronary artery calcification (CAC) is not fully explored. We sought to investigate the risk of CAC progression as per lipid profiles and to demonstrate lipid optimality in young adults.

Methods

From the KOrea Initiative on Coronary Artery calcification (KOICA) registry that was established in six large volume healthcare centers in Korea, 2,940 statin-naïve participants aged 20-45 years who underwent serial coronary calcium scans for routine health check-ups between 2002 and 2017 were included. The study outcome was CAC progression, which was assessed by the square root method. The risk of CAC progression was analyzed according to the lipid optimality and each lipid parameter.

Results

In this retrospective cohort (mean age, 41.3 years; men 82.4%), 477 participants (16.2%) had an optimal lipid profile, defined as triglycerides <150 mg/dl, LDL cholesterol <100 mg/dl, and HDL cholesterol >60 mg/dl. During follow-up (median, 39.7 months), CAC progression was observed in 434 participants (14.8%), and more frequent in the non-optimal lipid group (16.5% vs. 5.7%; p < 0.001). Non-optimal lipids independently increased the risk of CAC progression [adjusted hazard ratio (aHR), 1.97; p = 0.025], in a dose-dependent manner. Even in relatively low-risk participants with an initial calcium score of zero (aHR, 2.13; p = 0.014), in their 20 s or 30 s (aHR 2.15; p = 0.041), and without other risk factors (aHR 1.45; p = 0.038), similar results were demonstrable. High triglycerides had the greatest impact on CAC progression in this young adult population.

Conclusion

Non-optimal lipid levels were significantly associated with the risk of CAC progression in young adults, even at low-risk. Screening and intervention for non-optimal lipid levels, particularly triglycerides, from an early age might be of clinical value.

Predictive Value of Electromechanical Window for Risk of Fatal Ventricular Arrhythmia

BACKGROUND

As an indicator of electro-mechanical coupling, electromechanical window (EMW) can be used to predict fatal ventricular arrhythmias. We investigated the additive effect of EMW on the prediction of fatal ventricular arrhythmias in high-risk patients.

METHODS

We included patients who had implantable cardioverter-defibrillator (ICD) implanted for primary or secondary prevention. The event group was defined as those who received an appropriate ICD therapy. We acquired echocardiograms at ICD implantation and follow-up. The EMW was calculated as the difference between the interval from QRS onset to aortic valve closure and QT interval from the electrocardiogram embedded in the continuous wave doppler image. We evaluated the predictive value of EMW for predicting fatal ventricular arrhythmia.

RESULTS

Of 245 patients (67.2 ± 12.8 years, 63.7% men), the event group was 20.0%. EMW at baseline (EMW-Baseline) and follow-up (EMW-FU) was significantly different between event and control groups. After adjustment, both EMW-Baseline (odds ratio [OR]_adjust 1.02 [1.01-1.03], P = 0.004) and EMW-FU (OR_adjust 1.06 [1.04-1.07], P < 0.001) remained as significant predictors for fatal arrhythmic events. Adding EMW-Baseline significantly improved the discriminating ability of the multivariable model including clinical variables (area under the curve [AUC] 0.77 [0.70-0.84] vs. AUC 0.72 [0.64-0.80], P = 0.004), while a univariable model using EMW-FU alone showed the best performance among models (AUC 0.87 [0.81-0.94], P = 0.060 against model with clinical variables; P = 0.030 against model with clinical variables and EMW-Baseline).

CONCLUSION

The EMW could effectively predict severe ventricular arrhythmia in ICD implanted patients. This finding supports the importance of incorporating the electro-mechanical coupling index into the clinical practice for predicting future fatal arrhythmia events.

Increased risk of incident atrial fibrillation in young adults with mental disorders: A nationwide population-based study

BACKGROUND

Mental disorders and cardiovascular diseases are closely related. However, a paucity of information on the risk of incident atrial fibrillation (AF) in patients with mental disorders exists.

OBJECTIVE

We aimed to assess the association between mental disorders and the risk of AF, particularly in young adults.

METHODS

Using the Korean National Health Insurance Database between 2009 and 2012, we identified adults aged 20-39 years without a history of AF and who have been diagnosed with mental disorders. Mental disorders were defined as having one of the following diagnoses: depression, insomnia, anxiety disorder, bipolar disorder, or schizophrenia. The primary outcome was new-onset AF during follow-up.

RESULTS

A total of 6,576,582 subjects (mean age 30.9 ± 5.0 years; 3,919,339 [59.6%] men) were included. Among the total population, 10% had mental disorders. During the follow-up period, 8932 incident AF events occurred. Patients with mental disorders showed a higher AF incidence than did those without (25.4 per 100,000 person-years vs 17.7 per 100,000 person-years). After multivariable adjustment, mental disorders were associated with a significantly higher risk of AF (adjusted hazard ratio 1.526; 95% confidence interval 1.436-1.621). Patients with bipolar disorder or schizophrenia had a 2-fold higher risk of AF and those with depression, insomnia, and anxiety disorder had a 1.5- to 1.7-fold higher risk of AF than did those without mental disorders.

CONCLUSION

Young adults diagnosed with mental disorders have a higher risk of incident AF. Awareness for AF in high-risk populations should thus be considered.

Physical Activity Changes and the Risk of Incident Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: A Nationwide Longitudinal Follow-up Cohort Study of 1.8 Million Subjects

OBJECTIVE

We investigated the association between alterations in regular physical activity (PA) and the risk of developing AF in patients with type 2 diabetes mellitus (T2DM) and the optimal PA range based on energy expenditure.

RESEARCH DESIGN AND METHODS

In a nationwide database, subjects who underwent health examinations twice at a 2-year interval between 2009 and 2012 were studied. After 1,815,330 patients with T2DM who did not have a history of AF were identified, they were followed until 2018. Regular PA alterations over time were used to divide individuals into four groups: persistent nonexercisers (n = 1,181,837), new exercisers (n = 242,968), exercise dropouts (n = 225,124), and exercise maintainers (n = 165,401).

RESULTS

During a mean follow-up period of 5.6 ± 1.3 years, 46,589 cases (2.6%) of new-onset AF occurred. Compared with the persistent nonexerciser group, both the exercise dropout group (adjusted hazard ratio [HR] 0.96, 95% CI 0.94-0.99) and new exerciser group (HR 0.95, 95% CI 0.93-0.98) had lower risks of incident AF. The exercise maintainer group showed the lowest risk (HR 0.91, 95% CI 0.89-0.94). When we stratified patients with T2DM according to energy expenditure, undergoing regular PA with ≥1,500 MET-min/week in new exercisers and ≥1,000 MET-min/week in exercise maintainers was associated with lower risks of incident AF than nonexercisers.

CONCLUSIONS

In patients with T2DM, starting and maintaining regular PA were both associated with lower risk of incident AF. Optimal PA ranges based on energy expenditure, which were associated with lower risks of incident AF, can be defined.

Cumulative Alcohol Consumption Burden and the Risk of Stroke in Young Adults: A Nationwide Population-Based Study

BACKGROUND AND OBJECTIVE

Alcohol consumption is one of the important modifiable risk factors for stroke in young adults. The association between the cumulative burden of alcohol consumption and its impact on incident stroke in young adults is unknown. We aimed to investigate the association between cumulative alcohol burden and the risk for stroke among young adults.

METHODS

Using data from the Korean National Health Insurance Service database, patients age between 20 and 39 years, who underwent 4 consecutive annual health examinations between 2009 and 2012, were included. The cumulative alcohol burden score of moderate-to-heavy drinking was evaluated by assigning a score of 1 for alcohol consumption ≥105 g/wk at the health examination each year and calculating the sum of 4 years (0-4). The main outcome was incident stroke and its subtypes, ischemic stroke, and hemorrhagic stroke during the follow-up period.

RESULTS

Of 1 536 668 patients (mean age of 29.5 years, 71.5% male, and median follow-up of 6-year), 3 153 experienced an incident stroke (incidence rate, 0.37 per 1,000 person-years). After multivariable adjustment, patients with alcohol burden scores of 2, 3, and 4, who consumed more than 105 g/wk of alcohol for 2, 3, and 4 years, demonstrated significantly higher risks for stroke (hazard ratio [HR] 1.19, 95% CI 1.05-1.34 for 2; HR 1.22, 95% CI 1.09-1.38 for 3; HR 1.23, 95% CI 1.10-1.38 for 4) compared with those with a burden score of 0. This positive dose-response relationship was primarily driven by hemorrhagic rather than ischemic stroke. High alcohol burden scores (i.e., 2, 3, and 4) were significantly associated with higher risks for hemorrhagic stroke (HR 1.30, 95% CI 1.10-1.54 for 2; HR 1.42, 95% CI 1.21-1.67 for 3; HR 1.36, 95% CI 1.16-1.59 for 4) compared with a burden score of 0.

DISCUSSION

Young adults who engaged in moderate-to-heavy drinking demonstrated a higher risk for incident stroke, especially hemorrhagic stroke. Reducing alcohol consumption should be emphasized in young adults with heavy drinking habits as part of any stroke prevention strategy.

Neutrophil-to-lymphocyte ratio as a predictor of in-hospital complications and overall mortality in Takotsubo syndrome preceded by physical triggers

BACKGROUND

Takotsubo syndrome (TTS) with physical triggers has worse short- and long-term clinical courses than those with emotional triggers. However, predictive factors associated with poor outcomes of TTS with physical triggers are unknown.

METHODS

We included 231 patients identified as TTS preceded by physical triggers at two tertiary referral hospitals from 2010 to 2019. In-hospital complications (IHC)-a composite of malignant arrhythmia, need for mechanical circulatory support or mechanical ventilation, and in-hospital death-and overall mortality were retrospectively reviewed. The associations with clinical features were evaluated by multivariable logistic and Cox regression analyses.

RESULTS

The mean age was 69.3 ± 11.6 years, and 85 (36.8%) were male. The in-hospital complications rate was 46.8%. During a median follow-up of 883 days, 96 (41.6%) had died, and overall mortality was 13.6% per patient-year. Higher neutrophil-to-lymphocyte ratio (NLR) was associated with a higher risk of IHC (area under the receiver operating characteristic curve = 0.73; positive and negative predictive value = 60.9% and 67.2% for NLR ≤ 12); odds ratio (OR) with 95% confidence interval (CI) was 1.03 (1.01-1.05), p = 0.010. Subsequently, higher NLR was also related to a greater risk of overall mortality; patients with high NLR (NLR > 12) exhibited poor long-term survival than those with low NLR (NLR ≤ 5): hazard ratio (95% CI), 3.70 (1.72-7.94) with p < 0.001.

CONCLUSIONS

A high NLR at initial presentation is associated with an increased risk of IHC and overall mortality in TTS preceded by physical triggers. Given that the treatment of TTS is mainly supportive, intensive monitoring with careful follow-up would be warranted in patients with high NLR.

Accumulated hypertension burden on atrial fibrillation risk in diabetes mellitus: a nationwide population study

BACKGROUND

Patients with diabetes mellitus have an increased risk of incident atrial fibrillation (AF). The effect of accumulated hypertension burden is a less well-known modifiable risk factor. We explored the relationship between accumulated hypertension burden and incident AF in these patients.

METHODS

We evaluated data for 526,384 patients with diabetes who underwent three consecutive health examinations, between 2009 and 2012, from the Korean National Health Insurance Service. Hypertension burden was calculated by assigning points to each stage of hypertension in each health examination: 1 for stage 1 hypertension (systolic blood pressure [SBP] 130-139 mmHg; diastolic blood pressure [DBP] 80-89 mmHg); 2 for stage 2 (SBP 140-159 mmHg and DBP 90-99 mmHg); and 3 for stage 3 (SBP ≥ 160 mmHg or DBP ≥ 100 mmHg). Patients were categorized into 10 hypertensive burden groups (0-9). Groups 1-9 were then clustered into 1-3, 4-6, and 7-9.

RESULTS

During a mean follow-up duration of 6.7 ± 1.7 years, AF was newly diagnosed in 18,561 (3.5%) patients. Compared to patients with hypertension burden 0, those with burden 1 to 9 showed a progressively increasing risk of incident AF: 6%, 11%, 16%, 24%, 28%, 41%, 46%, 57%, and 67% respectively. Clusters 1-3, 4-6, and 7-9 showed increased risks by 10%, 26%, and 45%, respectively, when compared to a hypertension burden of 0.

CONCLUSIONS

Accumulated hypertension burden was associated with an increased risk of incident AF in patients with diabetes. Strict BP control should be emphasized for these patients.

Evaluation of the Paradoxical Association Between Lipid Levels and Incident Atrial Fibrillation According to Statin Usage: A Nationwide Cohort Study

Objective

Higher levels of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) are associated with a lower risk of atrial fibrillation (AF). Statin use might exert confounding effects on the paradoxical associations; however, the relationships that distinguish statin users from non-users have not been thoroughly evaluated.

Methods

From the Korean National Health Insurance Database, we included 9,778,014 adults who underwent a health examination in 2009. The levels of TC and LDL-C at the health examination were categorized into quartile values of the total study population. We grouped the study population into statin users and non-users and investigated the associations between TC, LDL-C, and the risk of incident AF.

Results

Of the total population, 867,336 (8.9%) were taking statins. During a mean follow-up of 8.2 years, inverse associations of TC - AF and LDL-C - AF were observed; higher levels of TC and LDL-C were associated with the lower risk of AF in the total population. Overall, statin users showed higher AF incidence rate than non-users, but the inverse associations of TC - AF and LDL-C - AF were consistently observed irrespective of statin usage; adjusted hazard ratio with 95% confidence interval was 0.81 (0.79-0.84) for statin users and 0.81 (0.80-0.83) for non-users in the highest TC quartile, and 0.84 (0.82-0.87) for statin users and 0.85 (0.84-0.86) for non-users in the highest LDL-C quartile (all p<0.001).

Conclusion

The paradoxical relationship between lipid levels (TC and LDL-C) and the risk of AF remains consistent in both statin users and non-users.

Impact of mental disorders on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study

BACKGROUND

It is unclear whether mental disorders are an independent risk factor for atrial fibrillation (AF) in patients with diabetes. We aimed to investigate whether patients with diabetes who have mental disorders have an increased risk for AF.

METHODS

Using the Korea National Health Insurance Service database, we enrolled 2,512,690 patients diagnosed with diabetes without AF between 2009 and 2012. We assessed five mental disorders: depression, insomnia, anxiety, bipolar disorder, and schizophrenia. Newly diagnosed AF was identified during the follow-up period, and multivariate Cox regression analysis was performed.

RESULTS

Among the 2,512,690 patients (mean age 57.2 ± 12.3 years; 60.1% men), 828,929 (33.0%) had mental disorders. Among the five mental disorders, anxiety (68.1%) was the most common, followed by insomnia (40.0%). During a median follow-up duration of 7.1 years, new-onset AF was diagnosed in 79,525 patients (4.66 per 1,000 person-years). Patients with diabetes who had mental disorders showed a higher risk for AF (adjusted hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.17-1.21; p-value < 0.001). Depression, insomnia, and anxiety were significantly associated with higher risk for AF (adjusted HR [95% CI]: 1.15 [1.12-1.17], 1.15 [1.13-1.18], and 1.19 [1.67-1.21], respectively; all p-values < 0.001), whereas bipolar disorder and schizophrenia were not.

CONCLUSIONS

Mental disorders, especially depression, insomnia, and anxiety, were associated with an increased risk for AF in patients with diabetes. Greater awareness with a prompt diagnosis of AF should be considered for patients with both DM and mental disorders.

Comparison of adhesive single-lead ECG device and Holter test for atrial fibrillation monitoring

Background

There is insufficient validation of diagnostic benefits of extended monitoring with an adhesive single-lead ECG device compared to Holter test for routine medical care of AF patients.

Purpose

The study aimed to compare AF detection rates between 72-hour monitoring using an adhesive single-lead ECG device (mobiCARE MC-100, Seers Technology, Republic of Korea) and 24-hour Holter test among AF patients at outpatient clinics.

Methods

A total of 200 AF patients indicated for Holter test at cardiology outpatient clinics enrolled in the study. Study participants equipped both Holter and MC-100 for the first 24 hours (Figure 1). After then, only MC-100 continued ECG monitoring for additional 48 hours. AF detection during the first 24 hours was compared between two devices. The diagnostic benefits of extended monitoring with MC-100 were evaluated.

Results

During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20.0%) patients (20 patients with paroxysmal and persistent AF each). Compared to 24-hour Holter, MC-100 increased AF detection rate by 1.5-fold (58/200; 29.0%) and 1.6-fold (64/200; 32.0%) with 48- and 72-hour monitoring, respectively (Figure 2A). With MC-100, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) for 24-, 48-, and 72-hour monitoring. Compared to 24-hour Holter, 72-hour monitoring with MC-100 increased the detection rate of paroxysmal AF by 2.2-fold (44/20). If only the episodes lasting over 30 seconds were counted as AF with MC-100, the detection rate of paroxysmal AF was decreased by 9.1% (Figure 2B).

Conclusion

Compared to Holter, AF detection rates could be improved with an adhesive single-lead device, especially for patients with paroxysmal AF. This device is expected to be useful for AF detection among patients whose conventional ECG tests were ineffective in documenting AF episodes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety)

The left atrial low-voltage area and persistent atrial fibrillation treated with pulmonary vein isolation alone

Background

There are limited data regarding the association between the burden of the left atrial low-voltage area (LVA) and the outcome of pulmonary vein isolation (PVI) alone in persistent atrial fibrillation (PeAF).

Purpose

The study aimed to investigate the impact of the burden of LVA on the patients with PeAF treated with PVI alone.

Methods

Using a retrospective cohort of PeAF patients who underwent PVI alone, both clinical and the left atrial voltage mapping data were reviewed. LVA was defined as an area of ≤0.5 mV (bipolar) when mapped during sinus rhythm and ≤0.2 mV during AF. The high burden of LVA was defined as a case when the LVA constitutes ≥10% of the total left atrial body area. The patients were categorized into either the high or low burden groups. The recurrence of any atrial tachyarrhythmia was followed up, and multivariable Cox's regression analysis was performed.

Results

A total of 50 and 25 patients were investigated for the low burden (LVA&lt;10%) and high burden (LVA≥10%) groups, respectively. Compared to the low burden group, the high burden group had a significantly less male proportion (56.0% versus 78.0%), a higher CHA2DS2-VASc score (median 3 versus 2), more chronic kidney disease (16.0% versus 2.0%), and a higher burden of LVA (20±11% versus 5±3%). During the median follow-up of 9.5 (6.2–16.2)months, there were 30.0% and 48.0% ofrecurrences for the low and high burden groups, respectively. Compared to the low burden group, the high burden group was associated with higher risks of both early and late recurrences (HR [95% CI] =2.67 [1.15–6.18] and 2.08 [1.03–4.20], respectively) (Figure 1). The best cut-off of LVA to predict 2-year recurrence was 10.1% (Figure 2).

Conclusion

The high burden of LVA was significantly associated with an increased risk of recurrence among PeAF patients treated with PVI alone. Tailored ablation in addition to PVI would be needed to improve outcomes in patients with PeAF having a high burden of LVA.

Funding Acknowledgement

Type of funding sources: None.

Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: a systematic review and meta-analysis

Background

The concurrent use of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients may be associated with a lower risk of gastrointestinal bleeding (GIB), but evidence is still conflicting according to individual OACs.

Purpose

We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy.

Methods

A systematic search of PubMed, EMBASE, and Cochrane was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. We calculated pooled estimates of GIB risk by a random-effect meta-analysis and reported as odds ratios (OR) and 95% CI. Stratified analyses according to the origin of GIB, ethnic groups, individual OACs, and the presence of underlying GIB risk factors were performed.

Results

A total of 10 studies (1 randomized controlled study and 9 observational studies) and 1,970,931 patients who received OAC were included. OAC and PPI co-therapy were associated with a lower risk of total GIB, and major GIB; OR (95% CI) was 0.67 (0.62–0.74) for total GIB and 0.68 (0.63–0.75) for major GIB, respectively. Among total GIB, only the risk of upper GIB was lower with OAC and PPI co-therapy (OR 0.67, 95% CI 0.64–0.70). No difference in the lower risk of primary GIB outcomes of PPI co-therapy was observed between Asians and non-Asians (p-for-difference, total GIB=0.695, major GIB=0.748, respectively) and among individual OACs except for edoxaban. The protective effect of PPI on total GIB was more significant in high-risk patients, defined as those with concurrent medication of antiplatelets or non-steroidal anti-inflammatory drugs (OR 0.62, 95% CI 0.52–0.73) and presence of high bleeding risk factors such as previous GIB history, HAS-BLED score ≥3, or underlying gastrointestinal diseases. (OR 0.65, 95% CI 0.61–0.70).

Conclusion

In patients who receive OAC, the use of PPI co-therapy was associated with a lower risk of total GIB and major GIB irrespective of ethnic group and OAC type except for edoxaban. PPI co-therapy can be considered particularly in patients on concomitant NSAID and antiplatelet use or patients with high GIB risk factors.

Funding Acknowledgement

Type of funding sources: None.

Increased risk of atrial fibrillation in patients with uterine fibroids: a nationwide population-based study

Background

Uterine fibroid, the most common benign neoplasm of the uterus, is associated with an elevated risk of cardiovascular disease. The link between incident atrial fibrillation (AF) and the uterine fibroid is unclear because earlier studies focused primarily on the development of atherosclerosis and hypertension. We aimed to investigate the risk of AF in patients with uterine fibroid.

Methods

This is a retrospective cohort study using the Korean National Health Insurance Service database (NHIS). From 2009 to 2012, a total of 2,574,349 women (20 to 40 years old) who underwent general health examinations were included. Diagnosis of uterine fibroids and surgical treatment status was defined by the international classification of diseases, 10th revision codes, and procedural codes from the Korean NHIS. The primary outcome was newly diagnosed AF. The risk of AF according to the uterine fibroids and their surgical treatment status was evaluated using Cox proportional-hazard models.

Results

Of the total population, the mean age was 29.76±4.27 years, and 20,682 (0.8%) were identified to have uterine fibroid. Incident AF was identified in 3,868 patients (61 in the fibroid group, 3,807 in the control group) during a mean follow-up of 7.3±1.1 years. Patients of the uterine fibroid group showed a higher incidence of AF compared to the control group (0.41 and 0.20 per 1000 person-years, respectively, Figure 1). Multivariate Cox-regression analysis presented that uterine fibroid was an independent risk factor of AF: hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.16–1.93, p=0.002. Compared to the control group, uterine fibroid patients who underwent surgical treatment tend to show a lower risk for AF (HR 1.22, 95% CI 0.79–1.90) than patients without surgical treatment (HR 1.69, 95% CI 1.24–2.30), though statistical significance was indeterminate (Figure 2). After propensity score matching, patients of the uterine fibroid group showed higher risk of AF when compared to the control group (HR 1.77, 95% CI 1.32–2.63, p&lt;0.001), which was in line with our main results. The presence of uterine fibroid was consistently associated with higher risk of AF among all subgroups except for the stroke subgroup.

Conclusion

Patients with uterine fibroids are predisposed to an increased risk of AF compared to the control group. Careful monitoring of arrhythmia development would be warranted in patients of uterine fibroid and surgical treatment as it is associated with a modest risk decrement of incident AF.

Funding Acknowledgement

Type of funding sources: None.

Paradoxical association between lipid levels and incident atrial fibrillation according to statin usage

Background

In epidemiology studies, a higher level of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) is associated with a lower risk of atrial fibrillation (AF). Statin use might exert possible confounding effects in the paradoxical relationship; however, the inverse link between AF and cholesterol level that distinguishes statin users from non-users has not been evaluated.

Objective

We investigated the epidemiological relationships of TC–AF and LDL-C–AF in statin users and non-users, respectively.

Methods

From the Korean National Health Insurance Service database, we included 9,778,014 adults who underwent a health examination in 2009 and had no prior AF history. The levels of TC and LCL-C at the health exam were categorized in quartile (Q) and decile (D) values of the total study population. The study population was grouped into statin users and non-users, and TC–AF and LDL-C–AF relationships were evaluated.

Results

867,336 (8.9%) were on statin use among the total population. Statin users showed higher TC level (208.4±55.6 vs. 194.1±39.5 mg/dL, p&lt;0.001) and LDL-C level (123.0±102.2 vs. 121.3±226.3, p&lt;0.001) compared to non-users. Inverse associations of TC–AF and LCL-C–AF were observed; higher levels of TC and LDL-C were associated with a lower risk of AF. The hazard ratios (HR) and 95% confidence intervals (CI) were 0.797 (0.786–0.809) for the highest quartile of TC (Q4, TC ≥218) and 0.832 (0.82–0.843) for the highest quartile of LDL-C (Q4, LDL-C ≥135) when adjusted by age, sex, lifestyle behaviors, comorbidities, and low-income status. Statin users exhibited higher AF incidence rate than non-statin users, but the association in statin users generally tracked that seen among non-statin users demonstrating similar HR in Q4 of TC [0.812 (0.790–0.835) for statin users and 0.812 (0.798–0.826) for non-statin users] and LDL-C [0.842 (0.819–0.865) for statin users and 0.849 (0.835–0.863) for non-statin users].

Conclusion

The paradoxical relationship between lipid levels (TC and LDL-C) and incident AF remained consistent both in statin users and non-users. Further research is required to investigate an underlying mechanism for the cholesterol paradox of AF which still seems evident despite the pleiotropic effects of statin.

Funding Acknowledgement

Type of funding sources: None.

Fish oil supplements increase atrial fibrillation risk in healthy individuals: a population-based cohort study and Mendelian randomization analysis

Background

There is a paucity of information on the risk of atrial fibrillation (AF) in healthy individuals taking fish oil supplements.

Purpose

We aimed to investigate the epidemiologic and causal relationships between fish oil supplement intake and the long-term risk of AF.

Methods

From the population-based UK Biobank, we selected healthy individuals without a history of AF, other cardiac arrhythmias, or cardiovascular diseases, who were not taking lipid-lowering medications or dietary supplements other than fish oil. The 10-year risk of AF in Fish-Oil-Users vs. Non-Users was evaluated in the total population and propensity-score matched cohort. The causal relationship between n-3 polyunsaturated fatty acids (PUFA) and AF was evaluated using a two-sample summary-level Mendelian randomization analysis with fixed effects robust inverse-variance weighted method, using genetic instruments from previous studies genome-wide association studies for n-3 PUFA levels and AF, respectively.

Results

A total of 338,199 participants (aged 55.2±8.1, 44.3% men) were analysed. Of these, 35.0% (n=118,300) was taking fish oil supplements. The 10-year risk of AF was significantly higher in the Fish-Oil-Users than in the Non-Users (3.83% vs. 2.91%, adjusted hazard ratio [HR] 1.05, 95% CI [1.01–1.10], P=0.023). The result was consistent in the propensity-score matched cohort (propensity-score matched HR 1.06, 95% CI [1.00–1.12], P=0.043). The increased risk of AF by fish oil supplement was prominent in low-risk participants with healthy lifestyles. Among n-3 PUFA, the docosapentaenoic acid (DPA) showed significant causal estimates for the increased risk of AF (odds ratio [OR] 1.15, 95% CI [1.08–1.22], P&lt;0.001), while higher eicosapentaenoic acid (EPA) levels caused a decrease of AF risk (OR 0.85, 95% CI [0.80–0.90], P&lt;0.001).

Conclusion

Fish oil supplement intake significantly increased the long-term risk of AF in a healthy population. The causal effect of fish oil intake on the risk of AF may depend on the specific types of n-3 PUFA.

Funding Acknowledgement

Type of funding sources: None.

Impact of metabolic syndrome on the risk of ischemic stroke in non-anticoagulated atrial fibrillation patients having low CHA2DS2-VASc scores

Background

Metabolic syndrome (MetS) predisposes to a thromboembolic state. However, conflicting results have been reported on whether MetS confers an increased risk of ischemic stroke in atrial fibrillation (AF), especially in patients with low CHA2DS2-VASc score who are not indicated for oral anticoagulant therapy.

Purpose

We investigated the risk of ischemic stroke according to the presence of MetS, the number of MetS components (metabolic burden), and the individual metabolic components in non-anticoagulated AF patients with low CHA2DS2-VASc score.

Methods

A total of 76,015 oral anticoagulant-naïve AF patients with low CHA2DS2-VASc score (0,1 in male and 1 in female) were included from the Korean National Health Insurance Service database. The status of MetS and individual metabolic components were evaluated based on health examination data within two years of AF diagnosis. We estimated the risk of ischemic stroke according to MetS, metabolic burden, and an individual component of MetS using Cox proportional-hazards models.

Results

The mean age was 49.8±11.1 years and 52,388 (68.9%) were male. The average CHA2DS2-VASc score was 0.7±0.5 and MetS was prevalent among 21,570 (28.4%) of the study population. During a mean follow-up of 5.1 years, ischemic stroke was developed in 1,395 (1.84%) patients. MetS was associated with a higher risk of ischemic stroke after adjustment for age, sex, lifestyle behaviors, low income, and cardiovascular comorbidities: adjusted hazard ratio (aHR) 1.19, 95% confidence interval (CI) 1.06–1.33, p=0.002. A positive linear correlation was observed between metabolic burden and ischemic stroke risk. Patients with five MetS components showed the highest aHR of 1.55 (95% CI 1.14–2.11, Figure 1 and Figure 2), whereas those with a single MetS component had a marginal risk of ischemic stroke (aHR 1.18, 95% CI 0.99–1.41). Among individual metabolic components, elevated blood pressure and increased waist circumference was significantly associated with an increased risk of ischemic stroke: aHR (95% CI), 1.45 (1.30–1.62), p&lt;0.001, and 1.15 (1.03–1.30), p=0.016, respectively.

Conclusions

Among AF patients initially with CHA2DS2-VASc score 0 and 1 with no anticoagulation, the presence of MetS is associated with an increased risk of ischemic stroke. Given the linear incremental correlation between metabolic burden and ischemic stroke, special attention to the care of metabolic derangements is required in AF patients who are not indicated for anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Atrial fibrillation detection in ambulatory patients using a smart ring powered by deep learning analysis of continuous photoplethysmography monitoring

Background

Atrial fibrillation (AF) detection could be effective with photoplethysmography (PPG) signal monitoring by a wearable device.

Purpose

We aimed to validate the performance of AF detection among ambulatory patients who underwent electrical cardioversion for AF using a smart ring capable of continuous PPG monitoring and deep learning analysis.

Methods

In this prospective single-arm study, participants who underwent successful electrical cardioversion for AF were enrolled. The participants equipped a smart ring (CardioTracker, Sky Labs Inc., Seongnam, Republic of Korea) after the electrical cardioversion. The smart ring then continuously monitored PPG over 14 days to detect AF recurrence. The smart ring alarmed AF episodes based on deep learning analysis of PPG. The participants were asked to measure at least three daily ECGs using the smart ring to validate AF recurrence detected by PPG. All ECG snapshots were recorded along with lead I and saved with simultaneous PPG. ECG data were examined by the three cardiologists independently (SK, SRL, and EKC). The monitoring time, analyzable proportions of monitored signals, detection rates of AF episodes, and the diagnostic performance of PPG-based deep learning were evaluated. At the end of the monitoring, a survey on the use of the smart ring was performed.

Results

A total of 35 participants (mean age 58.9 years, male 74.3%) were enrolled. Figure 1 illustrates an example of PPG monitoring and PPG-ECG snapshots by the smart ring. The study participation period was a median of 14 days and the wearing time of the smart ring was a median of 9.2 days (IQR 7.1–11.5 days). Signal artifacts during daily activity decreased the analyzable proportions of monitored PPG by 68.5%. Irregular pulse episodes were detected by the smart ring in 29 (82.9%) participants after a median of 1 day from the cardioversion (Figure 2). A total of 2532 PPG-ECG snapshots were acquired and 1623 (64.1%) were interpretable by both the cardiologists (using ECG) and the deep learning analysis (using PPG). Comparing PPG by simultaneous ECG, the performance of AF detection by the smart ring was 98.7% for sensitivity, 97.8% for specificity, 2.2% for false positives, and 1.3% for false negatives (Figure 2). After using the smart ring, 76.9% of the participants responded that they had no discomfort in using the smart ring in daily activity and another 76.9% responded that it was helpful to monitor their disease.

Conclusion

Despite the signal artifacts during daily activity, AF detection with PPG monitoring by a smart ring could be effective for AF screening among ambulatory patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This work was supported by Sky Labs Inc, Seongnam, Republic of Korea, and by the grant No. 0320202040 from the Seoul National University Hospital Research Fund.

Catheter ablation and thoracoscopic ablation in long persistent atrial fibrillation with large left atrium

Background

Pulmonary vein antrum isolation (PVAI) is the cornerstone of atrial fibrillation (AF) ablation, but the clinical outcomes of PVAI are unsatisfactory in patients with persistent AF and a large left atrium (LA).

Objectives

We investigated the clinical outcomes following radiofrequency ablation (RFCA), cryoballoon ablation (CBA), and thoracoscopic maze in patients with persistent AF and a large LA.

Methods

We included patients with consecutive persistent AF who had a large LA (LA diameter >50 mm) and underwent RFCA, CBA, or thoracoscopic maze surgery. In the RFCA group, additional linear ablation was performed at the physician’s discretion. The endpoint was 12 months without recurrence of an atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia, following a 90-day blanking period.

Results

We recruited 89 persistent AF patients with a large LA who underwent RFCA (n = 32), CBA (n = 38), or the thoracoscopic maze procedure (n = 19). During the 12-month follow-up, 48 (53.9%) cases of AF recurrence were observed. There was no prognostic difference between groups (50.0% in RFCA vs. 52.6% in CBA vs. 63.2% in thoracoscopic maze, all P > 0.05). Early recurrence during the blanking period was a significant predictor of late recurrence for RFCA and CBA, but not for the thoracoscopic maze.

Conclusion

In persistent AF patients with a large LA, we did not find a prognostic difference RFCA, CBA, or a thoracoscopic maze procedure in recurrence of atrial arrhythmia. Early recurrence predicted late recurrence in catheter ablation, but not in thoracoscopic maze.

Habitual Alcohol Intake and Risk of Atrial Fibrillation in Young Adults in Korea

IMPORTANCE

Guidelines recommend that all risk factors for early-onset atrial fibrillation, including lifestyle factors, be proactively managed, considering the poor prognosis of the disease. Not much is known about the association of cumulative alcohol intake with the risk of atrial fibrillation in young adults aged 20 to 39 years, especially among heavy drinkers.

OBJECTIVE

To explore the association of alcohol consumption with the risk of incident atrial fibrillation in young adults.

DESIGN, SETTING, AND PARTICIPANTS

Using the National Health Insurance Service database, a nationwide population-based cohort study of adults aged 20 to 39 years without prior atrial fibrillation who underwent 4 serial annual health examinations between 2009 and 2012 was conducted. The cumulative alcohol consumption burden over 4 years was calculated by assigning 1 point to more than moderate drinking (≥105 g of alcohol per week) each year. Additionally, a semiquantitative cumulative burden was calculated by assigning 0, 1, 2, and 3 points to non, mild (<105 g per week), moderate (105-210 g per week), and heavy (≥210 g per week) drinking, respectively. Data were analyzed from May to June 2021.

EXPOSURE

Amount of alcohol intake in 4 years.

MAIN OUTCOMES AND MEASURES

The primary outcome was incident atrial fibrillation during the follow-up period.

RESULTS

A total of 1 537 836 participants (mean [SD] age 29.5 [4.1] years, 1 100 099 [71.5%] male) were included in the final analysis. According to the 4-year cumulative burden of alcohol consumption stratified by moderate to heavy drinking, 889 382 participants (57.8%) were in the burden 0 group, 203 374 participants (13.2%) in the burden 1 group, 148 087 participants (9.6%) in the burden 2 group, 144 023 participants (9.4%) in the burden 3 group, and 152 970 participants (9.9%) in the burden 4 group. During a median (IQR) follow-up of 6.13 (4.59-6.48) years, atrial fibrillation was newly diagnosed in 3066 participants (0.36 per 1000 person-years). Participants with a cumulative burden of 4 points who continued more than moderate drinking for 4 years showed a 25% higher risk of atrial fibrillation compared with 0-point participants who kept non-to-mild drinking over 4 years (adjusted HR, 1.25; 95% CI, 1.12-1.40). In a semiquantitative analysis, participants who sustained heavy drinking for 4 consecutive years were associated with a 47% higher atrial fibrillation risk than those who remained nondrinkers over 4 years (aHR, 1.47, CI 1.18-1.83).

CONCLUSIONS AND RELEVANCE

Persistent moderate to heavy drinking and higher cumulative alcohol consumption burden might increase the risk of atrial fibrillation even in young adults aged 20 to 39 years.

Protective effect of proton pump inhibitor against gastrointestinal bleeding in patients receiving oral anticoagulants: A systematic review and meta-analysis

AIM

The evidence of a protective effect of proton pump inhibitor (PPI) in oral anticoagulant (OAC) treated patients against gastrointestinal bleeding (GIB) is still lacking. We conducted a meta-analysis to estimate the risk of GIB in patients with OAC and PPI co-therapy.

METHODS

A systematic search of PubMed, EMBASE, Cochrane, and Scopus databases was performed for studies reporting GIB risk in OAC and PPI co-therapy. Primary outcomes were total GIB and major GIB events. Pooled estimates of GIB risk were calculated by a random-effect meta-analysis and reported as odds ratios (OR) and 95% confidence interval (CI).

RESULTS

A total of 10 studies and 1,970,931 patients were included. OAC and PPI co-therapy were associated with a lower odds of total and major GIB; OR (95% CI) was 0.67 (0.62-0.74) for total and 0.68 (0.63-0.75) for major GIB, respectively. No differences in the GIB of PPI co-therapy were observed between Asians and non-Asians (p-for-difference, total GIB=0.70, major GIB=0.75, respectively). For all kinds of OAC except for edoxaban, PPI cotreatment was related to a lower odds of GIB by 24-44%. The protective effect of PPI on total GIB was more significant in concurrent antiplatelets or non-steroidal anti-inflammatory drug users and those with high bleeding risks: patients with previous GIB history, HAS-BLED ≥3, or underlying gastrointestinal diseases.

CONCLUSION

In patients who receive OAC, PPI co-therapy is associated with a lower total and major GIB irrespective of ethnic group and OAC type, except for edoxaban. PPI co-therapy can be considered particularly in high GIB risk patients.

Associations between obesity parameters and the risk of incident atrial fibrillation and ischaemic stroke in the different age groups

Objective

Obesity and aging are important predisposing factors to atrial fibrillation (AF) and ischaemic stroke (IS). However, limited data comprehensively evaluated the relationships between obesity measurements and AF and IS in different ages.

Methods

A total of 9,432,332 adults from the Korean National Health Insurance Service Database were included. The study population was categorized into the six age subgroups by an increase every decade from the twenties. We evaluated AF and IS risk according to body mass index (BMI) and waist circumference (WC) in the different age groups.

Results

During a mean follow-up of 8.2 ± 1.0 years, BMI-AF presented a J-shaped association across ages. The highest hazard ratio (HR) of the BMI ≥ 30 kg/m² group was observed in subjects aged 30–39 years [HR 1.80, 95% CI 1.63–1.98, p < 0.001]. Underweight adults over 60 years also presented an increased AF risk. Incident IS risk increased in those with BMI over the normal range in early and midlife, but the association became obscured in adults aged > 60 years. Among the BMI ≥ 30 kg/m² groups, subjects aged 20–29 years presented the highest risk of IS [HR 3.00, 95% CI (2.34–3.84), p < 0.001]. Overall, WC-AF and WC-IS showed positive linear correlations, but the WC-IS association was weak in subjects aged ≥ 40 years.

Conclusion

The higher risks of AF and IS according to an increment of BMI and WC were most apparent among the young ages. The association between obesity measurements and IS was not significantly above the midlife. Weight management in the young and integrated risk factor management in the elderly are warranted.

Type and Severity of Migraine Determines Risk of Atrial Fibrillation in Women

Objective

To evaluate sex differences in the risk of atrial fibrillation (AF) according to the type and severity of migraine.

Methods

We analyzed the nationwide health screening recipients in 2009 without previous AF diagnosis from the Korean National Health Insurance Service data. The diagnosis, type, and severity of migraine were determined using claims data. Newly developed AF was identified during a 10-year follow-up. Sex-difference in the effect of migraine on AF was evaluated.

Results

A total of 4,020,488 subjects were enrolled from January 1, to December 31, 2009 and followed-up through December 31, 2018; 4,986 subjects had migraine with aura (age 50.6 ± 14.0 years, men 29.3%); and 105,029 had migraine without aura (age 51.6 ± 14.3 years, men 30.9%). Risk of AF in a mild degree of migraine was similar to that in the control group, regardless of sex or the presence of aura. Severe migraine without aura modestly but significantly increased the risk of AF in both men and women compared to controls, with increase in AF risk being most prominent in women who had severe migraine with aura [incidence rate (IR) = 3.39, hazard ratio (HR)_adjust = 1.48, 95% confidence intervals (CI) = 1.18–1.85]. No significant association according to aura was observed in men with severe migraines (p for interaction 0.011).

Conclusion

Severe migraine with aura significantly increased the risk of incident AF in women, but not in men. Surveillance for incident AF and prompt lifestyle modification may be beneficial, particularly for young women suffering from severe migraine with aura.

Comparison Between the 24-hour Holter Test and 72-hour Single-Lead Electrocardiogram Monitoring With an Adhesive Patch-Type Device for Atrial Fibrillation Detection: Prospective Cohort Study

Background

There is insufficient evidence for the use of single-lead electrocardiogram (ECG) monitoring with an adhesive patch-type device (APD) over an extended period compared to that of the 24-hour Holter test for atrial fibrillation (AF) detection.

Objective

In this paper, we aimed to compare AF detection by the 24-hour Holter test and 72-hour single-lead ECG monitoring using an APD among patients with AF.

Methods

This was a prospective, single-center cohort study. A total of 210 patients with AF with clinical indications for the Holter test at cardiology outpatient clinics were enrolled in the study. The study participants were equipped with both the Holter device and APD for the first 24 hours. Subsequently, only the APD continued ECG monitoring for an additional 48 hours. AF detection during the first 24 hours was compared between the two devices. The diagnostic benefits of extended monitoring using the APD were evaluated.

Results

A total of 200 patients (mean age 60 years; n=141, 70.5% male; and n=59, 29.5% female) completed 72-hour ECG monitoring with the APD. During the first 24 hours, both monitoring methods detected AF in the same 40/200 (20%) patients (including 20 patients each with paroxysmal and persistent AF). Compared to the 24-hour Holter test, the APD increased the AF detection rate by 1.5-fold (58/200; 29%) and 1.6-fold (64/200; 32%) with 48- and 72-hour monitoring, respectively. With the APD, the number of newly discovered patients with paroxysmal AF was 20/44 (45.5%), 18/44 (40.9%), and 6/44 (13.6%) at 24-, 48-, and 72-hour monitoring, respectively. Compared with 24-hour Holter monitoring, 72-hour monitoring with the APD increased the detection rate of paroxysmal AF by 2.2-fold (44/20).

Conclusions

Compared to the 24-hour Holter test, AF detection could be improved with 72-hour single-lead ECG monitoring with the APD.