Simulation-Based Training for New-Onset Symptomatic Rapid Atrial Fibrillation Among Prehospital Health Care Providers

Recent Trends in the Incidence, Treatment, and Prognosis of Patients With Heart Failure and Atrial Fibrillation (the Worcester Heart Failure Study)

The quality of prehospital care impacts patient outcomes. Military efforts have focused on training revision and the creation of high-fidelity simulation models to address potentially survivable injuries. We sought to investigate the applicability of models emphasizing hemorrhage control and airway management to a civilian population. Prehospital health care providers (PHPs) undergoing their annual training were enrolled. A trauma scenario was simulated with two modules: hemorrhage control and airway management. Experienced raters used a validated tool to assess performance. Pearson correlation, logistic regression, and χ tests were used for analysis. Ninety-five PHPs participated with a mean experience of 15.9 ± 8.3 years, and 7.4% reported past military training. The PHPs' overall execution rate of the six hemorrhage control measures varied from 38.9% to 88.4%. The median blood loss was 1,700 mL (interquartile range, 1,043-2,000), and the mean global rater score was 25.0 ± 7.4 (scale, 5-40). There was a significant relationship between PHP profession and past military experience to their consideration of blood transfusion and tranexamic acid. An inverse relationship between blood loss and global rater score was found (r = -0.59, n = 88, p = 1.93 × 10). After simulated direct laryngoscope failure in the airway module, 58% of PHPs selected video laryngoscopy over placement of a supraglottic airway. Eighty-six percent of participants achieved bilateral chest rise in the manikin regardless of management method. Participants reported improved comfort with skills after simulation. Our data reveal marginal performance in hemorrhage control regardless of the PHP's prior experience. The majority of PHPs were able to secure an advanced airway if direct laryngoscope was unavailable with a predisposition for video laryngoscopy over supraglottic airway. Our findings support the need for continued training for PHPs highlighting hemorrhage control maneuvers and increased familiarity with airway management options. Improved participant confidence posttraining gives credence to simulation training. Prognostic/epidemiological study, level III.

Background Major emergency abdominal surgery (e.g. ileus, perforation) is relatively common and associated with postoperative complications and mortality. Long-term management of patients with atrial fibrillation (AF) associated with a secondary precipitant has recently received increased attention. It is further unknown whether the conflicting results regarding long-term outcomes in patients with new onset AF depends on surgical subtype or the arrhythmia itself. Purpose The aim of this study was to compare long-term clinical outcomes (AF related hospitalization, stroke, and mortality) in patients with perioperative new onset AF in relation to major emergency abdominal surgery and patients with non-perioperative new onset AF. Methods We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with new onset AF perioperatively, and patients who developed new onset AF in a non-perioperative setting. Patients with new onset perioperative AF were matched in a 1:5 ratio on age, sex and year of AF diagnosis with patients with non-perioperative new onset AF. From discharge, we examined unadjusted rates of outcomes and adjusted hazard ratios of outcomes were assessed using multivariable Cox regression analysis. Results The study population comprised 794 (out of 42,021) patients with perioperative new onset AF and 3970 patients with non-perioperative new onset AF (median age of 78 years [interquartile range: 70-83] and 57.3% women in both groups). In general, patients with new-onset perioperative AF had lower comorbid burden compared with patients with non-perioperative new onset AF. During the first month after the hospital admission, 15.0% of the patients with perioperative AF and 36.1% of the patients with new onset AF initiated oral anticoagulation therapy (after 2010, 19.7% and 41.2%, respectively). Two years after discharge, 3.9% of patients with perioperative AF and 5.8% of patients with new onset AF (p = 0.031) had had a stroke, while 32.9% and 40.1% (p = 0.002) had had a new hospitalization with AF. Cumulative incidences of stroke and AF related hospitalization are depicted in the Figure. In the multivariable models, perioperative AF was associated with a similar rate of stroke and lower rate of AF related hospitalization compared with non-perioperative new onset AF (HR 1.03, 95% confidence interval, CI: 0.54-1.96 for stroke and HR 0.68, 95% CI: 0.50-0.92 for AF related hospitalization, respectively). Conclusion Perioperative new onset atrial fibrillation in relation to major emergency abdominal surgery was associated with long-term similar rates of stroke and lower rates of AF related hospitalization compared with new onset atrial fibrillation in the non-perioperative setting. This study demonstrates a need for more knowledge about the progress of atrial fibrillation in the setting of non-cardiac surgery.Cumulative Incidence - strokeCumulative Incidence - AF_re

This article refers to ‘Dapagliflozin and atrial fibrillation in heart failure with reduced ejection fraction: insights from DAPA-HF’ by J.H. Butt et al., published in this issue on pages 513–525. Heart failure (HF) and atrial fibrillation (AF) are both heterogeneous conditions that affect millions of people worldwide.1 The overlap of clinical risk factors suggests that there may be similarities in remodelling processes ongoing in the heart.1 Advances in therapies have substantially improved the prognosis of HF patients with reduced ejection fraction (HFrEF) and AF separately, where treatment options in HF with preserved ejection fraction (HFpEF) are still limited.2, 3 Nonetheless, mortality persists high in both HFrEF and HFpEF, especially when combined with AF.1, 2 Therefore, new therapies targeting patients with the combination of HF and AF are eagerly needed. Sodium–glucose co-transporter type 2 (SGLT2) inhibitors, developed as a lowering-glucose therapy, were recently proven to prevent and treat HF.4 In the current issue of the Journal, Butt and colleagues add in timely manner evidence of the beneficial effects of dapagliflozin, an SGLT2 inhibitor, on outcomes of both with the combination of HFrEF and AF.5 The authors performed a sub-analysis of the DAPA-HF trial, and demonstrated that dapagliflozin, on top of guideline-recommended therapies, was as effective in patients with AF as compared to those without AF, to improve prognosis. In line with previous HF trials, approximately 40% of HFrEF patients had AF history or AF on electrocardiogram (ECG) at trial start, and the patients with the combination of HFrEF and AF were at increased risk of worsening HF and cardiovascular death.1, 6, 7 Most interestingly, dapagliflozin reduced the risk of HF hospitalization irrespective of AF presence. This is of great importance for all those patients with the combination of HFrEF and AF. Indeed, some of the established HF therapies demonstrate differential effects in HFrEF patients with and without AF. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, neprilysin inhibitors, mineralocorticoid receptor antagonists, and implantable cardioverter defibrillators, all have beneficial effects on HFrEF irrespective of AF presence.3, 5 However, AF precludes effective delivery of biventricular pacing, and impacts the success of cardiac resynchronization therapy in HFrEF patients.8 Also, presence of AF negatively influences the prognostic benefit of beta-blockers in patients with HFrEF. Two meta-analyses of the major beta-blocker randomized controlled trials have shown that prognostic benefit of beta-blockers in HF patients with AF is less compelling than in HF patients with sinus rhythm.9, 10 However, beta-blockers do prevent new-onset AF or recurrent AF in HF.11 Reasons for absence of prognostic benefit are still uncertain, and seem unrelated to dosage and achieved heart rate.12 To this background, present finding of effectiveness of SGLT2 inhibitors in patients with HFrEF and AF is great news for this large patient population. Another interesting, but somewhat surprising, finding of Butt and colleagues is the absence of a beneficial effect of dapagliflozin on new-onset AF in patients with HFrEF.5 New-onset AF has a negative impact on HF hospitalizations, stroke, mortality, quality of life and exercise tolerance in patients with HF.2, 3 Therefore, prevention of new-onset or recurrent AF is an important treatment goal for HF patients. Heretofore, current guideline-recommended HF therapies that have beneficial prognostic effects also reduce new-onset AF (Figure 1).2, 3 Whether beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, neprilysin inhibitors, mineralocorticoid receptor antagonists, and cardiac resynchronisation therapy prevent new-onset AF via (i) direct atrial substrate effects, (ii) indirectly by optimizing the treatment of associated HF, or (iii) a combination of both direct and indirect effects, is not completely understood.3, 13 Explanations for absence of a relation between dapagliflozin and new-onset AF may relate to the mechanisms and study design. Indeed, a preventive effect on new-onset AF of SGLT2 inhibitors was expected based on their metabolic mechanisms. SGLT2 inhibitors result in the increase of insulin sensitivity, improvement of glycaemic control, lowering of systolic blood pressure, and weight loss, which are risk factors of both HF and AF.14 In addition, SGLT2 inhibitors may have direct atrial effects by improving mitochondrial respiration by reducing reactive oxygen species and the consumption of adenosine triphosphate.14, 15 Mitochondrial dysfunction has been suggested as a driver of atrial remodelling through the generation of reactive oxygen species which disturb cellular electrical activity, promote cardiomyocyte hypertrophy and interstitial fibrosis.14 Moreover, SGLT2 inhibitors are suggested to affect epicardial fat, which in turn causes local atrial inflammation, fatty infiltration and, potentially, arrhythmogenic substrate.14 Finally, SGLT2 inhibitors are suggested to increase serum magnesium with anti-arrhythmogenic effects.14 Some of the study design aspects to consider are the following. The DAPA-HF trial was set up as a HF trial, and diagnosis of AF was based on history or a single 10 s ECG at each study visit. The low intensity of AF monitoring may have led to missed AF diagnoses, as we have learned from studies using extended or continuous rhythm monitoring.6 This potential misdiagnosis of AF may not only have led to underdetection of all AF cases in those without AF at study start, but also may have led to an overestimation of new-onset AF which was in reality recurrence of AF. Needless to say, the sub-analysis was relatively underpowered due to the low number of patients with new-onset AF. The relative short follow-up of median 18 months for new-onset AF to occur may not have provided enough time for the protective metabolic mechanisms of SGLT2 inhibitors to settle in.6, 7 In addition, since dapagliflozin was administered on top of the guideline-recommended HF therapies, a potential effect of dapagliflozin may be overlooked by studying in DAPA-HF the added value of dapagliflozin. Butt and colleagues are to be congratulated for their contribution to the literature on the combination of HF and AF. They demonstrated elegantly that dapagliflozin reduces the worsening of HF and cardiovascular death in patients with HFrEF irrespective of AF status, but unexpectedly, could not demonstrate a reduction in new-onset AF. Given that fact that we should interpret sub-studies and post-hoc analyses with caution and use it only for exploratory and hypothesis-generating purposes, we need future studies investigating the effects of SGLT2 inhibitors on AF prevention and treatment, in the setting of (all types of) HF and without HF. Ultimately, further studies may help to optimize personalized treatment decisions in patients with the troublesome combination of HF and AF. Conflict of interest: none declared.

Sex differences have the potential to impact diagnostic and therapeutic interventions in a wide variety of medical conditions, and cardiac arrhythmias are no exception.1 Studies evaluating pathophysiology, disease course, and therapeutic options for cardiac arrhythmias have been performed predominantly in male patients. However, catheter and device-based therapies coupled with landmark clinical trials have contributed to an improved understanding of this important aspect. The objective of this review is to present the current state of knowledge on sex differences in cardiac arrhythmias with a focus on clinical management, while highlighting gaps in knowledge that would benefit from future investigation. ### Atrial Fibrillation and Atrial Flutter #### Disease Burden Atrial fibrillation (AF) and atrial flutter (AFL) are the most commonly encountered tachyarrhythmias in clinical practice, with significant implications for public health and healthcare costs. Stroke, hospitalization, and loss of productivity are the major consequences of AF.2 The incidence of AF (per 1000 person-years) is reported to be between 1.6 and 2.7 in women and between 3.8 and 4.7 in men.2 The age-adjusted incidence and prevalence of AF is lower in women compared with that in men, and accordingly, the lifetime risk of AF from the Framingham Heart Study at 40 years of age was higher in men (26.0% for men versus 23.0% for women).3 Another analysis from the Framingham Heart Study demonstrated no significant sex differences in the risk of developing AFL.4 The prevalence of AF continues to rise among both men and women. In a study investigating the global burden of disease from 1980 to 2010, there was not only an increase in overall burden, incidence, and prevalence of AF, but most importantly an increase in AF-associated mortality in both men and women (Figure 1).5 The age-adjusted mortality for women was consistently higher compared with that for men from 1990 to 2010 (Figure …

Atrial fibrillation (AF) occurs commonly in patients with acute myocardial infarction (AMI) and has been established as a marker of adverse prognosis. There are only few clinical trials that investigate differences between new-onset and chronic AF in AMI. We hypothesize that chronic AF is associated with an increased rate of adverse short- and long-term outcomes. In a single center study, over a period of 28 months, 375 consecutive patients with AMI were included [337 patients without AF (89.9%) and 38 with AF (10.1%)]. As much as 16 patients had new-onset AF (42.1%) and 22 had chronic AF (57.9%). Patients with severe coronary artery disease develop AF more often in AMI, and the existence of AF was associated with a poor prognosis. Compared to patients with new-onset AF, chronic AF was more frequently associated with advanced age (75 vs. 70 years, p not significant), reduced left ventricular ejection fraction (44.8 vs. 54.0%, p < 0.05) and NSTEMI (63.6 vs. 36.4%, p < 0.05). Only chronic AF resulted in increased in-hospital death (18.2 vs. 0.0%; p < 0.005) at the 2-year follow-up, 14 patients with AF died (63.6%), predominantly due to cardiovascular reasons. Our results indicate that patients with chronic AF had a higher incidence of in-hospital death than those with new-onset AF or without. Chronic AF includes a group of older and sicker patients than their counterparts with new-onset AF. Understanding these findings may ultimately lead to better care of patients with this arrhythmia to prevent the development of the underlying atrial substrate in chronic AF patients and to improve their otherwise worse prognosis.

Background Comparative data on the effects of new-onset vs. preexisting atrial fibrillation (AF) on long-term mortality in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) are scarce. Therefore, the aim of this study was to assess the impact of new-onset vs. preexisting AF on mortality over 5 years after primary PCI. Methods Our analysis included 7 955 patients referred to primary PCI in the period from 2009 to 2019, for whom data regarding the presence and type of AF were available, from a prospective electronic registry of a high-volume catheterization laboratory. Patients were stratified into three groups according to the AF status: no AF vs. new-onset vs. preexisting AF. Cumulative mortality was compared with Kaplan Meier curves. Cox regression models were created to assess the mortality hazard at 30 days and 5 years according to the presence of new-onset and preexisting AF with no AF as the reference group. 30-day follow-up was available for 7 738 and 5-year for 5 049 patients. Results Preexisting AF was found in 3.1% of patients (n=246) and new-onset AF was recorded in 7.0% (n=560). Both new-onset and preexisting AF were associated with higher crude mortality rates compared to patients without AF, at 30 days (14.4% vs 16.0% vs. 5.2%, respectively; p&amp;lt;0.001) and at 5 years as well (56.6% vs. 65.7% vs. 25.4%, respectively; p&amp;lt;0.001). Cumulative mortality rates were significantly higher for both new-onset and preexisting AF, as compared to patients with no AF (Log rank p&amp;lt;0.001, Figure). Patients with new-onset and preexisting AF were older and had a higher baseline risk profile including more frequently prior MI and stroke, more diabetes, hypertension, hyperlipidaemia, renal failure, Killip class ≥2 on admission and lower ejection fraction. When adjusted for these baseline differences, both new-onset and pre-existing AF independently predicted 5 year mortality (HR 1.6, 95%CI 1.4-1.9, p&amp;lt;0.001, and HR 2.2, 95%CI 1.8-2.8, p&amp;lt;0.001, respectively), but not at 30 days (HR 1.4, 95%CI 0.9-2.0, p=0.1, and HR 1.5 95%CI 0.9-2.5, p=0.1, respectively). Conclusion Both new-onset and pre-existing AF are independently associated with an increased risk of long-term mortality in patients with STEMI treated with primary PCI, whereas their impact on short-term mortality reflects the higher baseline risk profile of those patients.Cumulative mortality rates

Background New-onset post-operative atrial fibrillation (AF) affects approximately 1 in 3 patients after cardiac surgery and is associated with adverse outcomes. Whether the amount of time spent in AF is associated with outcomes is unknown. Methods VISION Cardiac Surgery was an international, prospective cohort of patients who underwent cardiac surgery in 12 countries. We divided participants according to their pattern of AF: no new-onset AF, duration &amp;lt;24 h, duration 24-48 h, duration 48-72 h, duration &amp;gt;72 h and discharged in AF. We created a separate category for those who received electrical cardioversion. We excluded participants with a history of AF before surgery and participants with unknown duration of AF. We assessed the association of different patterns of AF, as compared to no AF, with clinical events occurring between 30 days post-operatively and 1 year of follow up. For each outcome, we created a Cox proportional hazards model adjusted for CHA2DS2-VASc score, smoking, hemodialysis, prior cardiac surgery, surgery type and antithrombotic use at hospital discharge (oral anticoagulation alone, oral anticoagulation plus antiplatelet, antiplatelet alone, or none). Results Among 12,234 eligible participants, 3,887 (30.3%) had new-onset post-operative AF and 3,711 had a known duration of AF. The proportion of patients with new-onset AF who were discharged from hospital on oral anticoagulation was 39%. Table 1 displays event rates by AF pattern. Compared to participants without AF, we observed a higher risk of a composite of stroke or vascular death at one year in participants with estimated AF duration &amp;gt;72 h (3.9%, adjusted hazard ratio (aHR) 1.72; 95% CI 1.03-2.87) and in those who underwent electrical cardioversion (3.7%, aHR 2.18; 95%CI 1.16-4.11). Only AF duration &amp;gt;72 h was associated with an increased risk of stroke (2.1%; aHR 2.42; 95%CI 1.15-5.09). We observed a higher risk of all-cause mortality in participants who were in AF at hospital discharge (4.1%, aHR 1.83; 95%CI 1.10-3.05) and in participants who received electrical cardioversion (5.8%, aHR 2.81; 95%CI 1.67-4.73). Only being in AF at discharge was associated with an increased risk of heart failure (3.8%; aHR 2.63; 95% CI 1.49-4.63). All patterns of AF were associated with AF detection in follow-up, with the strongest associations observed in participants who were in AF at hospital discharge (31.8%, aHR 73.4; 95%CI 51.4- 105.0) and in those who received electrical cardioversion (12.5%, aHR 17.9; 95%CI 11.1-28.8). Conclusions Among patients with new-onset post-operative AF following cardiac surgery, duration of AF &amp;gt;72 h, electrical cardioversion and being in AF at discharge are all markers of adverse events in the year following surgery. All patterns of AF confer a higher risk of AF detection in follow-up. Duration and treatment of early post-operative AF may have implications regarding the longer-term risk of adverse outcomes and recurrent AF.

Background: Pharmacological cardioversion (PC) with antiarrhythmic agents is a common initial rhythm control strategy in patients with new-onset atrial fibrillation (AF). However, predictive tools for estimating the likelihood of successful PC remain limited. The systemic immune-inflammation index (SII), a novel composite marker derived from neutrophil, lymphocyte, and platelet counts, may reflect atrial inflammatory burden and structural remodeling. This study aimed to investigate the prognostic value of SII in predicting pharmacological cardioversion success in patients with acute-onset symptomatic AF. Methods: This prospective observational study included patients with hemodynamically stable, new-onset symptomatic AF admitted since October 2025. All patients received intravenous amiodarone for pharmacological cardioversion. Baseline clinical, echocardiographic, and laboratory parameters were recorded. Patients were classified into cardioversion-success and non-response groups based on ECG-confirmed restoration of sinus rhythm. Logistic regression analyses were performed to identify independent predictors of rhythm control, and ROC curves were generated to determine predictive performance. Results: Among 95 patients (mean age 54.2 ± 9.8 years, 48.4% female), successful pharmacological cardioversion was achieved in 74.7%. Compared to the non-response group, the cardioversion-success group had significantly lower SII levels (p < 0.001) and left atrial volume index (LAVI, p < 0.001). Multivariate analysis identified both SII and LAVI as independent predictors of cardioversion success. Inverse correlations were observed between both SII (r = -0.419, p < 0.01) and LAVI (r = -0.567, p < 0.01) and rhythm control. The optimal SII cutoff of 645.16 predicted successful rhythm restoration with 75% sensitivity and 75% specificity (AUC: 0.803, 95% CI: 0.710-0.895). Conclusions: Higher SII levels were independently associated with lower rates of successful pharmacological cardioversion in patients with new-onset atrial fibrillation. Incorporating SII into routine assessment may enhance clinical decision-making and patient stratification for rhythm control strategies.

Impact of Pre-Existing and New-Onset Atrial Fibrillation on Outcomes After Transcatheter Aortic Valve Replacement

BackgroundNew-onset atrial fibrillation (AF) is the most common arrhythmia in critically ill patients. Although evidence base and expert consensus opinion for management have been summarised in several international guidelines, no specific considerations for critically ill patients have been included. We aimed to establish current practice of management of critically ill patients with new-onset AF.MethodsWe designed a short user-friendly online questionnaire. All members of the Intensive Care Society were invited via email containing a link to the questionnaire, which comprised 21 questions. The online survey was conducted between November 2016 and December 2016.ResultsThe response rate was 397/3152 (12.6%). The majority of respondents (81.1%) worked in mixed Intensive Care Units and were consultants (71.8%). Most respondents (39.5%) would start intervention on patients with fast new-onset AF and stable blood pressure at a heart rate between 120 and 139 beats/min. However, 34.8% of participants would treat all patients who developed new-onset fast AF. Amiodarone and beta-blockers (80.9% and 11.6% of answers) were the most commonly used anti-arrhythmics. A total of 63.8% of respondents do not regularly anti-coagulate critically ill patients with new-onset fast AF, while 30.8% anti-coagulate within 72 hours. A total of 68.0% of survey respondents do not routinely use stroke risk scores in critically ill patients with new-onset AF. A total of 85.4% of participants would consider taking part in a clinical trial investigating treatment of new-onset fast AF in the critically ill.DiscussionOur results suggest a considerable disparity between contemporary practice of management of new-onset AF in critical illness and treatment recommendations for the general patient population suffering from AF, particularly with regard to anti-arrhythmics and anti-coagulation used. Amongst intensivists, there is a substantial interest in research for management of new-onset AF in critically ill patients.

BackgroundPain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Low back pain (LBP) is a discomfort in the spinal area around the 12th rib...

ObjectivesTo investigate the characteristics of new-onset atrial fibrillation (AF) and its impact on prognosis in acute pulmonary embolism (aPE).DesignA retrospective cohort studySettingThe study cohort included patients diagnosed with aPE who...

Clinical assessment of clonidine in the treatment of new-onset rapid atrial fibrillation: A prospective, randomized clinical trial

Congenital interatrial shunt can unload the left atrium (LA) and may lower the risk of new-onset heart failure (HF) or atrial fibrillation (AF). We evaluated the risk of new-onset HF or AF in patients with and without interatrial shunt. We enrolled 2660 consecutive patients with acute stroke or transient ischemic attack (TIA) who underwent transesophageal echocardiography at Seoul National University Bundang Hospital from January 1, 2006 to December 31, 2018. The primary outcomes were 10-year new-onset HF, new-onset AF, and new-onset HF or AF composite. Overall, 466 (17.5%) patients with an interatrial shunt had smaller E velocity (0.66 ± 0.21 vs. 0.69 ± 0.22m/s, P = 0.037) and smaller E/e' (9.1 ± 4.0 vs. 10.0 ± 5.0, P = 0.001) than 2194 (82.5%) patients without an interatrial shunt. The 10-year incidence of AF, HF, and AF or HF composite was lower in patients with an interatrial shunt (10-year AF, 11.2 vs. 17.8%, P < 0.001; 10-year HF, 6.2 vs. 10.4%, P = 0.005; 10-year AF or HF composite, 16.5 vs. 23.4%, P = 0.001). In multivariable analysis, the presence of an interatrial shunt was associated with a 38% (HR 0.62, 95% CI 0.40-0.96), 40% (HR 0.60; 95% CI 0.39-0.93), and 26% (HR 0.74; 95% CI 0.57-0.96) reduced risk for new-onset HF, AF, and new-onset HF or AF composite, respectively. In patients with interatrial shunt, the risk of AF and HF was lower. Interatrial shunt may be beneficial, and the closure of an interatrial shunt should be performed only in carefully selected patients. An interatrial shunt can unload the left atrium. In patients with stroke or TIA, the presence of an interatrial shunt was associated with a reduced risk for new-onset HF and AF. AF atrial fibrillation, HF heart failure, HR hazard ratio, LA left atrium.