Atrial Fibrillation Symptom Severity Research Articles

Invasive haemodynamic assessment shows the obesity-HFpEF phenotype is common amongst patients with symptomatic AF

Abstract Background The obesity-HFpEF phenotype is a unique form of heart failure associated with elevated LA and RA pressures, cardiac remodelling and poor exercise capacity. The influence of this HFpEF phenotype amongst patients with AF is unknown. Objective We sought to determine the influence of the obesity-HFpEF phenotype amongst patients with symptomatic AF, using invasive testing, imaging and cardiopulmonary exercise testing to assess haemodynamics, cardiac remodelling and exercise capacity in patients undergoing AF ablation. Methods Consecutive patients with symptomatic AF due to undergo an AF ablation procedure were recruited. Participants were grouped according to the presence of obesity if body mass index (BMI) exceeded 30kg/m2. Mean LA pressure (mLAP) and mean RA pressure (mRAP) were measured invasively at AF ablation and HFpEF was defined as mLAP>15mmHg at rest or after infusion of 500mls saline. Cardiac remodelling was assessed using transthoracic echocardiography. Exercise capacity was evaluated using cardiopulmonary exercise testing and AF symptoms and quality of life were assessed using the AF Symptom Severity Questionnaire. Results Of 120 participants, 44 (36.7%) were obese and 76 (63.3%) were non-obese (Table 1). Despite younger age (p=0.003), obese participants were more likely to have a coexistent diagnosis of HFpEF (84.1% vs 67.1%, p=0.043). In addition to higher mLAP (p<0.001), obesity was associated with higher mRAP (p<0.001) compared to non-obese patients. Obesity was not associated with differences in LV volume (p=0.559) or function (p=0.381) but was associated with larger LA volumes (p=0.032). On functional assessment, obese participants demonstrated a higher burden of AF symptoms (p=0.049), poorer quality of life (p=0.017) and a trend towards reduced exercise capacity (p=0.068). Conclusion Obese patients with AF demonstrate characteristic features of the obesity-HFpEF phenotype, including elevated LA and RA pressure, left atrial enlargement and poorer functional capacity. Novel treatments for the obesity-HFpEF phenotype, such as GLP-1 inhibitors, may be useful in obese patients with AF.

Outcomes of Atrial Fibrillation Ablation in Heart Failure Subtypes.

Catheter ablation (CA) improves clinical outcomes in patients with atrial fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF). We aimed to evaluate the impact of CA on clinical and quality-of-life outcomes across HF subtypes. All patients undergoing AF ablation at a tertiary center were enrolled in a prospective registry and included in this study (2013-2021). The primary end point was AF recurrence. Secondary end points included AF-related hospitalizations and quality-of-life outcomes. Patients were categorized according to their HF status: no HF, HFrEF, HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). A total of 7020 patients were included (80% no HF, 8% HFrEF, 7% HFmrEF, and 5% HFpEF). Over 3 years, the cumulative incidence of AF recurrence after ablation was as follows: HFpEF (53%), HFmrEF (41%), HFrEF (41%), and no HF (34%); P<0.01. Multivariable Cox analyses confirmed these findings using no HF group as reference (HFpEF: hazard ratio, 1.47 [95% CI, 1.21-1.78]; HFmrEF: hazard ratio, 1.23 [95% CI, 1.04-1.45]; and HFrEF: hazard ratio, 1.17 [95% CI, 1.01-1.37]; P<0.05 for all). In all groups, CA resulted in a significant reduction of AF-related hospitalization (mean rate per 1 patient-years [before and after CA]; HFpEF [1.8 versus 0.3], HFmrEF [1.1 versus 0.2], HFrEF [1.1 versus 0.2], and no HF [1 versus 0.1]; P<0.01 for each comparison) and significant improvement in quality of life as measured by both the AF symptom severity score and the AF burden score (P<0.01 for the comparison between baseline and follow-up for each score when tested separately). AF recurrence rates after CA were higher in patients with HF compared with those without HF, with patients with HFpEF being at the highest risk of recurrence. Nonetheless, CA was associated with a significant reduction in AF symptoms, AF-related hospitalization, and HF symptoms in most patients irrespective of HF subtypes.

WHAT SCALES SHOULD THE CARDIOLOGIST USE IN PATIENTS WITH ATRIAL FIBRILLATION? WHAT IS NEW?

The current treatment algorithm for patients with non-valvular atrial fibrillation (AF) includes anticoagulation to prevent stroke and systemic embolism, improvement of AF symptom control by heart rate reduction or restoration and maintenance of sinus rhythm, and treatment of cardiovascular and other comorbidities. The evaluation of patients with AF should be structured and include assessment of stroke risk, symptom severity, severity of the AF burden (type of arrhythmia, number and duration of episodes, etc.) and predisposing condition. The use of the CHA2DS2-VASc (risk of stroke), HAS-BLED (risk of bleeding), EHRA (severity of AF symptoms), and 2MACE (risk of cardiovascular outcomes) scales is important to help assess the likelihood of adverse outcomes and select the optimal treatment to protect not only against stroke but also against cardiovascular events. It should be noted that the HAS-BLED scale is primarily necessary for identification of bleeding risk factors, the modification of which allows to increase the safety of anticoagulant therapy, and a high index value according to this scale can’t serve as a reason to refuse anticoagulation in a patient with AF. New scales of stroke and hemorrhagic complications risk assessment in patients with AF on the basis of clinical parameters and laboratory biomarkers have been proposed, but their possible advantages over the existing indices need to be confirmed in special studies

Identification of Subclinical Heart Failure With Preserved Ejection Fraction in Patients With Symptomatic Atrial Fibrillation

BackgroundAtrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) commonly coexist. We hypothesize that patients with symptomatic AF but without overt clinical HF commonly exhibit subclinical HFpEF according to established hemodynamic criteria. ObjectivesThe authors sought to use invasive hemodynamics to investigate the prevalence and implications of subclinical HFpEF in AF ablation patients. MethodsConsecutive symptomatic AF ablation patients were prospectively recruited. Diagnosis of subclinical HFpEF was undertaken by invasive assessment of left atrial pressure (LAP). Participants had HFpEF if the baseline mean LAP was >15 mm Hg and early HFpEF if the mean LAP was >15 mm Hg after a 500-mL fluid challenge. LA compliance was assessed invasively by monitoring the LAP and LA diameter during direct LA infusion of 15 mL/kg normal saline. LA compliance was calculated as Δ LA diameter/ΔLAP. LA cardiomyopathy was further studied with exercise echocardiography and electrophysiology study. Functional impact was evaluated using cardiopulmonary exercise testing and the AF Symptom Severity questionnaire. ResultsOf 120 participants, 57 (47.5%) had HFpEF, 31 (25.8%) had early HFpEF, and 32 (26.7%) had no HFpEF. Both HFpEF and early HFpEF were associated with lower LA compliance compared with those without HFpEF (P < 0.001). Participants with HFpEF and early HFpEF also displayed decreased LA emptying fraction (P = 0.004), decreased LA voltage (P = 0.001), decreased VO2peak (P < 0.001), and increased AF symptom burden (P = 0.002) compared with those without HFpEF. ConclusionsSubclinical HFpEF is common in AF ablation patients and is characterized by a LA cardiomyopathy, decreased cardiopulmonary reserve and increased symptom burden. The diagnosis of HFpEF may identify patients with AF with the potential to benefit from novel HFpEF therapies. (Characterising Left Atrial Function and Compliance in Atrial Fibrillation; ACTRN12620000639921)

Impact of obesity on catheter ablation of atrial fibrillation: Patient characteristics, procedural complications, outcomes, and quality of life.

Obesity is a well-known risk factor for atrial fibrillation (AF). We aim to evaluate the effect of baseline obesity on procedural complications, AF recurrence, and symptoms following catheter ablation (CA). All consecutive patients undergoing AF ablation (2013-2021) at our center were enrolled in a prospective registry. The study included all consecutive patients with available data on body mass index (BMI). Primary endpoint was AF recurrence based on electrocardiographic documentation. Patients were categorized into five groups according to their baseline BMI. Patients survey at baseline and at follow-up were used to calculate AF symptom severity score (AFSS) as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous and 9 frequencies/durations in between). Patients were scheduled for follow-up visits with 12-lead electrocardiogram at 3, 6, and 12 months after ablation, and every 6 months thereafter. A total of 5841 patients were included (17% normal weight, 34% overweight, 27% Class I, 13% Class II, and 9% Class III obesity). Major procedural complications were low (1.5%) among all BMI subgroups. At 3 years AF recurrence was the highest in Class III obesity patients (48%) followed by Class II (43%), whereas Class I, normal, and overweight had similar results with lower recurrence (35%). In multivariable analyses, Class III obesity (BMI ≥ 40) was independently associated with increased risk for AF recurrence (hazard ratio,1.30; confidence interval, 1.06-1.60; p = .01), whereas other groups had similar risk in comparison to normal weight. Baseline AFSS was lowest in normal weight, and highest in Obesity-III, median (interquartile range) 10 (5-16) versus 15 (10-21). In all groups, CA resulted in a significantimprovement in their AFSS with a similar magnitude among the groups. At follow-up, AF burden was minimal and did not differ significantly between the groups. AF ablation is safe with a low complication rate across all BMI groups. Morbid obesity (BMI ≥ 40) was significantly associated with reduced AF ablation success. However, ablation resulted in improvement in QoL including reduction of the AFSS, and AF burden regardless of BMI.

Cardiac rehabilitation designed for obese patients with atrial fibrillation: OPTICARE XL results on burden, frequency and severity of Atrial Fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial Fibrillation (AF) is associated with substantial morbidity, mortality and low quality of life. Obesity is an important risk factor for AF and weight reduction is associated with a decrease in AF burden. Previous studies showed that conventional CR programs lead to insufficient weight reduction in obese patients. The OPTImal CArdiac REhabilitation XL (OPTICARE XL) study was an open label randomized controlled trial (RCT), evaluating effects of a CR program specifically designed for weight reduction in patients with obesity and non-valvular AF. Objective We hypothesize that this novel tailor-made CR program (OPTICARE XL) will lead to reduced AF burden, as compared to conventional CR. Design and setting: Multi-center RCT, conducted between February 2017 and January 2019 in 2 large Dutch CR centers. Patients were randomized to the OPTICARE XL CR intervention-program or a conventional CR-program. Methods The primary endpoint was AF symptom burden, assessed by the Atrial Fibrillation Severity Scale (AFSS). Secondary endpoints were AF symptom number, AF symptom frequency and AF symptom severity. Data were collected at baseline (prior to CR, T0), at the end of the intervention and conventional program (T1) and 1.5 year after inclusion (T2). Results Of 68 included patients, 28 were randomized to conventional CR and 40 to OPTICARE XL CR. Patients were predominantly male (60%), had a mean age of 62.4 ± 10.4 years and a mean BMI of 36.1 ± 4.4 kg/m2. With regards to AF burden, no significant within and between-group differences were observed between T0 and T1, T1 and T2, and T0 and T2 (OPTICARE XL: T0 14.6 ± 4.4, T1 14.1 ± 5.9, T2 14.3 ± 6.9; conventional CR: T0 16.4 ± 6.5, T1 15.3 ± 6.3, T2 15.9 ± 7.6; Figure 1). There was a significant difference (p=0.02) in the AF symptom number at T2 in favor of the intervention group (Figure 2). AF symptom frequency decreased in the intervention group from T0 to T2 (31.5 to 25.8; p=0.027) and in conventional CR from T0 to T1 (32.2 to 28.2; p=0.010). However, for both AF symptom frequency and symptom severity, no significant between-group differences were observed. Conclusion Compared to conventional CR, OPTICARE XL CR did not result in a reduced AF burden. However, it did reduce the AF symptom number at long-term follow-up. Novel CR programs such as OPTICARE XL may have added value in the treatment of obese patients with AF.

Number of comorbidities is associated with symptom severity and arrhythmia progression in paroxysmal atrial fibrillation - Data from the RACE V study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): We acknowledge the support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF (RACE V). Unrestricted grant support from Medtronic Trading NL B.V. Background Atrial fibrillation (AF) progression is associated with morbidity and mortality. Both comorbidities and symptom severity are pillars in the ABC treatment pathway as proposed by the ESC guidelines. Interaction between comorbidities, symptom severity and AF progression seems evident, but evidence is lacking. Aims The aim of the present study is to investigate whether the number of comorbidities is related with severity of AF symptoms, and whether AF symptom severity is associated with AF progression in patients with paroxysmal AF. Methods Patients Underwent extensive phenotyping at baseline and received continuous rhythm monitoring with an implantable loop recorder during follow-up. We studied the relation between comorbidities, AF symptom severity [quantified with the Toronto AF Severity Scale (AFSS)], and AF progression in patients with paroxysmal AF included in the RACE V study. Multivariate regression analysis was performed to study the association between comorbidities and AFSS tertiles, and the association between AF progression and AFSS tertiles. Results Of 417 paroxysmal AF patients, AFSS questionnaires at baseline were available in 403 patients (97%). Mean age was 65 (IQR 58-71) years, 174 (43%) were women. 132 patients (33%) reported a low score [score 0–2; lowest tertile (T1)], 129 patients (32%) reported a moderate score [score 3–7; middle tertile (T2)], and 142 (35%) reported a high score [score 8–35; highest tertile (T3)]. Patients with the most severe symptoms were older, more often women, more often had coronary artery disease, kidney dysfunction, and a higher body mass index (BMI). The number of comorbidities [defined as hypertension, heart failure, age &amp;gt;65 years, diabetes mellitus; coronary artery disease, BMI &amp;gt;25kg/m2, moderate or severe mitral valve regurgitation and kidney dysfunction (estimated glomerular rate (eGFR) &amp;lt;60)] was a significant determinant of higher AFSS scores [2 (1-3) in T1, 2 (2-3) in T2, 3 (2-4) in T3, respectively P &amp;lt;0.001], with a coefficient of 1.417 (P &amp;lt;0.001) for each extra comorbidity. AF progression occurred most frequently in T3 of the AFSS [10 (7%) in T1, 19 (15%) in T2, 21 (15%) in T3, respectively, P = 0.01]. After adjusting the AFSS tertile for age, coronary artery disease, BMI and eGFR there was no significant association for AFSS with AF progression, AFSS T2 versus T1 OR 2.19 (CI 0.92 - 5.63, P = 0.087), and AFSS T3 versus T1 OR 2.23 (CI 0.92 - 5.84, P = 0.085). AF progression occurred in 14% of AF patients with multimorbidity, defined as ≥2 comorbidities, in comparison to 5% in the AF patients with ≤1 comorbidity (P = 0.023) Conclusions In paroxysmal AF, multimorbidity was associated with symptom severity and AF progression. However, symptom severity was not associated with AF progression.

PO-02-194 CHANGES IN ANXIETY AND DEPRESSION IN ATRIAL FIBRILLATION PATIENTS AFTER RECEIVING MULTIDISCIPLINARY CARE AT AN ATRIAL FIBRILLATION CENTER OF EXCELLENCE

Anxiety and depression are known to occur in over one third of patients with atrial fibrillation (AF) and may negatively affect quality of life (QoL) and AF symptom severity. Though highly prevalent, the relationship between anxiety and depression with AF care remains poorly defined. The goal of an Atrial Fibrillation Center of Excellence (AFCoE) is to improve outcomes by delivering team-based multidisciplinary care to streamline risk factor modification while incorporating performance -measures and ongoing quality improvement to facilitate data-driven delivery of high-quality, guideline directed care. In the pilot phase of the AFCoE at the Inova Heart and Vascular Institute, an AF care coordinator and specialists from electrophysiology and sleep medicine were included based on patient need. To investigate changes in mental health status following multidisciplinary AF care received in an AFCoE in patients with AF. 138 patients were referred to the Inova AFCoE pilot between 10/2021 and 4/2022. Demographic and clinical comorbidities were ascertained. The frequency and severity of anxiety and depression were measured in a subset of participants (n=41) using the General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) tools administered at baseline and again between 3 to 6 months after their initial AFCoE visit. Baseline and follow-up summed GAD-7 and PHQ-9 scores were compared using the Wilcoxon test. Additional analyses were performed among patients with clinically significant baseline anxiety (GAD-7 score ≥5 points) or depression (PHQ-9 score ≥5 points). A total of 12/41 (29%) patients had clinically significant depression or anxiety (scores ≥5 points) at baseline. Among patients with clinically significant depression or anxiety at baseline, the median [interquartile range] summed score improved at follow-up from 13[11–15] to 6[1–9] points (p=0.005, score reduction 8[2–14] points). Nearly one third of patients referred to the Inova AFCoE pilot phase had clinically significant anxiety and/or depression at baseline. Multidisciplinary AF treatment without specific behavioral health intervention was associated with clinically significant improvements in anxiety and depression.

AB-452643-1 CATHETER ABLATION FOR ATRIAL FIBRILLATION IN PATIENTS WITH HEART FAILURE WITH PRESERVED OR MILDLY REDUCED EJECTION FRACTION

Evidence from randomized controlled trials is building for benefit of catheter atrial fibrillation (AF) ablation among heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF), whereas data are still limited in HF patients with preserved or mildly reduced LVEF (HFpEF). To examine longitudinal variations in quality of life (QoL) and AF burden following AF ablation in HFpEF patients from a large patient-reported outcomes (PRO) database. All patients with HFpEF undergoing AF ablation (2013-2018) at Cleveland Clinic were included. HFpEF was defined as LVEF≥40% with clinical HF and/or HF admissions. Automated PRO surveys at baseline and 1-year post ablation were used to assess outcomes. QoL was measured via the AF symptom severity scale (AFSSS). AF burden was estimated using AF frequency and AF duration scores (Scale 0-9 for both). We enrolled a total of 813 consecutive patients, of which 609 (75%) were male and 562 (69%) had persistent AF. Mean±SD age, LVEF, and CHA2DS2VASc were 66±9y, 49.6±6.9%, and 3.3±1.6, respectively. Major periprocedural complications occurred in less than 2% of cases, with pericardial effusion being the most common (n=5, 0.6%). Freedom from AF recurrence at 1-year follow-up was 68%. After catheter AF ablation, patients either became asymptomatic or experienced an improvement of ≥1 AF-related symptoms in 81% of cases on average. Notably, the majority of patients experienced remarkable improvement in hallmark HFpEF symptoms, including fatigue, resting/exertional dyspnea and exercise intolerance. QoL was significantly improved from a baseline mean AFSSS of 12.8±9 to 6±6.5 at 1-year (p≤0.0001). AF burden was significantly decreased at 1-year, including frequency and duration of episodes (from a median of 9 to 0, p≤0.0001 for both). Catheter AF ablation was associated with a substantial improvement of QoL, AF burden, and pathognomonic HF symptoms in HF patients with preserved or mildly reduced EF.

An Exercise and Physical Activity Program in Patients With Atrial Fibrillation: The ACTIVE-AF Randomized Controlled Trial

BackgroundThere are limited data on the effect of exercise interventions on atrial fibrillation (AF) recurrence and symptoms. ObjectivesThe aim of this study was to determine the efficacy of an exercise and physical activity intervention on AF burden and symptoms among patients with symptomatic AF. MethodsThis prospective, randomized controlled trial included 120 patients with paroxysmal or persistent, symptomatic AF, randomized 1:1 to receive an exercise intervention, combining home and supervised aerobic exercise over 6 months, or to receive usual care. The coprimary outcomes were: 1) AF recurrence, off antiarrhythmic medications and without catheter ablation; and 2) symptom severity assessed by using a validated questionnaire. ResultsBy 12 months, freedom from AF was achieved in 24 (40%) of 60 patients in the exercise group and 12 (20%) of 60 patients in the control group (HR: 0.50: 95% CI: 0.33 to 0.78). At 6 months, AF symptom severity was lower in the exercise group compared with the control group (mean difference –2.3; 95% CI: –4.3 to –0.2; P = 0.033). This difference persisted at 12 months (–2.3; 95% CI: –4.5 to –0.1; P = 0.041). Total symptom burden was lower at 6 months in the exercise group but not at 12 months. Peak oxygen consumption was increased in the exercise group at both 6 and 12 months. There were no between-group differences in cardiac structure or function, body mass index, or blood pressure. ConclusionsParticipation in an exercise-based intervention over 6 months reduced arrhythmia recurrence and improved symptom severity among patients with AF. (A Lifestyle-based, PhysiCal AcTIVity IntErvention for Patients With Symptomatic Atrial Fibrillation [the ACTIVE-AF Study]; ACTRN12615000734561)

Anxiety and Depressive Symptoms, Frailty and Quality of Life in Atrial Fibrillation.

Introduction: Symptoms of atrial fibrillation (AF) can significantly affect functioning in daily life and reduce patients’ quality of life (QoL). The severity and type of AF symptoms affects not only patient’s QoL, but can be a cause of the development of emotional and psychological disorders. In addition, frailty syndrome (FS) plays important role from the point of view of developing disability and dependence on others, as well as reducing QoL. Aim: To assess the symptoms of anxiety and depression, to evaluate the co-occurrence of frailty syndrome and the impact of these factors on the quality of life of patients with AF. Methods: The study used a Polish adaptation of the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia part III (ASTA part III), the Tilburg Frailty Indicator (TFI) and the Hospital Anxiety Depression Scale (HADS). Results: Analysis showed that anxiety symptoms and depressive symptoms correlate significantly (p < 0.05) and positively with the physical (r = 0.24; p < 0.001, r = 0.29, p = 0.002, respectively), psychological (r = 0.34, p < 0.001, r = 0.49 p < 0.001, respectively) and total quality of life (r = 0.31, p = 0.001, r = 0.414; p < 0.001, respectively) ASTA III domains. A significant (p < 0.05) positive correlation was observed between the TFI total score and the physical (r = 0.34, p < 0.001), psychological (r = 0.36, p < 0.001) and overall quality of life (r = 0.38, p < 0.001) in ASTA III domains. Conclusions: Both FS and depressive and anxiety symptoms significantly affect QoL. Understanding the relationship between anxiety and depressive symptoms, FS and QoL may allow for a more targeted approach to the treatment and care of patients with AF.

Abstract 14227: Development of a Tool To Improve Risk Stratification of Patients With Atrial Fibrillation in the Emergency Department

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.

Abstract 14845: Evaluation of Heart Failure With Preserved Ejection Fraction in Patients With Symptomatic Atrial Fibrillation by Invasive Assessment of Left Atrial Compliance

Background: Atrial fibrillation (AF) and HFpEF are both associated with left atrial (LA) cardiomyopathy. We hypothesise that HFpEF is common in patients with symptomatic AF due to the presence of LA cardiomyopathy involving reduced LA compliance (LAC). Methods: Consecutive patients with AF and preserved left ventricular (LV) function were prospectively recruited. Gold-standard diagnosis of HFpEF was undertaken by invasive assessment of LA pressure; participants had ‘AF-HFpEF’ if baseline mean LA pressure (mLAP) was &gt;15mmHg and ‘early AF-HFpEF’ if mLAP exceeded 15mmHg only after 500mls fluid challenge. LAC was assessed by monitoring atrial pressures and LA size during infusion of 15mL/kg normal saline over 8 minutes. Transmural LAC was calculated as ΔLA diameter/Δ(LA pressure - RA pressure). All participants were also studied with resting and exercise echocardiography, electrophysiology (EP) study, cardiopulmonary exercise testing and AF Symptom Severity questionnaires. Results: Of 105 participants, 49 (46.7%) had AF-HFpEF, 26 (24.8%) had early AF-HFpEF and 30 (28.6%) had no HFpEF. AF-HFpEF was associated with increased BMI (p=0.03) and higher prevalence of hypertension (p&lt;0.01). AF-HFpEF was associated with lower transmural LAC compared to those with no HFpEF (1.36±0.45 vs 3.32±0.46, p=0.01). As shown in the table, participants with AF-HFpEF also displayed reduced LA mechanical function at rest and during exercise, LA electrical remodelling, reduced cardiorespiratory fitness and increased AF symptom burden. Conclusions: HFpEF is common in patients with symptomatic AF and is associated with increased BMI and hypertension. AF-HFpEF is characterized by a global LA cardiomyopathy involving reduced LAC, reduced LA mechanical function and LA electrical remodelling. Diagnosis of HFpEF in patients with AF may identify those with increased symptom burden, reduced exercise capacity and increased risk of stroke. (Trial registration: ACTRN12620000639921)

Abstract 15414: Impact of Frequency and Duration of Atrial Fibrillation Events on Outcomes in Patients Undergoing Catheter Ablation

Introduction: Catheter ablation is a well-established treatment option for patients with atrial fibrillation (AF). We aimed to evaluate the impact of baseline AF events frequency, duration, and symptoms severity on AF recurrence Methods: The study included patients with first time AF ablation at a tertiary US center between 2013 and 2021. Patients prospectively completed a baseline and follow up survey (12 months) for patients reported outcomes assessing AF frequency, duration, and severity (AF symptom severity scale). The duration and frequency scores ranged between 0 and 9 (no AF to continuous). Patients were grouped into quartiles (Q1-Q4) based on their baseline scores. The quartile with the lowest score was used as the reference group. AF recurrence was assessed during follow up Results: A total of 2150 patients (age 65±9 yrs, 75% male, and 65% paroxysmal AF). At one year, only 17% of patients had AF recurrence. Frequency score: The risk for AF recurrence was similar between Q2/Q3 when compared with Q1 (Q2: HR=0.82, p=0.15, Q3: HR=0.98, p=0.91; Figure Upper), whereas patients in Q4 (score of 10) had a significant risk increase compared to Q1 (HR=1.28, p=0.047; Figure Left). Duration score: The risk for AF recurrence (Figure Middle) was similar between Q2 and Q1 (HR=0.97, p=0.83), was higher for Q3 (score ≥6 and &lt;9; HR=1.39, p=0.015), and highest for Q4 (score ≥9; HR=1.46, p=0.002). Severity score: The baseline severity score did not predict or correlate with AF recurrence during FU. Ablation resulted in a significant reduction (≥10%) in each score category. The highest benefit was seen among the Frequency category (96% of the patients had an improvement in their score at one year), followed by duration (90%) and severity (89%) Conclusions: Patients’ reported high frequency, and/or high duration were associated with increased risk for AF recurrence. Following ablation, improvement in all patients’ reported outcomes was significantly higher than reported AF free survivals

Benefit of atrial fibrillation ablation on symptoms and quality of life does not differ between patients with paroxysmal and persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Indications for atrial fibrillation (AF) ablation in current ESC and ACC/HRS guidelines are different for paroxysmal and persistent AF patients. Although previous research has established that the AF recurrence rate after AF ablation is lower in paroxysmal AF patients, there is little data on differences in post-ablation improvement of quality of life (QoL) and AF-related symptoms. Purpose This study aimed to determine whether QoL and symptom improvement differ between patients with paroxysmal and persistent AF after AF ablation. Methods From December 2017 to June 2020, patients undergoing first AF ablation at a medical center were included in a prospective registry. Circumferential pulmonary vein isolation (PVI) was performed using radiofrequency ablation with a contact force-sensing catheter. Patient reported outcomes were assessed at baseline, 4 months follow-up, and 1 year follow-up using the Toronto Atrial Fibrillation Severity Scale (AFSS). The AFSS was used to quantify global well-being (scale 1-10), patient-perceived AF burden (scale 3-30), and AF symptom severity (scale 0-35). AF symptom severity was based on 7 questions (scale 0-5) leading to a 0-35 scale. AF recurrence was defined as any documented episode of AF or atrial flutter after a blanking period of 3 months. Results The study population consisted of 306 AF patients (66% paroxysmal AF, 68% male, mean age 64±8 years). AF recurrence during 1 year follow-up occurred in 29% of paroxysmal AF patients and in 42% of persistent AF patients (p=0.021). At baseline, patient perceived AF burden was lower in paroxysmal AF patients than in persistent AF patients (18.4±3.7 vs. 20.2±5.0, p=0.001), whereas symptom severity (10.6±6.5 vs. 9.9±6.7, p=0.384) and global well-being (7.1±1.5 vs. 7.3±1.4, p=0.327) were similar. Paroxysmal AF patients reported more palpitations (2.4±1.3 vs. 1.6±1.5, p&amp;lt;0.001) and less shortness of breath during physical activity (1.9±1.6 vs. 2.3±1.7, p=0.048) than patients with persistent AF. Significant improvements in global well-being (0.5±1.7, p&amp;lt;0.001), symptom severity (3.8±7.2, p&amp;lt;0.001), and patient-perceived AF burden (7.2±7.5, p&amp;lt;0.001) were found in the entire study cohort between baseline and 1 year follow-up, without differences between paroxysmal and persistent patients (Figure). Conclusion Although persistent AF patients have a higher chance of recurrent AF after AF ablation, symptom severity and QoL improve equally in paroxysmal and persistent AF patients. These results suggest that different recommendations for AF ablation to improve symptoms in paroxysmal and persistent AF patients may not be justified.

Efficacy of Cryoballoon Ablation for Atrial Fibrillation and Recurrence Predictors in an Asian Cohort.

Background: Cryoballoon ablation (CBA) for atrial fibrillation (AF) is a rhythm control procedure used in clinical trials, mostly in Western countries. Its efficacy and the predictors of AF recurrence after CBA remain unclear for Asian populations. We aimed to investigate the efficacy of CBA and the predictors of AF recurrence after CBA in Asian AF patients. Methods: We included consecutive AF patients undergoing CBA for rhythm control between 2014 and 2020. The baseline characteristics, including AF types, symptom severity, and left atrial diameter (LAD), were analyzed. Holter’s monitoring and 12-lead ECG were performed to document AF recurrence. A multivariate Cox hazards regression model was used to evaluate the risk of AF recurrence. Results: A total of 120 AF patients (aged 61.9 ± 9.3 years) were included. The percentage of patients free from AF in the year following CBA was 74.2%. Among the three independent predictors of AF recurrence within one year were the presence of persistent AF (p = 0.025), an LAD ≥ 4.75 cm (p = 0.016), and pre-procedural cardioversion (p = 0.025). All patients survived and none had a stroke after CBA. Conclusion: CBA for AF is an effective and safe procedure in Asian populations. The presence of persistent AF, an LAD ≥ 4.75 cm, and severe symptoms are predictors of AF recurrence in the year following CBA.

Characteristics of patients presenting to emergency department for primary atrial fibrillation or flutter at an academic medical center

ObjectiveIn the United States, atrial fibrillation (AF) accounts for over 400,000 hospitalizations annually. Emergency Department (ED) physicians have few resources available to guide AF/AFL (atrial flutter) patient triage, and the majority of these patients are subsequently admitted. Our aim is to describe the characteristics and disposition of AF/AFL patients presenting to the University of North Carolina (UNC) ED with the goal of developing a protocol to prevent unnecessary hospitalizations. MethodsWe performed a retrospective electronic medical chart review of AF/AFL patients presenting to the UNC ED over a 15-month period from January 2015 to March 2016. Demographic and ED visit variables were collected. Additionally, patients were designated as either having primary or secondary AF/AFL where primary AF/AFL patients were those in whom AF/AFL was the primary reason for ED presentation. These primary AF/AFL patients were categorized by AF symptom severity score according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) Scale. ResultsA total of 935 patients presented to the ED during the study period with 202 (21.5%) having primary AF/AFL. Of the primary AF/AFL patients, 189 (93.6%) had mild-moderate symptom severity (CCS-SAF ≤ 3). The majority of primary AF/AFL patients were hemodynamically stable, with a mean (SD) SBP of 123.8 (21.3), DBP of 76.6 (14.1), and ventricular rate of 93 (21.9). Patients with secondary AF/AFL were older 76 (13.1), p < 0.001 with a longer mean length of stay 6.1 (7.7), p = 0.31. Despite their mild-moderate symptom severity and hemodynamic stability, nearly 2/3 of primary AF/AFL patients were admitted. ConclusionDeveloping a protocol to triage and discharge hemodynamically stable AF/AFL patients without severe AF/AFL symptoms to a dedicated AF/AFL clinic may help to conserve healthcare resources and potentially deliver more effective care.

The impact of the acceptance of illness on the quality of life of patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background. Atrial fibrillation (AF) is the most common supraventricular arrhythmia. AF and the complications associated with it interfere with the physical, mental and social well-being of a person, thus affecting the quality of life. An important factor affecting the quality of life of patients with AF is the acceptance of illness (AI). In spite of the large problem related to this subject, the analysis of the relation between the acceptance of illness and the quality of life of patients with AF is insufficient. The aim of the study was to assess the impact of the acceptance of illness on the quality of life of patients with AF. Material and methods. 84 patients (including 51 men) aged 57.86 ± 17.72 years hospitalized in the cardiology department due to heart rhythm disorders. Standardized tools were used in the study: Acceptance of Illness Scale (AIS) to assess the acceptance of illness and Arrhythmia-Specific questionnaire In Tachycardia and Arrhythmia (ASTA) to assess quality of life. Results. The majority of patients were secondary educated (64.27%), lived in a city (78.58%), were inactive (57.15%), were hospitalized 3-5 times (42.85%), had a cardiostimulator (23.80%) or underwent ablation (22.62%) during the last year. The average result of the acceptance of illness was 27.67 ± 7.70. 48.8% of patients had a high level of the acceptance of illness, 38.09% average, and 13.11% did not accept their illness. The mean result of quality of life for the whole studied group was (ASTA III) 25.64 ± 8.64. As regards the severity of symptoms (ASTA II) the mean result was 17.15 ± 5.89. Correlation analysis showed that the higher the level of the acceptance of illness the higher the quality of life (r = 0.640; p = 0.002) and lower the severity of AF symptoms (r=-0.51, p &amp;lt; 0.001). Conclusions. Patients with AF present a moderate level of disease acceptance and quality of life. The acceptance of illnessis the independent predictor and significantly increases quality of life of patients with AF.

Super and Nonresponders to Catheter Ablation for Atrial Fibrillation: A Quality-of-Life Assessment Using Patient Reported Outcomes.

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A SMART approach to reducing paroxysmal atrial fibrillation symptoms: Results from a pilot randomized controlled trial.

BackgroundStress and negative emotions contribute to atrial fibrillation (AF). Mind-body practices decrease stress and negative emotions and may reduce AF episodes and improve quality of life for patients with AF.ObjectiveWe examined the effects of a multimodal mind-body program, the SMART Program, on AF-related quality of life in patients with paroxysmal AF (PAF).MethodsIn this randomized, waitlist-controlled pilot trial, 18 subjects with PAF participated in an 8-week SMART Program delivered online immediately or 3 months later. Validated measures were completed at baseline and at 3 and 6 months (waitlist group only).ResultsComparing pre- vs post-program scores among all 18 participants, subjects reported improvement in AF-related quality of life (Cohen’s d = 0.75, P = .005) and depression (d = 0.50, P = .05) but not anxiety (d = 0.35, P = .16). Subjects also reported improvements in AF symptom severity (P = .026), distress (P = .014), positive affect (P = .003), and ability to cope with stress (P = .001). Compared to waitlist control subjects, those in the immediate group reported improvement in positive affect (d = 1.20, P = .021) and coping with stress (d = 1.36, P = .011) after participating in the program.ConclusionThe SMART Program, delivered virtually, may enhance positive emotions and coping with stress as well as decrease negative emotions and AF symptoms. These results warrant a larger trial to better understand the potential benefits of such programs for patients with PAF.