Atrial Fibrillation And Flutter Research Articles

Results of a prospective randomized study comparing efficacy and safety of refralon and amiodarone for cardioversion in patients with paroxysmal atrial fibrillation and flutter

Aim. To compare efficacy and safety of refralon and amiodarone for cardioversion in patients with paroxysmal atrial fibrillation and flutter (AF/AFL). Methods. The study included 60 patients (32 men and 28 women) with symptomatic paroxysmal AF/AFL. All patients underwent a preliminary examination to exclude contraindications to cardioversion. The procedure of pharmacological cardioversion was carried out in the intensive care unit. By the method of envelope randomization, patients were divided into equal groups of refralon and amiodarone, 30 participants each. Both groups did not differ significantly in terms of main clinical characteristics. Cardioversion with refralon consisted of four subsequent iv injections: 5-5 - 10-10 µg/kg of body weight at intervals of 15 minutes. Patients of the second group were intravenously administered amiodarone at a dose of 5 mg/kg of body weight for 20-60 minutes, depending on the tolerability of the drug. In case of AF/AFL maintaining after 60 minutes from the start of administration, the infusion of amiodarone 100 mg/h continued until restoration of sinus rhythm (SR) or until the maximal total dose of 1200 mg/day was reached. Patients were observed for 24 hours.Results. SR restored in 96.7% (29 of 30) of patients in the refralon group, of which 56.7% (17 of 30) - after a dose of 5 μg / kg. In the amiodarone group SR restored in 53.3% (16 of 30) patients (p<0.001). Median time to arrhythmia conversion in refralon group was 14 [7;23] min, while in amiodarone group it was 150 [82;240] min (p<0.001). Within 60 minutes SR was restored in 26 patients in group of refralon and only in 4 patients in group of amiodarone (p<0.001). There were no statistically significant differences in the incidence of major adverse cardiac events, bradyarrhythmias, lowering of blood pressure, and QT prolongation between the groups.Conclusion. In randomized trial Refralon demonstrated higher rate of successful AF/AFL conversion and shorter time to SR restoration than amiodarone. The most of patients restored SR after administration of the lowest dose of refralon, that ensures the safety of cardioversion.

Sexual behavior and cardiovascular diseases: univariable and multivariable Mendelian randomization.

To assess the relationship of genetically predicted sexual behavior (age at first sex (AFS) and the number of sexual partners (NSP)) on cardiovascular diseases (CVDs). We performed two-sample Mendelian randomization (MR) with publicly available datasets from the UK Biobank and FinnGen Study, and analyzed genome-wide association results for sexual behaviors and twelve types of CVDs. The univariable MR method provided a total effect of AFS and NSP on CVDs, and showed evidence that early AFS rather than NSP was associated with CVDs, including angina pectoris (AP), atrial fibrillation and flutter (AFF), coronary atherosclerosis (CAS), deep vein thrombosis of the lower extremity (DVT-LE), heart failure (HF), hypertension (HTN), ischaemic stroke (IS), and myocardial infarction (MI). Given sex as a social determinant of CVD risk, we used gender-stratified SNPs to investigate gender differences in the development of CVDs. These results showed a stronger causal relationship of AFS on CVDs in females than in males. Further multivariable MR analyses indicated a direct effect after accounting for insomnia, number of days of vigorous physical activity 10 + minutes (VPA 10 + min), and time spent watching television (TV). Two-step MR demonstrated these three risk factors act as a mediator in AFS associated AP/HTN/HF. We provide evidence that early AFS increased the risk of CVDs. These associations may be partly caused by VPA 10 + min, insomnia, and the time spent on TV. The causality of AFS on CVDs in females was stronger than in males. Conversely, genetically predicted NSP was not associated with CVDs.

Automatic segmentation of atrial fibrillation and flutter in single-lead electrocardiograms by self-supervised learning and Transformer architecture.

Automatic detection of atrial fibrillation and flutter (AF/AFL) is a significant concern in preventing stroke and mitigating hemodynamic instability. Herein, we developed a Transformer-based deep learning model for AF/AFL segmentation in single-lead electrocardiograms (ECGs) by self-supervised learning with masked signal modeling (MSM). We retrieved data from 11 open-source databases on PhysioNet; 7 of these databases included labeled ECGs, while the other 4 were without labels. Each database contained ECG recordings with durations of ≥30s. A total of 24 intradialytic ECGs with paroxysmal AF/AFL during 4h of hemodialysis sessions at Seoul National University Hospital were used for external validation. The model was pretrained by predicting masked areas of ECG signals and fine-tuned by predicting AF/AFL areas. Cross-database validation was used for evaluation, and the intersection over union (IOU) was used as a main performance metric in external database validation. In the 7 labeled databases, the areas marked as AF/AFL constituted 41.1% of the total ECG signals, ranging from 0.19% to 51.31%. In the evaluation per ECG segment, the model achieved IOU values of 0.9254 and 0.9477 for AF/AFL segmentation and other segmentation tasks, respectively. When applied to intradialytic ECGs with paroxysmal AF/AFL, the IOUs for the segmentation of AF/AFL and non-AF/AFL were 0.9896 and 0.9650, respectively. Model performance by different training procedure indicated that pretraining with MSM and the application of an appropriate masking ratio both contributed to the model performance. It also showed higher IOUs of AF/AFL labels than in previous studies when training and test databases were matched. The present model with self-supervised learning by MSM performs robustly in segmenting AF/AFL.

Abstract 16494: Cardiac Structure and Function Predict Incident Atrial Fibrillation and Flutter in Patients With HFpEF - Lessons From PARAGON-HF

Introduction: Incident atrial fibrillation and flutter (AFF) are common among patients with heart failure with preserved ejection fraction (HFpEF) portending a worse prognosis. Cardiac echocardiographic predictors of incident AFF in patients with HFpEF are not well known. Methods: Patients without history of AFF enrolled in the echocardiographic sub-study of the PARAGON-HF trial with adequate image quality were included in this analysis. Cardiac structure and function parameters were measured per the American Society of Echocardiography guidelines. Incident AFF was ascertained during serial trial visits. Multivariable Cox proportional hazards models were used to identify parameters of echocardiography associated with incident AFF and were adjusted for variables previously known to associate with incident AFF (age, heart rate, body mass index and NT-pro-BNP). Results: Among patients without prior AFF (N=425, 54% women, mean age 71 ± 8 years), 63 developed incident AFF over a median follow-up of 2.8 years (5.4 per 100 person-years). After multivariable adjustment, higher left atrial (LA) volume index (HR: 1.35 per 11.3 ml/m 2 , 95% CI: 1.10-1.66, p=0.004), left ventricular mass index (HR: 1.40 per 25.7 g/m 2 , 95% CI: 1.09-1.80, p=0.008), septal E/e’ ratio (HR: 1.72 per 6.4 units, 95% CI: 1.29-2.28, p<0.001), and lower septal a’ (HR: 0.48 per 2.0 cm/s, 95% CI: 0.33-0.70, p<0.001) were associated with a significantly higher risk of incident AFF. Furthermore, higher (better) LA reservoir strain (LAsr) (HR: 0.66 per 10.8%, 95% CI: 0.48-0.92, p=0.014) and LA contractile strain (absolute LAsct) (HR: 0.71 per 6.7%, 95% CI: 0.51-0.98, p=0.040) predicted lower risk of incident AFF. Conclusions: In the PARAGON-HF echocardiographic sub-study, worse diastolic and LA function, larger LA size and higher LV mass were associated with a higher risk of incident AFF.

Trends of hospitalisation for cardiovascular diseases among people with diabetes in Australia

ObjectiveTo describe trends in hospitalisation for subtypes of cardiovascular diseases among people with diabetes. MethodsThe data sources included the Australian diabetes registry, admitted hospitalisation datasets, and death registry from 2011 to 2019. The outcomes comprised hospital admissions for: all CVD; all cerebrovascular diseases, ischaemic and haemorrhagic stroke; angina and ischaemic heart disease (AIHD); non-ST elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI); atrial fibrillation and flutter (AFF). Data were analysed using Stata and Joinpoint regression software.Rates were standardised for age and sex. Annual percentage change (APC) was reported. ResultsIn type 1 diabetes, there were increases in hospitalisation for all cerebrovascular diseases (APC 4.5, 95 % CI: 1.2, 7.9) and ischaemic stroke (2.3, 95 % CI: 1.6, 3.0). There were declines in STEMI (-2.6, 95 % CI: −5.0, −0.1) and AIHD (-3.1, 95 % CI: −5.5, −0.7). In type 2 diabetes, hospitalisation for all CVD declined (-0.9, 95 % CI: −1.4, −0.3). Hospitalisation rates for ischaemic stroke increased (4.1, 95 % CI: 3.1, 5.1). There were declines in NSTEMI (-2.5, 95 % CI: −3.2, −1.8) and AIHD (-4.2, 95 % CI: −4.8, −3.5). ConclusionIn type 1 and 2 diabetes, hospitalisation for ischaemic stroke increased while coronary diagnoses declined.

Causal association between basal metabolic rate and risk of cardiovascular diseases: a univariable and multivariable Mendelian randomization study

Basal metabolic rate (BMR) is associated with cardiovascular health; however, the causal relationship between BMR and the risk of cardiovascular diseases (CVDs) remains unclear. This study aimed to investigate the potential causal relationship of BMR on common CVDs including aortic aneurysm (AA), atrial fibrillation and flutter (AFF), calcific aortic valvular stenosis (CAVS), heart failure (HF), and myocardial infarction (MI) by Mendelian randomization (MR). The univariable MR analysis using inverse variance weighted (IVW) model as the primary analysis method revealed that genetically predicted higher BMR causally increased the risk of AA [IVW odds ratio (OR) = 1.34, 95% confidence interval CI 1.09–1.65, p = 0.00527], AFF (IVW OR = 1.87, 95% CI 1.65–2.12, p = 1.697 × E-22), and HF (IVW OR = 1.35, 95% CI 1.20–1.51, p = 2.364 × E-07), while causally decreasing the risk of MI (IVW OR = 0.83, 95% CI 0.73–0.93, p = 0.00255). In the multivariable MR analysis, which controlled for common cardiovascular risk factors, direct effects of BMR on an increased risk of AA and AFF, as well as a decreased risk of MI, but an attenuated causal effect on HF, were observed. In conclusion, the current MR study provides evidence for a causal relationship between BMR and the risk of AA, AFF, HF, and MI.

Preliminary results of a prospective randomized study comparing the efficacy and safety of refralon and amiodarone in cardioversion in patients with paroxysmal atrial fibrillation and flutter

Aim. To compare the efficacy and safety of chemical cardioversion (CCV) with refralon and amiodarone in patients with paroxysmal atrial fibril­lation and flutter (AF/AFL).Material and methods. Fifty five patients (mean age, 65±11 years) with paroxysmal AF/AFL were included. All patients underwent a preliminary examination to rule out contraindications to CCV. Further, patients were randomized into groups of refralon (n=30) and amiodarone (n=28), respectively. CCV with refralon was carried out as follows: administration in doses of 5-5-10-10 µg/kg at intervals of 15 minutes. Patients of the second group were intravenously injected with amiodarone at a dose of 5 mg/kg of body weight for 20-60 minutes, depending on the drug tolerability. If AF/AFL persists after 60 minutes, infusion of amio­darone 100 mg/hour until restoration of sinus rhythm (SR) or reaching a dose of 1200 mg/day. Treatment efficacy was assessed by SR reco­very, absence of AF/AFL recurrence, and arrhythmia relief time, and safety was assessed by detection of ventricular arrhythmogenic effects, bradyarrhythmias, blood pressure reduction, and QT interval prolongation. The follow-up period lasted 24 hours.Results. SR was restored in 96,7% (n=29) of patients in the refralon group, of which 56,7% (n=17) after a dose of 5 mcg/kg. In the amio­darone group, SR was restored in 57,1% (n=16) of patients (p<0,001). The arrhythmia relief time in the refralon group was 14 [7;23] min, while in the amiodarone group — 150 [82;240] min (p<0,001). There were no significant differences in the incidence of bradyarrhythmias, lowering blood pressure, and QT prolongation in the groups.Conclusion. Refralon demonstrates a higher efficiency and lower time to AF/AFL relief compared with amiodarone, while in most patients, SR recovery occurs after the administration of the lowest doses, which ensures CCV safety.

Cardiac arrhythmias and conduction abnormalities in patients with type 2 diabetes

The association between type 2 diabetes (T2D) and the development of cardiac arrhythmias and conduction disturbances has not been extensively studied. Arrhythmia was defined as atrial fibrillation and flutter (AF/AFl), ventricular tachycardia (VT) and ventricular fibrillation (VF), and conduction abnormality as sinus node disease (SND), atrioventricular (AV) block or pacemaker implantation, and intraventricular conduction blocks (IVCB). Incidence rates and Cox regression were used to compare outcomes, and to assess optimal levels for cardiometabolic risk factors and risk associated with multifactorial risk factor control (i.e., HbA1c, LDL-C, systolic blood pressure (SBP), BMI and eGFR), between patients with versus without T2D. The analyses included data from 617,000 patients with T2D and 2,303,391 matched controls. Patients with diabetes and the general population demonstrated a gradual increase in rates for cardiac conduction abnormalities and virtually all age-groups for AF/AFI showed increased incidence during follow-up. For patients with versus without T2D, risks for cardiac arrhythmias were higher, including for AF/AFl (HR 1.17, 95% CI 1.16–1.18), the composite of SND, AV-block or pacemaker implantation (HR 1.40, 95% CI 1.37–1.43), IVCB (HR 1.23, 95% CI 1.18–1.28) and VT/VF (HR 1.08, 95% CI 1.04–1.13). For patients with T2D who had selected cardiometabolic risk factors within target ranges, compared with controls, risk of arrythmia and conduction abnormalities for T2D vs not were: AF/AFl (HR 1.09, 95% CI 1.05–1.14), the composite of SND, AV-block or pacemaker implantation (HR 1.06, 95% CI 0.94–1.18), IVCB (HR 0.80, 95% CI 0.60–0.98), and for VT/VF (HR 0.97, 95% CI 0.80–1.17). Cox models showed a linear risk increase for SBP and BMI, while eGFR showed a U-shaped association. Individuals with T2D had a higher risk of arrhythmias and conduction abnormalities than controls, but excess risk associated with T2D was virtually not evident among patients with T2D with all risk factors within target range. BMI, SBP and eGFR displayed significant associations with outcomes among patients with T2D.

Atrial fibrillation following transcatheter atrial septal defect closure: a systematic review and meta-analysis

ObjectiveThe ostium secundum atrial septal defect (ASD) is among the most common congenital cardiac anomalies diagnosed in adulthood. A known complication of transcatheter ASD closure is the development of new-onset...

Predictors of Acute Atrial Fibrillation and Flutter Hospitalization across 7 U.S. Emergency Departments: A Prospective Study.

International rates of hospitalization for atrial fibrillation and flutter (AFF) from the emergency department (ED) vary widely without clear evidence to guide the identification of high-risk patients requiring inpatient management. We sought to determine (1) variation in hospital admission and (2) modifiable factors associated with hospitalization of AFF patients within a U.S. integrated health system. This multicenter prospective observational study of health plan members with symptomatic AFF was conducted using convenience sampling in 7 urban community EDs from 05/2011 to 08/2012. Prospective data collection included presenting symptoms, characteristics of atrial dysrhythmia, ED physician impression of hemodynamic instability, comorbid diagnoses, ED management, and ED discharge rhythm. All centers had full-time on-call cardiology consultation available. Additional variables were extracted from the electronic health record. We identified factors associated with hospitalization and included predictors in a multivariate Poisson Generalized Estimating Equations regression model to estimate adjusted relative risks while accounting for clustering by physician. Among 1,942 eligible AFF patients, 1,074 (55.3%) were discharged home and 868 (44.7%) were hospitalized. Hospitalization rates ranged from 37.4% to 60.4% across medical centers. After adjustment, modifiable factors associated with increased hospital admission from the ED included non-sinus rhythm at ED discharge, no attempted cardioversion, and heart rate reduction. Within an integrated health system, we found significant variation in AFF hospitalization rates and identified several modifiable factors associated with hospital admission. Standardizing treatment goals that specifically address best practices for ED rate reduction and rhythm control may reduce hospitalizations.

Abstract 15165: Routine Ambulatory Heart Rhythm Monitoring in Patients With Transthyretin Cardiac Amyloidosis

Introduction: Atrial fibrillation and flutter (AF/AFL) are common with transthyretin cardiac amyloidosis (ATTR-CM). These patients have higher risk for thromboembolism. Detection of AF/AFL may thus be especially important, but the role of routine ambulatory monitoring in asymptomatic patients is unclear. Methods: A single center observational study of patients seen at our Amyloidosis Center with wild-type or hereditary ATTR-CM diagnosed between 2005-2019. Records were reviewed to see if AF/AFL was present at baseline. In those without known AF/AFL, ambulatory monitor (duration 2-30 days) was done every 6 months when feasible as part of our routine practice. Patients with cardiovascular implantable electronic devices (CIED) instead had routine device interrogations. Results: Ninety-four patients with ATTR-CM (mean age 71.4±11.4 years, 88.3% male) had mean follow-up 2.2±1.9 years (200 patient-years). AF/AFL was seen in 62 patients (66.0%): 35 (56.5%) by symptoms, 18 (29.0%) incidentally by monitor or CIED, and 9 in whom method of AF/AFL diagnosis was unknown. Forty-one patients (66.1%) had AF/AFL before ATTR-CM diagnosis by of median 26.3 (IQR 4.3-40.9) months. New AF/AFL was diagnosed in 21/53 remaining patients with known ATTR-CM - 11 (52.4%) were incidentally diagnosed (Figure 1). Median time between ATTR-CM and AF/AFL diagnoses was 10.3 (IQR 7.0-25.8) months and 5.9 (IQR 2.2-22.3) months in symptomatic versus incidentally diagnosed patients (Mann-Whitney U=35, p=0.14). Anticoagulation (AC) was started in 9/11 (81.8%) due to incidental AF/AFL. One patient had AC for prior DVT; the other had no AC per patient preference. No strokes occurred in patients on AC. Conclusions: We found a high rate of incidentally diagnosed AF/AFL in patients with ATTR-CM. Detection of AF/AFL led to change in therapy. This finding affirms a need for routine ambulatory monitoring in asymptomatic patients with ATTR-CM. Optimal duration of monitoring needs further investigation.

Screening for atrial fibrillation in subjects aged 65 using a long-term continuous ECG telemonitoring vest: the NOninvasive Monitoring for early detection of atrial fibrillation (NOMED-AF) study

Abstract Background Atrial fibrillation (AF) confers a high healthcare burden from stroke, heart failure, dementia and hospitalisation, and one challenge is. Early detection of this arrhythmia in the community, given that it is often asymptomatic. Aim To perform population screening for atrial fibrillation and flutter (AF/AFl) using a mobile long-term continuous ECG telemonitoring vest in a representative Polish and European population aged ≥65 years (age range 65–100 years). Methods The NOMED-AF study is a cross-sectional study based on a representative sample of adults aged ≥65 years (n=3014; mean age 77.5±7.9 years; 49.1% female). All study participants were equipped with a mobile long-term continuous ECG telemonitoring vest. National and European estimations were calculated on weighted data. Results In 680 subjects AF/AFl (including 279 with SAF; 9.3%) was confirmed. In the NOMED-AF population, the prevalence of AF/AFl was 22.6%, estimated to be 19.2% for Poland [1,251,100 (95% CI: 1,158,300–1,344,000) and 480,100 (95% CI: 426,60–533,700) subjects with AF/AFl and SAF, respectively] and 20.4% for Europe [20,300,000 (95% CI 18.8–21.9 M), including 8,000,000 (95% CI: 6.9–9.3 M) subjects with AF/AFl and SAF, respectively]. The prevalence of AF/AFl was 2.56-fold higher in men than in women and the incidence of silent AF (SAF) was 4.73-fold higher in men than in women. Although the risk of either AF/AFl or SAF increased with age, the odds ratio was significantly higher in women of a particular age group than in men of the corresponding age. Based on our survey, the total number of subjects with AF/AFl in Europe is estimated to be roughly 20.3 million (95% CI 18.8–21.9M), including 8.0 million (95% CI: 6.9–9.3M) subjects with silent AF/AFl (Figure). Conclusions Approximately 1 in 5 subjects aged ≥65 years suffers from AF/AFl. The risk for AF/AFl and SAF is higher in men than that in women, but when correlated to a particular age group, the risk increases significantly in women. Continuous ECG telemonitoring allows for more credible AF/AFl and SAF detection. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The research has received funding from the National Centre for Research and Development under grant agreement (STRATEGMED2/269343/18/NCBR/2016

Atrial Fibrillation and Ventricular Tachyarrhythmias: Advancements for Better Outcomes

Cardiac arrhythmias are associated with several cardiac diseases and are prevalent in people with or without structural and valvular abnormalities. Ventricular arrhythmias (VA) can be life threating and their onset require immediate medical attention. Similarly, atrial fibrillation and flutter lead to stroke, heart failure and even death. Optimal treatment of VA is variable and depends on the medical condition associated with the rhythm disorder (which includes reversible causes such as myocardial ischemia or pro-arrhythmic drugs). While an implanted cardioverter defibrillator is often indicated in secondary prevention of VA. This review highlights the newest advancements in these techniques and management of ventricular and atrial tachyarrhythmias, along with pharmacological therapy.

MP08: Using administrative data to explore emergency department management of patients presenting with acute atrial fibrillation/flutter: Is Shock-First a more effective strategy than Drug-Shock?

Introduction: Atrial fibrillation and flutter (AFF) are the most common arrhythmias managed in the emergency department (ED). Equipoise in cardioversion strategies for patients with recent onset AFF contributes to observed practice variation. Using administrative data, the objective of this study was to explore the pattern of practice and the comparative effectiveness (outcomes and costs) between Shock-First and Drug-Shock approaches in AFF. Methods: Adult patients >17 years of age with AFF from one academic Canadian hospital ED were eligible. Using administrative data linkage among the National Ambulatory Care Record System, provincial practitioner claims data repository and a local hospital pharmacy database, patients who received treatment with procainamide and/or electrical cardioversion for AFF were identified. Outcomes including disposition, length of stay, revisit within 72 hours and 30-days, and ED costs were analyzed over a seven-year period. Categorical variables are reported as percentages. Continuous variables are reported as median and interquartile range (IQR). Univariate and multivariate logistic regression analyses were completed and reported as odds ratios (OR) and 95% confidence intervals (CI). Results: Overall, 5,372 patients were identified with AFF; the median age was 70 years and 55% were male. The majority of patients had chronic or secondary AFF; however, in 1687 (31%) cardioversion options were employed for presumed were recent onset AFF. A Shock-First strategy was most common (1379 {82%}); 308 (18%) received a Drug-Shock approach. Discharge time was 33 minutes (95% CI: 4–63) longer in the Drug-Shock approach compared to the Shock-First approach. Hospital admissions were higher (OR = 2.33; 95% CI: 1.68, 3.24) and revisits within 30-days were lower (OR = 0.74; 95% CI: 0.54, 0.95) in the Drug-Shock group. The Shock-First strategy demonstrated marginally higher costs (median = $106 CND; 95% CI: $68.89, $144.40) in adjusted analyses. Conclusion: In patients with acute AFF, when cardioversion was attempted, a Shock-First strategy was employed 80% of the time and resulted in shorter ED length of stay and lower hospitalization; however, higher costs and ED revisits within 30-days were observed. Many factors, including physician and/or patient preferences, influence ED decision-making in patients with AFF and understanding the factors influencing these decisions requires further attention.

ATRIAL ARRHYTHMIA COMMON AFTER LUNG TRANSPLANTATION AND REDUCED WITH BETA BLOCKER USE

Atrial fibrillation and flutter (AF/AFL) are common following lung transplant surgery although risk factors for AF/AFL development are controversial. We reevaluated risk factors and the effects of prophylactic beta blocker use on incident AF/AFL. We performed a single-center retrospective study of

POST-OPERATIVE ATRIAL FIBRILLATION AND FLUTTER AFTER LUNG TRANSPLANTATION IS ASSOCIATED WITH INCREASED HOSPITAL LENGTH OF STAY, ICU LENGTH OF STAY, AND RISK OF RE-INTUBATION

Post-operative atrial fibrillation and flutter (AF/AFL) are common following lung transplant surgery and may affect hospital and early clinical outcomes. We performed a single-center retrospective study of consecutive patients undergoing lung transplantation at a tertiary, academic medical center

96 Appropriate Stroke Prophylaxis Action After US Emergency Department Diagnosis and Discharge of Atrial Fibrillation and Flutter Patients

Oral anticoagulation (OAC) reduces stroke and mortality risk in patients with nonvalvular atrial fibrillation and flutter (AFF). The incidence of US emergency department (ED) OAC initiation is poorly understood, as are the appropriate actions following discharge. We examined stroke prophylaxis actions on, and shortly following, ED discharge of stroke-prone AFF patients in a large integrated health care delivery system. We included all adults with a primary diagnosis of nonvalvular AFF, high stroke risk (CHA2DS2-VASc ≥2), and no recent (<90d) OAC at discharge from 21 EDs in Kaiser Permanente Northern California between 2010-2017. Rates of appropriate stroke prevention action were calculated for all eligible discharges per calendar year. Actions were defined as either (1) an OAC prescription by an ED or follow-up provider, (2) a referral to a pharmacy-led anticoagulation management service (AMS), or (3) receipt of both an OAC prescription and AMS referral, within 10 days of ED discharge. We estimated appropriate OAC action (yes/no) with a mixed logistic model with sex, age, race, Hispanic ethnicity, stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) risk and year as a fixed effect, and accounting for clustering by patient. Among 10,281 eligible ED discharges, mean age was 73.7 (STD 11.4) years, 61% were female, and mean CHA2DS2-VASc score was 3.7 (STD 1.62). From 2010 to 2017, there was steady increase in patients receiving both an OAC prescription and referral to AMS, 16.0 to 27.9% (Figure). The rate of no intervention decreased from 82.4 to 65.0% of eligible patients. Factors inversely associated with stroke prevention action within 10 days of ED discharge include female sex (aOR 0.79, 95% CI 0.71-0.88), age >74 years (0.59, 0.45-0.76) vs <64yo, high bleeding risk by HAS-BLED score (0.70, 0.58-0.85) vs low risk respectively, and highest stroke risk (CHA2DS2-VASc score 6-9) (0.70, 0.60-0.84) vs lower risk (CHA2DS2-VASc scores 2-4). The odds of receiving any action was 2.6 times higher in 2017 compared to 2010 (aOR 2.60, 2.08-3.24). Within a community-based ED population of AFF patients at high-stroke risk, the rate of appropriate stroke prevention action increased over the 7-year study period. However, there remains an opportunity to improve AFF thromboprophylaxis as more than half of the eligible patients in 2017 were not receiving appropriate stroke prevention action within 10 days of their index visit. Additionally, female sex and those greater than 74yo were less likely to receive appropriate action compared to men and those younger than 65yo. The undertreatment of those greater than 74yo suggests a misunderstanding of the net clinical benefit associated with OAC in the elderly. Furthermore, opportunities to address sex disparities exist as we seek to improve stroke prophylaxis in nonvalvular AF patients discharged from the ED.

Prognostic impact of atrial fibrillation and flutter temporal pattern on anticoagulation and return visits to the emergency department: A historic cohort of 1112 patients

BackgroundEmergency department (ED) visits due to atrial fibrillation and flutter (AFF) are common, and provide an opportunity to define stroke risk. The prognostic impact of AFF duration on return ED visits is unknown. We aimed to investigate both the prognostic impact of AFF classification on ED visits and the adherence to guideline recommendations on anticoagulation. MethodsThis single-center historic cohort of every patient treated for AFF in our ED during 2012. Follow-up data was obtained on May 2015 (median follow-up of 863 days). ResultsAmong 1112 patients (495 Paroxysmal AF - parAF, 475 Persistent AF – persAF, and 142 flutter), those with parAF were less frequently under oral anticoagulation than persAF and flutter patients (15.8%, 39.4%, 40.1%, p < 0.01). Mean CHA2DS2-VASc scores of parAF were lower than persAF (2.2 vs. 3.12, p < 0.01), and did not differ from those with flutter. Return visits to the ED were highest among flutter patients and lowest among parAF (49.3% vs. 37.2%, p < 0.01). Heart failure, hypertension, female gender and atrial flutter were independent risk factors for repeated visits on multivariate regression. ConclusionsAFF duration provide prognostic information in the ED. ED return visits were common and particularly incident among flutter patients. Furthermore, stroke risk was high and anticoagulation rates were low across all groups. Patients with paroxysmal AF were less commonly anticoagulated even though their mean CHA2DS2-VASc scores were 2.2. These results reveal that guideline adherence is still lacking and should raise awareness to a stricter patient follow-up after ED visits.

INFLUENCE OF SEX, ETHNICITY, AND HOSPITAL CHARACTERISTICS ON OUTCOMES IN PATIENTS WITH ATRIAL FIBRILLATION: A REPORT FROM THE NATIONAL INPATIENT SAMPLE

Outcomes data related to sex, ethnicity, and hospital characteristics remains scarce in patients admitted with atrial fibrillation and flutter (AF/FL). We queried the National Inpatient Sample database from Jan 2010 to Sept 2015 for patients with a primary discharge diagnosis of AF/FL using

Levels of and Changes in Childhood Body Mass Index in Relation to Risk of Atrial Fibrillation and Atrial Flutter in Adulthood.

Children with obesity have a cardiometabolic risk profile that may predispose them to cardiovascular diseases. We examined the associations of childhood body mass index (BMI) and changes in BMI with the risk of atrial fibrillation and flutter (AFF) in adulthood. We conducted a population-based cohort study of Danish schoolchildren aged 7-13 years born from 1930 to 1989. Among 314,140 children, 17,594 were diagnosed with AFF as adults (1977-2014). In both men and women, above-average BMIs in childhood were associated with increased risks of AFF. Children who were persistently heavy at ages 7 and 13 years and children whose BMIs increased from the internal 25.0th-75.0th percentiles or from the internal 75.1th-90.0th percentiles between ages 7 and 13 years had higher risks of AFF in adulthood than children whose BMIs remained in the internal 25.0th-75.0th percentiles at both ages. A decrease in BMI percentile categories between 7 and 13 years of age reduced risks of AFF in adulthood, with risks of AFF reverting to levels similar to those in the reference group for women but not for men. In conclusion, risks of AFF in adulthood increased with higher childhood BMIs. Remission from overweight by age 13 years reduced AFF risks, especially in women.