AbstractIntroductionAtrial Fibrillation Research Articles

1891 Role of telemetry in detecting atrial fibrillation in acute ischaemic stroke

Abstract Introduction Atrial Fibrillation (AF) causes 15% of ischaemic strokes. The National Clinical Guideline for Stroke recommends at least 24 hours of cardiac monitoring and a longer duration if cardio-embolic stroke is suspected. The British Heart Rhythm Society suggests up to 72 hours of cardiac monitoring. Currently, there is little data on the use of telemetry in detecting AF in acute strokes. Our study aims to evaluate the detection rate of new onset AF in acute stroke with telemetry and to determine if there was any correlation between the duration of telemetry and the detection rate of AF. Method All patients with ischaemic stroke who were admitted to stroke ward over a 3-month period were retrospectively analysed. Exclusion criteria were patients who were known to have AF, had new AF on admission electrocardiogram, patients receiving palliative care, patients who were discharged home early without having a telemetry and patients with missing records. Results 61 patients met the inclusion criteria and 5 (8.2%) had AF on telemetry. Two patients had AF on day 1, one on day 2 and two on day 3. All of these patients were anticoagulated. The duration of telemetry ranged between 1- 19 days however no AF was detected beyond the third day of this study. Conclusions AF was detected in 8% of patients with ischaemic stroke within the first 72 hours of admission. Among the patients in whom AF was detected, 5% were detected between 24 hours and 72 hours of admission. Studies (EMBRACE and CRYSTAL trials) have shown that prolonged cardiac monitoring (30 days and 6 months to a year respectively) resulted in higher detection rates of AF. This study suggests that patients with ischaemic stroke should be monitored for at least 72 hours due to a higher detection rate of AF.

Simulating atrial fibrillation patterns and screening strategies using virtual patient-level models

Abstract Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity and mortality. However, early detection and treatment of AF are hampered by highly variable occurrence and duration of AF episodes, heterogenous patterns of AF progression, and poor symptom-rhythm correlation present in many patients. Purpose To develop a computational patient-level model for simulating individual AF episodes, AF progression, and associated clinical outcomes, and to compare the effectiveness of systematic or symptom-based 1-minute electrocardiography (ECG) or 14-day Holter screening using this model. Methods We developed a Markov model with 7 different rhythm and/or clinical states (sinus rhythm (SR), asymptomatic and symptomatic AF, each with or without previous stroke, and death) and age/sex-dependent transition probabilities estimated based on clinical data (Figure 1A). Additionally, transitions between SR and AF states were modulated by AF-related remodeling, which itself was controlled by the time in AF and age. Results The virtual patient-level model enabled the simulation of changes in rhythm status and clinical outcomes during an entire lifetime with minute-level resolution (Figure 1B). Age/sex-specific AF prevalence / incidence, the proportion of symptomatic episodes and mortality in 4000 virtual patients were in good agreement with clinical data (Figure 1C). We employed the perfect knowledge about rhythm status at any moment in time provided by the model to evaluate systematic and symptom-based 1-minute ECG and 14-day Holter screening for AF in this population. In total, 2372 virtual patients >65 years developed AF. Systematic yearly 1-minute ECG recordings only identified 58 (2.4%) patients. In contrast, 14-day Holter-monitoring detected 18% of AF patients over 65 with a median of 532 days earlier than their clinical AF diagnosis, and identified 11.8% of AF patients who were either completely asymptomatic or only had symptomatic episodes <3 hours. Short-term (2-week) screening after a first symptom had a very low yield, which increased with increasing screening frequency and duration of follow-up (Figure 2). The majority of the remaining AF patients could be diagnosed when their symptoms lasted ≥3 hours, providing time for a traditional clinical diagnosis. Conclusion Our novel patient-level AF model can simulate individual AF patterns and clinical outcomes such as stroke and death in large cohorts of virtual patients. The model highlights the variability of AF episodes that makes effective early detection of asymptomatic AF with short-term monitoring challenging, and provides a tool for future studies into AF progression, screening and prevention of AF-related stroke and mortality.Figure 1Figure 2

AF in TAVR patients: double trouble means double care

Abstract Introduction Atrial fibrillation (AF) and aortic stenosis share multiple common risk factors and aortic valve stenosis itself is associated with higher rate of AF. Patients submitted to transcatheter aortic valve replacement (TAVR) are particularly frail and AF is associated with increased mortality, ischemic and hemorrhagic events. Thus, a thorough approach, especially in such frail population, is warranted to reduce morbi-mortality. Bearing this in mind, a risk assessment tool derived from ENVISAGE-AF trial was recently developed to stratify the mortality risk of AF patients after completion of successful TVR. Purpose To characterize a population of patients with AF who implanted TAVR and test a newly proposed mortality score to estimate prognosis in this population. Methods Single-center observational retrospective study including consecutive pts with AF who implanted TAVI from 2017 to 2021. Clinical data was collected at baseline and during follow-up. The AF mortality score groups pts in three crescent strata of severity (0-10; 11-16; >16) by summing seven variables: age, creatinine clearance, duration of AF, NYHA class, alcohol consumption, peripheral artery disease and prior major bleeding. Kaplan Meyer survival analysis was performed using SPSS statistics. Results For 5 years, 621 pts underwent TAVR, of which 189 (30,4%) had previously diagnosed AF. 102pts were female, mean age of 82,6± 6,1 years. More than half (53%) had permanent AF, 28% paroxysmal AF and 19% persistent AF. During a mean follow up of 953 days, 8 (4,2%) pts suffered a major hemorrhagic event, two pts had ischemic arterial events (peripheral and mesenteric) and no venous thrombotic events were observed. As anticipated, event rate was high: at 1 year follow-up, 27 were admitted for cardiovascular events (3 with acute myocardial infarction and 4 with stroke). 26 pts died after 1-year (13,7%) and 30 died during available FUP (15,8%). The aforementioned AF mortality score was applied to our pts at baseline, before TAVR: 63%, 17.5% and 8.5% of patients were categorized as low, moderate or high risk. Patients in the high risk group (score>16) had a significantly higher rate of events during follow-up – figure1. Lower and intermediate group failed to show a clear separation in terms of risk estimation between them, which may be attributed to the paucity of events in these two groups. Conclusion AF and aortic stenosis are both burdensome diseases and AF increases the risk of events in TAVR population. We showed that a newly proposed score that stemmed from ENVISGE-AF can effectively select pts at high risk of mortality, in whom close clinical surveillance should be particularly rigorous.

Remote heart rhythm assessment using smartphone-based photoplethysmography in primary care to detect undiagnosed atrial fibrillation in patients with chronic obstructive pulmonary disease

Abstract Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia leading to healthcare consultation in primary care. The increased risk to develop AF when suffering from chronic obstructive pulmonary disease (COPD) has been extensively described in literature. However, it remains challenging to perform in-office, opportunistic screening for AF in COPD patients during daily routine using pulse checks or single-spot ECGs due to the increasing pressure on primary care. Purpose The goal of this study was to evaluate the accuracy and effectiveness of a smartphone-based photoplethysmography (PPG) technology to enable remote heart rhythm monitoring and new AF detection in patients with COPD. Methods Diagnosed COPD patients, without an established AF diagnosis, were identified via the electronic medical record. Patients who fulfilled these criteria and hadn’t had an ECG in the past two years were selected to take part in this study. Other inclusion criteria were access to a smartphone and the physical ability to place their fingertip on a smartphone camera. Eligible patients were contacted via text message and after providing informed consent, the study team invited them to activate a 7-day invitation code to access a medically certified smartphone application. Patients were instructed to perform PPG measurements twice daily and when experiencing symptoms. Those with possible AF based on the PPG recordings were invited for a confirmatory ECG to establish the AF diagnosis. Results In total, 90/270 eligible patients (30%) provided informed consent and activated the on-demand invitation code to remotely monitor their heart rhythm using a PPG-based smartphone application. Of these, 50 (55.6%) were female and the median age was 68 years old (IQR: 59-74). The newly discovered AF detection yield was 5.6% (5/90). In-office 12-lead ECG confirmed AF in 3/5 patients (60%). The remaining patients, with a negative in-office 12-lead ECG, were invited for long-term intermittent ECG monitoring using a handheld ECG device (Zenicor). One patient accepted the proposal and paroxysmal AF was confirmed after 4 weeks of intermittent, symptom-triggered ECG monitoring. The remaining patient was not willing to perform long-term monitoring after the negative in-office ECG. However, this patient was diagnosed with paroxysmal AF as well after presentation at the emergency department while suffering from a transient ischemic attack three months after the initial AF detection using PPG technology. Conclusion Remote heart rhythm assessment using smartphone-based PPG in primary care within a COPD population was feasible and resulted in the detection of newly diagnosed AF in COPD patients. All patients identified with possible AF based on PPG monitoring were confirmed and diagnosed via ECG which enabled the initiation of guideline-based AF management.

Safety and efficacy of anticoagulation for atrial fibrillation in cirrhotic patients

Abstract Introduction Atrial fibrillation (AF) is the most prevalent sustained arrhythmia and increases thromboembolism risk. AF is more prevalent in patients with cirrhosis and cirrhotics are at higher risk for ischemic stroke from thromboembolic mechanisms such as AF. Cirrhotics have complex pathophysiology of coagulation which can lead to bleeding diathesis or hypercoagulability. Cirrhotics have been excluded from major trials of anticoagulants (AC), thus there are currently no guidelines for AC in cirrhotics with AF. We aim to investigate how the incidence of ischemic stroke, major bleeding, hospitalizations, and mortality vary in patients with AF and cirrhosis between AC choices including no AC. Methods De-identified electronic health records from a U.S. health system between March 2013 and December 2022 were reviewed to identify patients with International Classification of Diseases (ICD) diagnoses of both AF and cirrhosis and who also had Creatinine, Bilirubin, and INR values within 6 months of their second diagnosis (either AF or cirrhosis). Model for End-stage Liver Disease (MELD) scores were calculated from these values and patients were followed from the first date of their second diagnosis. Incidences of ICD-coded ischemic stroke, ICD-coded bleeds, Current Procedural Terminology (CPT) coded transfusions, all-cause mortality, and hospitalizations were recorded. Propensity score weighting between AC and non-AC groups balanced covariates (Table 1). Bivariate analyses for outcomes were conducted between AC and non-AC groups and among warfarin, DOAC, and injectable AC subgroups. Results 1,205 patients with AF and cirrhosis were included. 605 patients were prescribed AC (50.2%), 384 were prescribed DOACs (63.5%), 275 were prescribed Warfarin (45.4%), and 131 (21.7%) were prescribed injectable AC. After propensity weighting, patients prescribed AC had similar rates of bleed (p=0.607), transfusion (p=0.225), and death (p=0.779) but decreased rates of ischemic stroke (p=0.001) and number of hospitalizations (p<0.001) compared to non-AC patients. Patients prescribed DOACs had similar rates of bleed (p=0.529), ischemic stroke (p=0.108), number of hospitalizations (p=0.870), and death (p=0.230) but decreased rates of transfusion (p<0.001) compared to patients on other forms of AC. Patients prescribed warfarin had similar rates of death (p=0.230) and decreased rates of bleed (p=0.013) but increased rates of transfusion (p<0.001), ischemic stroke (p<0.001), and number of hospitalizations (p = 0.024) (Table 2). Conclusions Patients with AF and cirrhosis receiving AC experienced decreased rates of ischemic stroke and number of hospitalizations compared to patients who did not receive AC. Among AC subgroups, patients prescribed DOACs had lower rates of transfusion compared to other AC therapies while patients prescribed warfarin had increased rates of transfusion, ischemic stroke, and number of hospitalizations compared to other AC therapies.

Early repeat ablation strategy in atrial fibrillation patients is associated with lower recurrence rates

Abstract Introduction Atrial fibrillation (AF) ablation at early stages of AF improves the ablation outcomes in de novo ablations. Whether this is true in repeat ablations is unknown. Therefore, data pertaining the impact of early repeat ablation on AF recurrence in large, unselected cohorts is highly warranted. Purpose To examine AF recurrence after repeat ablation by time from recurrent AF to repeat ablation. Method Using Danish nationwide registries, all Danish patients above 18 years who underwent repeat AF ablation from January1st 2010 to December31st 2018 were identified and included at the date of repeat ablation. Exposure of interest was time from recurrent AF after de novo ablation to repeat ablation. The primary outcome was recurrent AF, defined from using a composite endpoint comprising claimed prescriptions of AAD, hospital admissions due to AF, re-ablation, or electrical cardioversions. The cumulative incidence of recurrent AF by time from recurrent AF to repeat ablation at 5-year follow-up after a blanking period of 90 days, was estimated using the Aalen-Johansen estimator, taking death as a competing risk into account. The Hazard Ratios of recurrent AF by time from recurrent AF to repeat ablation were examined using Cox models adjusted for sex, age, procedure-year, heart failure, ischemic heart disease, chronic obstructive pulmonary disease, and hypertension. Sub-group analysis of the impact of procedural year and AF-type (paroxysmal vs persistent) were made. Results The study cohort consisted of 2,704 patients. Median age [IQR] was 63 [55, 68] in the early ablation group (repeat ablation within 0.5 year after recurrent AF) and 65 [58, 70] in the late ablation group (repeat ablation at least 0.5 year after recurrent AF). It was predominately males and paroxysmal AF patients accounted for 62% and 59% in early vs late repeat ablations. Patient characteristics regarding left atrium size, left ventricular ejection fraction, and body mass index were relatively similar. Prior use of amiodarone was slightly higher in the early ablation group, while use of class 1C antiarrhythmics was highest in the late ablation group. A total of 1,625 (60%) patients had recurrent AF within 5 years after the blanking period. The mean follow-up time was 874 days. The cumulative incidence (95% CI) of recurrent AF was 54.8% (52.4%, 57.2%) and 67.3% (64.5%, 70.2%) in the early and late repeat ablation groups respectively. (Figure 1) The HR (95% CI) for the late repeat ablation group was 1.25 (1.10, 1.41) with the early repeat ablation group as reference. (Figure 2) Conclusion Among 2,704 patients undergoing repeat AF ablations from 2010-2018, we found that early repeat ablation was associated with significantly lower recurrence rates. Therefore, early repeat ablation could potentially provide substantial benefits and improve outcomes, indicating repeat ablation as first-line therapy might be ideal.

Impact of atrial fibrillation ablation in heart failure with reduced ejection fraction

Abstract Introduction Atrial fibrillation (AF) is the most common supraventricular arrhythmia in patients with heart failure (HF) and is associated with a significant increase in morbidity and mortality. Some studies have shown evidence in favor of ablation over pharmacological treatment in patients with AF and reduced ejection fraction (HFrEF). However, little is known about the generalizability of the trial results to routine clinical practice, particularly in a low- and middle-income country. Objective To evaluate whether catheter ablation (CA) of AF reduces morbidity and mortality compared to medical therapy alone in patients with HFrEF and AF in a real-word contemporary cohort from Argentina. Methods We consecutively identified patients with HF with ejection fraction less than 40% associated with paroxysmal or persistent AF who presented to our hospital, either as outpatients or inpatients, between February 2018 and June 2020. Baseline characteristics and outcomes were compared among patients undergoing CA or medical therapy alone. The primary outcome was all-cause mortality and first HF hospitalization until completing a 3-year follow-up. Propensity score overlap weighting was used to balance ablated and drug-treated patients on sex, age, body mass index, hypertension, diabetes, dyslipidemia, smoking, previous atrial fibrillation ablation, use of antiarrhythmic drugs, cardiac resynchronization, cardiac defibrillator, left ventricular ejection fraction, cardiovascular surgery, infarction, stroke, peripheral vascular disease, etiology of heart failure, respiratory disease and renal disease baseline characteristics. Results Data from 6297 patients with AF were analyzed, of whom 430 had ejection fraction ≤ 40%. We excluded 20 patients who were ablated for atrial flutter. 53 patients in the ablation and 357 patients in the medical therapy group were identified. After PS matching, the primary outcome occurred in 9 patients (23,7%) in the ablation group and in 19 patients (50%) in the control group. Catheter ablation was associated with a statistically significant reduction of the primary outcome in a 3-year follow up (Hazard ratio [HR] 0.33 [95%CI, 0.12-0.93]). Conclusion Catheter ablation for atrial fibrillation in patients with HFrEF was associated with decreased risk of mortality and heart failure hospitalisations relative to medical therapy.Kaplan-Meier survival estimates

Predicting incident atrial fibrillation in patients with embolic stroke of undetermined source

Abstract Introduction Atrial fibrillation (AF) is an important potential embolic source in patients who have suffered an embolic stroke of undetermined source (ESUS). AF has been detected in over 40% of patients when monitored with an implantable loop recorder (ILR). Recent clinical trials, however, have suggested that empirical anticoagulation of all patients with an ESUS is not an effective approach to reduce stroke risk. Thus predicting which patients are most likely to develop AF is of increased importance. Risk models for predicting incident AF exist but they do not incorporate modern techniques such as advanced echocardiographic parameters to create a comprehensive risk model. Purpose We sought to create a multi-parametric risk score for the prediction of incident AF in patients with ESUS. Methods This was a single-centre retrospective study. Consecutive adult patients referred for ILR implantation following ESUS, between March 2009 and November 2019, without prevalent AF or atrial flutter, were included. Patients’ notes were reviewed for clinical and anthropometric data. Each patients’ echo was re-reviewed both for conventional measures, and advanced parameters including left atrial strain using speckle-tracking (figure 1) and atrial electromechanical delay utilising the time from onset of the electrocardiographic P-wave to the lateral tissue Doppler A’ wave- "lateral PA". Univariate and multivariable analyses were performed, and a subsequent Lasso regression analysis used to develop a risk prediction model. Bootstrapping was used to perform internal validation. Results A total of 323 patients with ESUS who underwent a loop recorder implantation were included. Incident AF was detected in 142 patients (47.1%). Increased duration of the time between the electrocardiographic P-wave and the lateral tissue Doppler A’ wave (greater lateral PA), older age, higher diastolic blood pressure, abnormal left atrial reservoir strain were most strongly associated with increased AF risk. These were combined to form the PADS score below. Model discrimination was good, with an area under the curve of 0.72. Conclusion(s) The PADS score is a novel risk score for the prediction of incident AF in patients who have suffered an ESUS, based on the duration of the P-wave to the lateral tissue Doppler A’ wave, Age, Diastolic blood pressure and left atrial strain reservoir . Further work is required to assess whether the PADS score can be used to risk stratify patients into a high risk group which would derive benefit from immediate anticoagulation, an intermediate risk group who require prolonged continuous monitoring and a low risk group who can continue on conventional management for their stroke.PADS formulaLA strain using speckle strain analysis

Preliminary results of studying the prevalence of atrial fibrillation and the adequacy of prevention of thromboembolic complications

Abstract Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia that complicates the course of various cardiovascular diseases, and is also accompanied by the frequent development of thromboembolic complications (TEC), primarily ischemic stroke. In this regard, AF represents a huge socio-economic problem for the health system and society as a whole. Purpose study the real situation in terms of the incidence of various forms of AF and the adequacy of the prevention of TEC among the population of family clinic (FC) №5 in Tashkent. Materials and methods To achieve this goal, out of 12 districts of Tashkent, a (FP) №5 of M. Ulugbek district of Tashkent was selected with a total population of 21,606 people. After exclusion from the study of persons under 18 years of age (n=3546), the total number of adults was 18060 people. Random selection (n=1407) was performed using computer programs with the function of a random number generator in Microsoft Excel. The risk of TEC and bleeding in patients with various forms of AF was assessed using the CHA2DS2-VASc and HAS-BLED score. The study of the situation regarding the compliance of the use of anticoagulants with the current recommendations of the ESC (2020) was carried out by analyzing the structure of the pharmacological prevention of feasibility studies at the time of the survey. Research results: A total of 1407 (725 (51.53%) men) of the population were examined, registered with FC№5 in the M. Ulugbek district of Tashkent. It was found that 406 (28.86%) of the examined patients were diagnosed with coronary heart disease and/or hypertension, 5 (0.36%) of the population were diagnosed with chronic rheumatic heart disease and 369 (26.23%) people with a disease of other organs and systems. In 627 (44.56%) examined patients, non-organic pathologies were found. In general, it was found that 16 (1.13%) out of the total number of examined patients had various clinical forms of AF of both valvular (18.75%) and non-valvular etiology (81.25%). In general, among the identified clinical forms of AF, the permanent form of AF prevailed, amounting to 56.25%, and persistent ones, including long-term persistent and paroxysmal AF were detected in 4 (25%) and 2 (18.75%) patients, respectively. An analysis of the characteristics of the pharmacological prevention of thromboembolic complications showed that at the time of the survey, only 50% of patients were taking the oral anticoagulant therapy recommended in the standards (12.5% warfarin, without proper control of INR and 37.5% of novel oral anticoagulants). Conclusions 1) It was found that the prevalence of various forms of AF was 16 (1.13%) of the total number of patients examined: of these, 56.25% had a permanent form, 25% had a persistent form, and 18.75% had a paroxysmal form. 2) According to the ESC 2020 recommendations, the prevention thromboembolic complications in patients with AF is assessed as unsatisfactory.

Digital follow-up program for patients undergoing atrial fibrillation ablation: a pilot single-center study

Abstract Introduction Atrial fibrillation (AF) carries significant burden in health expenditure worldwide. Digital health technology may improve healthcare delivery, but its applicability in clinical practice and related outcomes remain a gap in evidence. Aim To report the implementation of a digital follow-up program (FUP) for patients submitted to AF ablation in an European center. Methods A digital FUP was implemented at a high-volume ablation center in 2020. The program featured a web platform for professionals, to record Clinician Reported Outcome Measurements (CROMs), during remote medical visits, and access Patient Reported Outcomes Measurements (PROMs). The program also included a mobile app for patients to report symptoms, vital signs, anthropometric and electrocardiographic data. Patients were invited to complete questionnaires at prespecified timepoints: Atrial Fibrillation Effect on qualiTy-of-life [AFEQT]; the Epworth and STOP-BANG for obstructive sleep apnea; nutritional questionnaire. Completeness rate was defined by the ratio of queries completed/queries sent at each timepoint. The mHealth App Usability Questionnaire (MAUQ) questionnaire was sent to patients and doctors; patients also received a Patient Reported Experience Measure (PREMs) 15 days after the ablation, from which a Net Promotor Score (NPS, -100 to 100) was calculated to express user’s satisfaction. This retrospective analysis includes data collected from December 2020 to September 2022. Results From the 305 ablations performed in this period, 253 patients were enrolled in the digital FUP: age 60±11 years, 67% male, 78% paroxysmal AF, body mass index 27.4±4.2 kg/m2. During a mean follow-up time of 11.9±5.8 months, 1120 CROMs were registered; 1449 PROMs were collected, including 5865 metrics reported by 90 different patients. App usage, measured by unique logins/month, was recorded in 54% of patients, of whom 13% submitted symptom checks weekly. 160 PREMs were registered; NPS scores for ablation and the app were 85.5 and 31.5, respectively [image]. Questionnaire overall completeness rate was: 54.5% for AFEQT; 14.4% for Epworth; 20.8% for STOP-BANG, that identified 55% of patients at high risk for sleep apnea. Nutritional assessment was completed by 18.7%; obese/pre-obese status was found in 21% and 48%, respectively; 18 patients were enrolled in a nutritional program. All doctors "agreed"/"strongly agreed" to overall satisfaction with the app. Conclusions The digital FUP was feasible and aided comorbidities assessment. Strategies to improve patient’s engagement and digital literacy are warranted. Further studies are needed to evaluate the platform’s impact on clinical outcomes.

Association of red cell omega-3 fatty acids, particularly EPA, with cognitive performance in atrial fibrillation

Abstract Introduction Atrial fibrillation (AF) is associated with cognitive impairment and dementia. Whether or not omega-3 Fatty Acids (n-3 FAs) have neuroprotective effects is controversial. We therefore aimed to determine the correlation of n-3 FAs with cognitive function in a large cohort of AF patients. Methods Red cell n-3 FAs levels were determined by gas chromatography and mass spectrometry in 2359 patients from the prospective ongoing multicenter Swiss Atrial Fibrillation study (Swiss-AF). To assess the overall cognitive performance of patients, we used several validated neurocognitive assessment tools, including the Montreal Cognitive Assessment (MoCA), Semantic Fluency Tests (SF), Trail Making Test (TMT A&B), and the Digit Symbol Substitution Test (DST). We also used a summary score that we have previously developed (the cognitive construct (CoCo) score). We performed mixed-effect linear regression analyses. Two adjustment models were applied; model 1 (adjusted for age, sex, and educational level) and model 2 (adjusted for age, sex, educational level, history of stroke/TIA, AF type, heart rate, arterial hypertension, diabetes, coronary artery disease, BMI, chronic kidney disease, smoking status, alcohol consumption, geriatric depression scale, use of oral anticoagulation and antiplatelet medication). We also included a random intercept to control for center-effect in both models. Results The mean age of our study population was 73 years (standard deviation [SD] 8.4), and 662 patients were females (28%), 318 had a history of stroke (13%), and 716 suffered from coronary artery disease (30%). We observed statistically significant associations of total n-3 FAs levels (EPA + DHA + DPA + ALA) with all neurocognitive assessments, as seen in figure a. Individual n-3 FAs levels (EPA and ALA) were positively associated with MoCA score in both models. EPA was significantly associated with multiple neurocognitive assessments including MoCA, SF, TMT-B, DST, and overall CoCo score in both models (figure b). We found that a 1% red cell EPA level increase was associated with 0.19 (Model 1, 95%CI 0.06-0.31, p=0.003) and 0.14 (Model 2, 95% CI 0.01-0.26, p=0.02) units increase in the standardized MoCA score. Conclusions Red cell n-3 FAs levels are associated with better cognitive performance in AF patients. We observed a particularly strong association of EPA levels with all neurocognitive assessments.

Incidence and predictors of the novo significant mitral and tricuspid regurgitation in patients with permanent atrial fibrillation

Abstract Introduction Atrial fibrillation (AF) is related to atrial remodeling and annular enlargement, which leads to functional mitral and tricuspid regurgitation. These two entities can derive in heart failure with preserved left ventricular ejection fraction (LVEF), the reason why it is becoming a rising concern in recent years. However, its incidence and predictors have not been well established. Purpose This study aimed to assess the incidence and predictors of significant atrial functional mitral and tricuspid regurgitation in patients with permanent AF. Methods The study population comprised 547 patients from a Spanish health area diagnosed with permanent AF between 2014 and 2019 (CardioCHUVI-AF registry; ClinicalTrials.gov identifier: NCT04364516). Individuals who presented with atrial enlargement at the diagnosis, primary moderate to severe valve disease, previous cardiac surgery (including valve replacement or repair), decreased LVEF, pulmonary hypertension, or right ventricular pacing that could interfere with tricuspid valve closure were excluded. The median age was 78.0 (IQ 70.4-85.6), and men represented 43% of the population (235 patients) compared to women, which represented 57% (312 patients). During a median follow-up of 3.5 years (IQ 2.03-4.95) we assessed the incidence of moderate to severe de novo mitral and tricuspid valve regurgitation and its predictors. Results The development of moderate to severe mitral and tricuspid valve regurgitation was higher after three years of diagnosis. The incidence of mitral regurgitation was 3.8 (3.0-4.9) per 100 persons/year. The incidence of tricuspid regurgitation was 5.5 (4.5-6.8) per 100 persons/year. In addition, multivariate analysis showed an association between the development of mitral regurgitation and older age (HR 1.05 [CI 95% 1.01-1.09]), female sex (HR 1.82 [CI 95% 1.1-3]) and prior admission for HF (HR 2.35 [CI 95% 1.18-4.7]). On the other hand, the development of tricuspid regurgitation did not show an association with age (HR 1.02 [CI 95% 0.97-1.05]), but it did with prior admission for HF (HR 2.11 [CI 95% 1.17-3.79]) and female sex (HR 2.17 [CI 95% 1.43-3.3]). Conclusion Permanent atrial fibrillation was associated with an increased risk of developing atrial functional mitral and tricuspid regurgitation, especially after three years of the diagnosis and in the female sex. Older age was associated with a higher incidence of mitral regurgitation. Prior admission for HF was associated with a higher incidence of tricuspid regurgitation. Based on the preceding, monitoring a specific profile of patients with atrial fibrillation may be especially important in preventing and early treating valve disease that can compromise their prognosis.Incidence of mitral regurgitationIncidence of tricuspid regurgitation

0863 Evaluation of sleep apnea among consecutive patients with all patterns of atrial fibrillation

Abstract Introduction Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and is associated with significant morbidity, mortality, and financial burden. Obstructive sleep apnea is more common in individuals with AF and may impair AF treatment efficacy including with catheter ablation. However, the prevalence of undiagnosed OSA in all-comers with AF is unknown. Methods This pragmatic, phase IV prospective cohort study will test 250-300 consecutive ambulatory AF patients with all patterns of atrial fibrillation (paroxysmal, persistent, and long-term persistent) and no prior sleep testing for OSA using the WatchPAT system, a home sleep test. Results We report the design, methodology, and results from the initial pilot enrollment of approximately 25% (N=52) of the planned sample size. The primary outcome is the prevalence of undiagnosed OSA in all-comers with AF. Additional outcomes of interest include the sensitivity and specificity of clinical screening instruments for OSA in the AF population and AF-related quality of life measurements among those with and without OSA. Results of the pilot dataset demonstrate a 77.5% prevalence of at least mild (AHI≥5) OSA or greater in all-comers with AF. Conclusion Based on our preliminary dataset representing one quarter of the planned total enrollment size of 250-300, there is a high prevalence of OSA in all-comers with AF. Support (if any) Zoll Medical

0982 Atrial fibrillation diagnosed from a home-based sleep study in a patient with REM behavior disorder

Abstract Introduction Atrial fibrillation (A-Fib) is the most common form of cardiac arrhythmia and is a major cause of stroke. Obstructive sleep apnea (OSA) is an established risk factor of A-Fib, but sleep disruption with frequent awakenings was recently identified as another risk factor, independent from OSA. Home sleep apnea test (HSAT) is widely used to diagnose OSA with low cost and short wait time, and HSAT that uses peripheral arterial tonometry (PAT) can reveal cardiac arrhythmia. Here we report a case of A-Fib detected by PAT-based HSAT in a patient with REM sleep disorder. Report of case(s) A 60-year-old man with hypertension, depression, anxiety, tobacco and alcohol use disorders presented to sleep clinic for frightening vivid dreams and violent dream enactments that gradually developed over the last two years. A diagnostic polysomnography study showed mild OSA, normal heart rhythm, and no epoch of REM sleep without atonia (RSWA). In the following four years, he used CPAP therapy, imagery rehearsal therapy, high-dose melatonin, doxepin and hydroxyzine. However, the frightening dreams and dream enactments persisted despite full adherence to CPAP. To reassess OSA, the patient took a PAT-based HSAT, which showed not only mild OSA, but one episode of irregularly irregular PAT-derived pulsation variations that lasted three hours and started and stopped abruptly. We therefore ordered longitudinal cardiac monitoring, which showed multiple asymptomatic episodes of A-Fib during nighttime. After treatments for A-Fib were started, a polysomnography study with effective CPAP titration showed one episode of A-Fib with rapid ventricular response that lasted 2.5 hours during non-REM sleep, and multiple epochs of RSWA. The diagnosis of REM sleep behavior disorder (RBD) was thus established. Conclusion We reported concurrent developments of RBD and asymptomatic paroxysmal A-Fib in a man in his early sixties. Our case suggests a potential association between RBD and A-Fib, which has not been studied but is conceivable, given that RBD causes frequent awakenings with surges of sympathetic activity. Our case also highlights the advantage of PAT in capturing not only OSA but cardiac arrhythmia. Clinical interpreters of PAT-based HSAT can seize the opportunity to diagnose A-Fib and prevent stroke. Support (if any)

P386 ATRIAL FIBRILLATION ABLATION IN PATIENTS WITH SEVERELY DEPRESSED EJECTION FRACTION. META–ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Abstract Introduction Atrial fibrillation (AF) and severely depressed ejection fraction (SDEF) are two conditions that often coexist. AF increases overall mortality in these patients. The current available guidelines do not provide a clear consensus regarding the best management approach. We conducted this meta–analysis in order to determine if catheter ablation for AF is superior to medical therapy in this patients. Methods Data collection We applied the methods recommended by the Preferred Reporting Items for Systematic Reviews and Meta–Analyses (PRISMA) statement. We searched Pubmed, and the Cochrane Central Register for randomized controlled trials (RCT) that evaluated AF catheter ablation in patients with SDEF (lower than 35%). Outcome: The primary outcomes were left ventricular ejection fraction (LVEF), 6–minute walk test (6MWT) distance, AF recurrence, and mortality Statistical Analysis: The analyses were performed using RevMan version 5.3. The results are presented as a mean difference for continuous outcome measures (inverse variance random effect model), and odds ratios (OR) for dichotomous outcomes (Mantel–Haenszel random effect model) with 95% confidence interval (CI). Results Four full texts met inclusion criteria. A total of 665 patients were included (324 patients randomized to catheter ablation and 341 patients randomized to medical therapy), with a mean follow–up of 15.2 months. Arrhythmia recurrence: AF catheter ablation was effective and significantly more patients were in sinus rhythm at the end of the follow–up (OR 14.51 (4.9–42) p < 0.001) LVEF: compared to medical therapy, AF catheter ablation was associated with a significant increase in LVEF outcome (MD 5.17 (2.06–8.27) p 0.001) 6MWT distance in meters: The mean increase in 6MWT distance was higher in the AF catheter ablation group compared to the medical therapy group (MD 32.7 (13.2–52.3) p 0.001) All–Cause mortality: the risk of death from any cause was significantly lower in the AF ablation arm (OR…). Conclusions Summary evidence from the included RCTs showed that AF catheter ablation significantly increases LVEF, 6MWT distance, sinus rhythm maintenance, and overall mortality.

P462 ATRIAL FIBRILLATION CIED DETECTED; WHEN TO SCOAGULATE? OUR EXPERIENCE ON A STILL VERY CONTROVERSIAL TOPIC

Abstract Introduction Atrial fibrillation (AF), which is constantly increasing in the population, is associated with an important care burden linked, in particular, to its consequences (stroke, heart failure, etc.). In patients with an implantable cardiac device (CIED) it is frequent the detection of high atrial frequency episodes (AHRE), often asymptomatic, for which an increased thromboembolic risk has been described (about 2.5 times) but lower than the clinical AF for which there is still no unanimous consensus regarding the initiation of oral anticoagulant therapy (OAT). We report below our experience in patients undergoing CIED implantation in whom AHRE was detected and OAT started, evaluating the characteristics of thromboembolic risk and the follow–up of complications. Methods From 01 January 2020 to 31 December 2021, 242 patients (mean age 74.8 years) underwent CIED implant. Among these, 41 patients (16.9% mean age 78.6 years – 30 males and 11 females) presented episodes of AHRE, detected by remote monitoring, lasting between a few seconds and more than 24 hours. The mean CHADsVasc score of these patients was 3.8. Seven patients were not anticoagulated due to arrhythmic episodes lasting a few minutes and CHADsVasc score equal to 1–2, while the other 34 started OAT with DOAC. Results No thromboembolic events or major bleeding events have been recorded to date; only minor bleedings (11 epistaxis, 4 haematuria and 5 SOF positivity) were easily treated. Conclusions The current guidelines indicate to prolong monitoring until the detection of clinical AF or an arrhythmic burden > 24 hours before considering OAT; however, there are studies that recommend carefully correlating the duration of arrhythmic events with the determination of the thromboembolic risk. In our experience, the high thromboembolic risk of patients, sometimes not adequately represented by the CHADsVasc score, led us to start OAT even when the duration of the episodes was not particularly long and at the moment no major complications have been observed. The two ongoing trials (ARTESia and NOAH) dedicated to the evaluation of these situations will provide valuable indications on the treatment of these patients in whom the thromboembolic risk is certainly lower than that of patients with clinical AF but still not negligible.

Protocol for a Systematic Review and Individual Participant Data Meta-Analysis of Randomized Trials of Screening for Atrial Fibrillation to Prevent Stroke.

Atrial fibrillation (AF) is a common cause of stroke. Timely diagnosis of AF and treatment with oral anticoagulation (OAC) can prevent up to two-thirds of AF-related strokes. Ambulatory electrocardiographic (ECG) monitoring can identify undiagnosed AF in at-risk individuals, but the impact of population-based ECG screening on stroke is uncertain, as ongoing and published randomized controlled trials (RCTs) have generally been underpowered for stroke. The AF-SCREEN Collaboration, with support from AFFECT-EU, have begun a systematic review and individual participant data meta-analysis of RCTs evaluating ECG screening for AF. The primary outcome is stroke. Secondary outcomes include AF detection, OAC prescription, hospitalization, mortality, and bleeding.After developing a common data dictionary, anonymized data will be collated from individual trials into a central database. We will assess risk of bias using the Cochrane Collaboration tool, and overall quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach.We will pool data using random effects models. Prespecified subgroup and multilevel meta-regression analyses will explore heterogeneity. We will perform prespecified trial sequential meta-analyses of published trials to determine when the optimal information size has been reached, and account for unpublished trials using the SAMURAI approach. Individual participant data meta-analysis will generate adequate power to assess the risks and benefits of AF screening. Meta-regression will permit exploration of the specific patient, screening methodology, and health system factors that influence outcomes. PROSPERO CRD42022310308.

Prediction of new onset atrial fibrillation recurrence or persistence with artificial intelligence: first insights of the PRAFAI study

Abstract Introduction Atrial fibrillation (AF) is the most prevalent arrhythmia in the world and it is associated with a high rate of cardiovascular morbidity and mortality. A higher burden of atrial fibrillation is related to more adverse cardiovascular events and the rhythm control strategy (maintenance or recovery of sinus rhythm) is particularly indicated in patients with paroxysmal symptomatic atrial fibrillation. All things considered, in order to select the optimal therapeutic strategy, it might be useful to accurately predict the probability of recurrence or permanence of AF after its onset. The predictive models implemented so far, show a limited predictive power or were built on samples of patients undergoing specific therapies. Thus, developing an specific model based on features derived from electronic health records (EHR) of patients with a first AF episode seems essential. Purpose To develop an artificial intelligence powered predictive model based on EHR variables in order to predict the AF recurrence after its onset. Methods The methodological design of the research is based on the analysis of secondary data from a retrospective cohort obtained from the EHR of a tertiary hospital. All new onset AF from 2015 to 2018 were identified by ICD codes, and a 2 years EHR driven follow-up was made to determine the AF recurrence or permanence of the arrhythmia in those patients. A systematic review was pursued to determine which features exhibited a greater predictive power for AF recurrence, and they were inquired to the system for the mentioned participants. After the standardization of the variables and a feature selection process, several missing value imputation methods and around 12 different Machine Learning algorithms were tested to predict the AF recurrence in a subset of patients who developed AF in the first semester of 2015, in order to select the algorithms with the highest prediction accuracy for further tests. Results 523 patients had an AF onset in the first semester of 2015. Among them, 310 (59.3%) had AF recurrence in a 2 years period. A support vector machine (SVM) algorithm with a median imputation method to handle missing values performed the best and had an 0.77 AUC in the training set and 0.71 in the test set. Hyperthyroidism, vasodilator drug use and obstructive sleep apnea were notoriously related to AF recurrence, while Ic antiarrhythmic drugs, AF ablation, cognitive impairment and anxiety were the most influential variables for the absence of recurrence. Classical AF recurrence factors such as age or left atrium diameter ratify their role in this setting. Conclusion A SVM Machine Learning algorithm discloses an accurate AF recurrence probability based on EHR features. Pharmacologic and epidemiological variables, added to classically assessed ones, seem to be specially related to this arrhythmic recurrence. Further research including the whole cohort features will probably improve the accuracy of this selected SVM algorithm. Funding Acknowledgement Type of funding sources: None.

1120 DIAGNOSTIC ACCURACY OF SMART GADGETS/WEREABLE DEVICES IN ATRIAL FIBRILLATION DETECTION: A METANALYSIS

Abstract Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart. Recent technology advances have allowed for heart rhythm monitoring using smart gadgets/wearable devices which can be used for early AF diagnosis. Hypothesis We performed a systemic review and meta-analysis to assess the accuracy of AF diagnosis by smart gadgets/wearable devices. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to April 15th, 2022 for observational studies of the diagnostic accuracy of smartphone application, wrist-worn wearables and external devices in detecting AF. We calculated the area under the curve (AUC) of the summary receiver operating characteristic curves (SROC) and pooled sensitivities and specificities. Results A total of 79 studies were included enrolling 36903 patients, 66.3% male with average age of 68.3±8 years. In the overall analysis of all devices, the AUC was 0.99 (95% CI: 0.98-1.00), the sensitivity 95%(95% CI: 94–96%), the specificity 96%(95% CI: 96–97%). Wrist-worn wearables had AUC of 0.99 (95% CI: 0.98-1.00), the sensitivity 95%(9% CI: 92–97%), the specificity 97%(95% CI: 96–98%)(Figure 1A). Smartphone applications had AUC of 0.98 (95% CI: 0.96-0.99), the sensitivity 96%(9% CI: 94–97%), the specificity 96%(95% CI: 93–98%)(Figure 1B). External devices had AUC of 0.99 (95% CI: 0.98-1.00), the sensitivity 95%(9% CI: 93–97%), the specificity 96%(95% CI: 95–97%)(Figure 1C). Single-lead ECG had AUC of 0.99 (95% CI: 0.98- 1.00), the sensitivity 95%(9% CI: 92–96%), the specificity 96%(95% CI: 95–97%). PPG had AUC of 0.99 (95% CI: 0.98-1.00), the sensitivity 96%(9% CI: 95–97%), the specificity 97%(95% CI: 95–98%). Conclusions Smartphone application, wrist-worn devices and external devices with PPG and single-lead ECG have excellent diagnostic accuracy in atrial fibrillation diagnosis. Figure 1. Summary Receiver Operating Characteristic curves and Areas Under The Curve of Wrist-worn wearables (A), Smartphone applications (B) and External devices (C).

1123 DIAGNOSTIC ACCURACY OF SMART GADGETS/WEREABLE DEVICES IN ATRIAL FIBRILLATION DETECTION: A METANALYSIS

Abstract Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart. Recent technology advances have allowed for heart rhythm monitoring using smart gadgets/wearable devices which can be used for early AF diagnosis. Hypothesis We performed a systemic review and meta-analysis to assess the accuracy of AF diagnosis by smart gadgets/wearable devices. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to April 15th, 2022 for observational studies of the diagnostic accuracy of smartphone application, wrist-worn wearables and external devices in detecting AF. We calculated the area under the curve (AUC) of the summary receiver operating characteristic curves (SROC) and pooled sensitivities and specificities. Results A total of 79 studies were included enrolling 36903 patients, 66.3% male with average age of 68.3±8 years. In the overall analysis of all devices, the AUC was 0.99 (95% CI: 0.98-1.00), the sensitivity 95%(95% CI: 94–96%), the specificity 96%(95% CI: 96–97%). Wrist-worn wearables had AUC of 0.99 (95% CI: 0.98-1.00), the sensitivity 95%(9% CI: 92–97%), the specificity 97%(95% CI: 96–98%)(Figure 1A). Smartphone applications had AUC of 0.98 (95% CI: 0.96-0.99), the sensitivity 96%(9% CI: 94–97%), the specificity 96%(95% CI: 93–98%)(Figure 1B). External devices had AUC of 0.99 (95% CI: 0.98-1.00), the sensitivity 95%(9% CI: 93–97%), the specificity 96%(95% CI: 95–97%)(Figure 1C). Single-lead ECG had AUC of 0.99 (95% CI: 0.98- 1.00), the sensitivity 95%(9% CI: 92–96%), the specificity 96%(95% CI: 95–97%). PPG had AUC of 0.99 (95% CI: 0.98-1.00), the sensitivity 96%(9% CI: 95–97%), the specificity 97%(95% CI: 95–98%). Conclusions Smartphone application, wrist-worn devices and external devices with PPG and single-lead ECG have excellent diagnostic accuracy in atrial fibrillation diagnosis. Figure 1. Summary Receiver Operating Characteristic curves and Areas Under The Curve of Wrist-worn wearables (A), Smartphone applications (B) and External devices (C).