Atrial Fibrillation Flutter Research Articles

Atrial Fibrillation/Flutter Pathway Improves Care

Atrial fibrillation/flutter (AFF) increases risk for stroke and is an indication for anticoagulation in appropriate patients (as determined by the

Abstract 21273: Burden of Arrhythmias in Hypertrophic Obstructive Cardiomyopathy in United States From 2000 Through 2014: A National Population-Based Cohort Study

Background: Hypertrophic obstructive cardiomyopathy (HOCM) is the leading cause of sudden cardiac death (SCD) in young adults and ventricular arrhythmias are known to cause SCD in these high-risk patients. The risk of SCD increases with increasing age. This data is first of its kind to address the trends in the prevalence of arrhythmias in HOCM population. Methods: The study cohort was extracted from Nationwide inpatient sample (NIS) from 2000 to 2014. Appropriate international classification of diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes were used to diagnose HOCM (425.1 and 425.11) and arrhythmias (427.xx). P-values for trends were generated by Cochrane-Armitage test for categorical variables and simple linear regression for continuous variables. Results: We noted 49.13 % incidence of any arrhythmias in HOCM patients with a relative increase of 27.92% over study period (2000-2014). Atrial fibrillation was most prevalent arrhythmia in this patient population (33.39%).Highest increase in incidence over study period was observed in bundle branch blocks ( relative increase 189.64%), atrioventricular blocks ( relative increase 119.85%), premature atrial/ventricular complex ( relative increase 123.28%), atrial flutter ( relative increase 66.86%), ventricular tachycardia (relative increase 60.54%) and atrial fibrillation ( relative increase 24.31%). Conclusion: Patients with HOCM are at increased risk of arrhythmias. Even after improvement in the early diagnosis and treatment of these high-risk patients, the burden of arrhythmias i.e., AF, ventricular arrhythmias, premature arrhythmias and atrioventricular blocks has increased exponentially through 2000-2014. It was also accompanied by increase in-hospital mortality in HOCM population.

Risk profiles for acute health events after incident atrial fibrillation in patients with end-stage renal disease on hemodialysis.

Little is known about the cardiovascular risks of incident atrial fibrillation/flutter (AF) in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD). We studied older US patients who newly initiated HD for ESRD (2006-11) and who had not previously been diagnosed with AF, stroke, myocardial infarction (MI) or hip fracture. We used Cox regression with AF as a time-varying covariate, adjusted for socio-demographic characteristics and comorbidities to estimate hazard ratios [HRs (95% confidence intervals)] for the events of ischemic stroke, MI and death. Hip fracture served as a negative control outcome. We identified 85 377 older patients (mean age: 76.5 years) who initiated HD; of these, 14.3% were subsequently diagnosed with AF (14.9% thereof as primary diagnosis) and 49.8% died during follow-up. Incident AF was associated with nine times higher adjusted mortality during the first 30 days [9.2 (8.8-9.6)], 5-fold higher mortality between 31 and 90 days [4.6 (4.3-4.8)] and double the mortality beyond 90 days from first AF diagnosis [2.2 (2.1-2.3)]. Incident AF was similarly associated with higher adjusted risk of ischemic stroke: 2.1 (1.6-2.7) during the first 30 days, 2.5 (2.0-3.0) between 31 and 90 days and 1.5 (1.3-1.7) beyond 90 days. Similar findings were obtained for MI. However, the risk of hip fracture was only marginally increased following AF diagnosis [≤30 days: 1.1 (0.7-1.6); 31-90 days: 1.4 (1.0-1.8); >90 days: 1.2 (1.1-1.4)]. All associations were attenuated and the association with hip fracture was null when incident AF was defined by a primary diagnosis code. AF was strongly associated with increased risks of ischemic stroke, MI and death, with risks highest soon after AF diagnosis but extending beyond 90 days.

Lamin A/C cardiomyopathy: young onset, high penetrance, and frequent need for heart transplantation.

AimsLamin A/C (LMNA) mutations cause familial dilated cardiomyopathy (DCM) with frequent conduction blocks and arrhythmias. We explored the prevalence, cardiac penetrance, and expressivity of LMNA mutations among familial DCM in Norway. Furthermore, we explored the risk factors and the outcomes in LMNA patients.Methods and resultsDuring 2003–15, genetic testing was performed in patients referred for familial DCM. LMNA genotype-positive subjects were examined by electrocardiography, Holter monitoring, cardiac magnetic resonance imaging, and echocardiography. A positive cardiac phenotype was defined as the presence of atrioventricular (AV) block, atrial fibrillation/flutter (AF), ventricular tachycardia (VT), and/or echocardiographic DCM. Heart transplantation was recorded and compared with non-ischaemic DCM of other origin. Of 561 unrelated familial DCM probands, 35 (6.2%) had an LMNA mutation. Family screening diagnosed an additional 93 LMNA genotype-positive family members. We clinically followed up 79 LMNA genotype-positive [age 42 ± 16 years, ejection fraction (EF) 45 ± 13%], including 44 (56%) with VT. Asymptomatic LMNA genotype-positive family members (age 31 ± 15 years) had a 9% annual incidence of a newly documented cardiac phenotype and 61% (19/31) of cardiac penetrance during 4.4 ± 2.9 years of follow-up. Ten (32%) had AV block, 7 (23%) AF, and 12 (39%) non-sustained VT. Heart transplantation was performed in 15 of 79 (19%) LMNA patients during 7.8 ± 6.3 years of follow-up.ConclusionLMNA mutation prevalence was 6.2% of familial DCM in Norway. Cardiac penetrance was high in young asymptomatic LMNA genotype-positive family members with frequent AV block and VT, highlighting the importance of early family screening and cardiological follow-up. Nearly 20% of the LMNA patients required heart transplantation.

A meta-analysis of continuous positive airway pressure therapy in prevention of cardiovascular events in patients with obstructive sleep apnoea.

To assess whether continuous positive airway pressure (CPAP) therapy reduces major adverse cardiovascular events (MACE) in patients with moderate-to-severe obstructive sleep apnoea (OSA). A total of 235 articles were recovered using MEDLINE, EMBASE and Cochrane library (inception-December 2016) and references contained in the identified articles. Seven randomized controlled trials (RCTs) were selected for final analysis. Analysis of 4268 patients demonstrated non-significant 26% relative risk reduction in MACE with CPAP [risk ratio (RR) 0.74; 95% confidence interval (CI) 0.47-1.17; P = 0.19, I2 = 48%]. A series of sensitivity analyses suggested that increased CPAP usage time yielded significant risk reduction in MACE. and stroke. Subgroup analysis revealed that CPAP adherence time ≥4 hours (h)/night reduced the risk of MACE by 57% (RR 0.43; 95% CI 0.23-0.80; P = 0.01, I2 = 0%). CPAP therapy showed no beneficial effect on myocardial infarction (MI), all-cause mortality, atrial fibrillation/flutter (AF), or heart failure (HF) (P > 0.05). CPAP had positive effect on mood and reduced the daytime sleepiness [Epworth Sleepiness Scale (ESS): mean difference (MD) -2.50, 95% CI - 3.62, -1.39; P < 0.001, I2 = 81%]. CPAP therapy might reduce MACE and stroke among subjects with CPAP time exceeding 4 h/night. Additional randomized trials mandating adequate CPAP time adherence are required to confirm this impression.

Increased risk of heart failure and atrial fibrillation in heterozygous familial hypercholesterolemia

Background and aimsHeart failure (HF) and atrial fibrillation/flutter (AF) are important causes of morbidity and mortality. Subjects with familial hypercholesterolemia (FH) carry a high risk of coronary artery disease (CAD) but it is not known if the risk of HF and AF is increased in FH. The present study investigated the incidence of hospitalization for HF and AF in a genetically verified FH cohort, age 25 years and older, compared to the general population. MethodsIncidence rates of hospitalization for HF and AF were estimated from national registry data. Standardized incidence ratios (SIRs) were calculated. Results4273 genotyped FH patients (51.7% women) with a total observation period of 18,300 patient years were studied. Overall, the expected number of FH patients with HF was 27.7 and the observed number of cases was 54 (SIR (95% CI) 2.0 (1.5–2.6)). The highest excess risk was observed in the age group 25–49 years, where SIRs were 3.8 (1.2–11.8) and 4.2 (2.0–8.8) in women and men, respectively. The total expected number of FH patients with AF was 39.4 while the observed number of cases was 77 (SIR 2.0 (1.6–2.4)). Among FH patients with an incident event of HF, nearly 90% had a previous diagnosis of CAD, and nearly 40% had suffered from a myocardial infarction. ConclusionsWe demonstrate a doubling of the risk of hospitalization for HF or AF in patients with FH. This is could have an important prognostic impact for patients and economic impact for the society.

Wolff-Parkinson-White Syndrome with Ventricular Hypertrophy in a Brazilian Family.

Case seriesPatient: —Final Diagnosis: PRKAG2 syndromeSymptoms: Palpitation • dyspnea and fatigue • syncopeMedication: —Clinical Procedure: Radiofrequency catheter ablation • pacemaker implantion • antiarrhythmic drugsSpecialty: CardiologyObjective:Rare diseaseBackground:PRKAG2 syndrome diagnosis is already well-defined as Wolff-Parkinson-White syndrome (WPW), ventricular hypertrophy (VH) due to glycogen accumulation, and conduction system disease (CSD). Because of its rarity, there is a lack of literature focused on the treatment. The present study aimed to describe appropriate strategies for the treatment of affected family members with PRKAG2 syndrome with a long follow-up period.Case Report:We studied 60 selected individuals from 84 family members (32 males, 53.3%) (mean age 27±16 years). Patients with WPW and/or VH were placed in a group of 18 individuals, in which 11 (61.1%) had VH and WPW, 6 (33.3%) had isolated WPW, and 1 (5.6%) had isolated VH. Palpitations occurred in 16 patients (88.9%), chest pain in 11 (61.1%), dizziness in 13 (72.2%), syncope in 15 (83.3%), and dyspnea in 13 (72%). Sudden cardiac death (SCD) occurred in 2 (11.1%), and 2 patients with cardiac arrest (CA) had asystole and pre-excited atrial flutter-fibrillation (AFL and AF) as the documented mechanism. Transient ischemic attack (TIA) and learning/language disabilities with delayed development were observed. Genetic analysis identified a new missense pathogenic variant (p.K290I) in the PRKAG2 gene. Cardiac histopathology demonstrated the predominance of vacuoles containing glycogen derivative and fibrosis. The treatment was based on hypertension and diabetes mellitus (DM) control, antiarrhythmic drugs (AD), anticoagulation, and radiofrequency catheter ablation (RCA). Six patients (33.3%) underwent pacemaker implantation (PM).Conclusions:The present study describes the clinical treatment for a rare cardiac syndrome caused by a PRKAG2 mutation.

COMPARISON RESULTS OF THE INTRACARDIAC ELECTROPHYSIOLOGICAL STUDY IN PATIENTS WITH TYPICAL ATRIAL FLUTTER AND FIBRILLATION

Aim. Comparison study of the parameters of intracardiac electrophysiological study (EPS) in patients with the typical atrial flutter (TAF) and atrial fibrillation (AF), of the courses as isolated types of arrhythmia. Material and methods. Totally, 82 patients included (59 (72%) males, mean age 55±10 y.o.), directed for catheter ablation procedure for TAF or AF. Depending on the anamnesis of arrhythmia, patients were selected to 4 groups: 1 — isolated TAF (n=26, 32%), 2 — AF with “spontaneous” TAF (n=27, 33%), 3 — AF and TAF, when the latter had been registered only under treatment by antiarrhythmics of IC and III classes (n=14, 17%), 4 — isolated AF (n=15, 18%). All patients underwent EPS within sinus rhythm and no antiarrhythmic therapy. During EPS the following parameters were defined: P-wave duration, time of interand intra-atrial conduction, effective refractory periods (ERP) in various areas of the atria. By the results of EPS, comparative statistical study performed of the listed parameters in the groups. Results. Patients with TAF (groups 1, 2, 3), in difference with isolated AF (group 4) had significantly longer P-wave and inter-atrial conduction time. Analysis of ERP showed similar heterogeneity of the parameters in different areas of the atria in all studied groups: the lowest ERP is found in the lateral area of the right atrium, the highest — in the distal area of coronary sinus. Intergroup differences by these parameters were non-significant. Conclusion . For TAF patients, as an isolated disorder or with AF, the characteristical is significant prolongation of the inter-atrial conduction time, that might expain tendency to tachiarrhythmias of re-entry genesis.

Abstract 13416: The Days of the Holter Monitor Are Numbered: Extended Continuous Rhythm Monitoring Detects More Clinically Significant Arrhythmias in Adults With Congenital Heart Disease

Introduction: Arrhythmias are a leading cause of death in adults with congenital heart disease (ACHD). Arrhythmia detection is essential to management and risk assessment in ACHD. While 24 to 48-hour Holter monitors are often used to assess arrhythmia burden, extended continuous rhythm monitors (ECRM) can record 2 weeks of data. We hypothesized that more clinically significant arrhythmias would be detected on ECRM beyond the first 48 hrs of monitoring. Methods: We reviewed ambulatory Zio® (iRhythm, San Francisco, CA) monitors performed in ACHD patients from June 2013 - May 2016. Atrial fibrillation/flutter (AF), ventricular tachycardia (VT), supraventricular tachycardia (SVT), sinus pause &gt;3 sec, and 3 rd or 2 nd degree type II atrioventricular block (AVB) were considered significant. Number and type of arrhythmias detected within the first 48 hrs were compared to those identified beyond 48 hrs. Results: A total of 387 monitors were performed in 306 patients (34 ± 12.5 yrs, 40% male). The most common diagnoses were Tetralogy of Fallot, transposition of the great arteries, and single ventricle after Fontan. Average wear time was 9.4 ± 4.2 d. Overall, 51% of ECRM showed a significant arrhythmia, fewer than half of which were noted during the first 48 hrs (25% overall). VT was detected by ECRM in 17%, only 30% of which were within 48 hrs. SVT was detected by ECRM in 40%, 48% of which were within 48 hrs. Kaplan-Meier estimates of freedom from arrhythmia are shown in the table and figure. Conclusion: ECRM was more likely to detect a significant arrhythmia beyond the standard 48-hour monitoring period in ACHD patients, suggesting that ECRM may be more useful than Holter monitoring in this population.

Influence of atrial fibrillation on post-discharge natriuretic peptide trajectory and clinical outcomes among patients hospitalized for heart failure: insights from the ASTRONAUT trial.

Change in NT-proBNP level is a common surrogate endpoint in early phase heart failure (HF) trials, but whether this endpoint is influenced by atrial fibrillation/flutter (AFF) is unclear. This analysis included 1358 patients from the ASTRONAUT trial, which randomized patients hospitalized for HF with EF ≤40% to aliskiren or placebo in addition to standard care. Patients were stratified by presence of AFF on baseline ECG. NT-proBNP was measured longitudinally by a core laboratory at baseline, 1 month, 6 months, and 12 months. Compared with non-AFF patients, AFF patients experienced greater reduction from baseline in log-transformed NT-proBNP (interaction P < 0.001), but this difference was not significant after adjustment (interaction P = 0.726). The ability of aliskiren to lower NT-proBNP during follow-up differed by AFF status (interaction P = 0.001), with aliskiren lowering NT-proBNP more than placebo among non-AFF patients only. After adjustment, baseline AFF was not associated with mortality or HF hospitalization at 12 months (all P ≥ 0.152). In this hospitalized HF cohort, AFF status did not influence post-discharge NT-proBNP trajectory or clinical outcomes after adjustment for patient characteristics. Aliskiren lowered follow-up NT-proBNP levels in patients without AFF, but had no influence among patients with AFF. This study generates the hypothesis that the ability of a HF trial to meet an NT-proBNP defined endpoint may be influenced by the prevalence of AFF in the population. Because aliskiren did not improve outcomes in patients without AFF, this analysis suggests changes in NT-proBNP induced by investigational therapies may be dissociated from clinical effects.

GW27-e0888 Comparation of the efficacy between pulmonary vein antral isolation plus high density left atrial voltage mapping and pulmonary vein isolation on paroxysmal atrial fibrillation

This study aims to discuss the efficacy between Pulmonary Vein Antral Isolation (PVAI) plus High Density Left Atrial Voltage Mapping (HDVM) and pulmonary vein isolation on Paroxysmal Atrial Fibrillation (PAF). A total of 60 patients with paroxysmal atrial fibrillation underwent radioablation in our department from January 2012 to January 2014; all cases were divided into two groups: 30 patients in group A (PVAI), 30 patients in group B (PVAI+HDVM). Atrial arrthymic data including atrial premature, atrial tachycardia, atrial flutter, and atrial fibrillation were collected by routine Electrocardiogram (ECG) and 24 h-Holter every month during 1-year post-operation follow-ups. Ablation recurrence was defined as any atrial arrthymic events (atrial tachycardia, atrial flutter, atrial fibrillation) persisting for more than 30 seconds by real-time ECG record and/or 24 h-Holter 3-month after ablation. 60 cases of PVAI were operated successfully. Low-Voltage Zones (LVZs) were located on right superior pulmonary vein outside antrum in 7 cases, right inferior pulmonary vein outside in 3 cases, left anterosuperior wall in 6 cases, left anteroinferior wall in 9 cases, roof in 3 cases, upperposterior wall in 2 cases. 1-year atrial fibrillation ablation success rate were at the same level (83.3% vs. 80.0%, P>0.05). No difference were found in 3-month atrial arrthymic recurrences between two groups statistically (43.1% vs. 40.7% at 1 st month, 20.7% vs. 21.3% at 2 nd month, 21.3% vs. 20.2% at 3 rd month, P>0.05). Combination of pulmonary vein isolation with high density left atrial voltage mapping cannot improve ablation success rate of paroxysmal atrial fibrillation and increase the recurrence of atrial arrthymias.

Early Detection of Subclinical Atrial Flutter-Fibrillation in Patients with Unexplained Palpitation Using a Novel VDD Defibrillator with Integrated Atrial-Sensing Rings

Early Detection of Subclinical Atrial Flutter-Fibrillation in Patients with Unexplained Palpitation Using a Novel VDD Defibrillator with Integrated Atrial-Sensing Rings

Longitudinal relationships of periodic limb movements during sleep and incident atrial fibrillation

ObjectivesThis study aimed to examine relationship between periodic limb movements during sleep (PLMS) and incident atrial fibrillation/flutter (AF). MethodsProspective multicenter cohort (n = 2273: adjudicated AF group; n = 843: self-reported AF group) of community-dwelling men without prevalent AF were followed for an average of 8.3 years (adjudicated) and 6.5 years (self-reported). PLMS index (PLMI, <5 (ref), ≥5 to <30, ≥30) and PLM arousal index (PLMAI, <1 (ref), ≥1 to <5, ≥5) were measured by polysomnography. Incident adjudicated and self-reported AF were analyzed by Cox proportional hazards and logistic regression, respectively, and adjusted for age, clinic, race, body mass index (BMI), alcohol use, cholesterol level, cardiac medications, pacemaker, apnea–hypopnea index, renal function, and cardiac risk. The interaction of age and PLMS was examined. ResultsIn this primarily Caucasian (89.8%) cohort of older men (mean age 76.1 ± 5.5 years) with BMI of 27.2 ± 3.7, there were 261 cases (11.5%) of adjudicated and 85 cases (10.1%) of self-reported incident AF. In the overall cohort, PLMI and PLMAI were not associated with adjudicated or self-reported AF. There was some evidence of an interaction of age and PLMI (p = 0.08, adjudicated AF) and PLMAI (p ≤ 0.06, both outcomes). Among men aged ≥76 years, the highest PLMI tertile was at increased risk of adjudicated AF (≥30 vs. <5; hazard ratio (HR) = 1.63, 1.01–2.63) and the middle PLMAI tertile predicted increased risk of both outcomes (1 to <5 vs. <1; adjudicated, HR = 1.65, 1.05–2.58; self-reported HR = 5.76, 1.76–18.84). No such associations were found in men aged <76 years. ConclusionsAlthough PLMS do not predict AF incidence in the overall cohort, the findings suggest PLMS increases incident AF risk in the older subgroup.

Role of electrocardiogram in predicting cardiac resynchronization therapy response

To explore the role of electrocardiogram(ECG)in predicting cardiac resynchronization therapy (CRT) response. This study retrospectively analyzed ECG of 92 CRT patients, who received CRT therapy from 2001 to 2013 in our center and were followed up for 6 months. The patients were divided into responder group (n=64) and non-responder group (n=28). The baseline and 6-month data including QRS width, heart rhythm and axis variation were analyzed. The definition of responder is left ventricular end systolic volume (LVESV) reduction ≥15% within 6 months after CRT. After CRT therapy, the ventricular activation was changed as left to right (frontal plane), posterior to anterior and axis changed in a clockwise direction. The change in more than two directions was defined as prominent axis change. Logistic analysis was performed to analyze the role of ECG in predicting CRT response. (1) Baseline parameter comparison between the two groups: the proportion of female and LBBB is significantly higher (P<0.01; P=0.04), while the proportion of atrial fibrillation/flutter (Af/AF) is significantly lower (P<0.01) in responder group than in non-responder group. The pre-CRT average QRS duration is much wider in responder group than in non-responder group (P=0.01). (2) Comparison of follow-up with baseline results in two groups: NYHA heart function level, 6 minutes walking distance, QRS duration, LVEF, LVESV improved significantly (P<0.01) post-CRT in responder group. In non-responder group, the QRS duration and LVESV deteriorated significantly (P=0.02, P<0.01), while post-CRT NYHA heart function level improved significantly. In responder group, pre-CRT ECG axis of 53 patients (82.8%) pointed to left and 58 patients (90.6%) pointed to posterior; post-CRT ECG axis of 49 patients (76.6%) pointed to right and 30 patients (40.6%) pointed to anterior. In non-responder group, pre-CRT ECG axis of 25 patients (89.3%) pointed to left and 24 patients (85.7%) pointed to posterior; post-CRT ECG axis of 17 patients (60.7%) pointed to right and 12 patients (42.9%) pointed to anterior. Post-CRT, the proportion of ECG axis prominent change was significantly higher in responder than in non-responder group (62.5%(40/64) vs. 32.1%(9/28), P=0.007). (3)Predicting value: pre-CRT QRS width ≥140 ms (OR=4.97, 95% CI 1.53 to 16.13, P=0.008)and post-CRT prominent axis change (OR=5.1, 95% CI 1.67 to 15.5, P=0.004)were found to be independent predictors of CRT responders. Af/AF pre-CRT was associated with reduced CRT response (OR=0.25, 95% CI 0.08 to 0.80, P=0.02). ECG may play a role in predicting CRT response. QRS width and Af/AF before CRT and ECG axis change post-CRT could be used to predict CRT response.

Relationship of Bisphosphonate Therapy and Atrial Fibrillation/Flutter: Outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study.

Prior studies suggested an association between bisphosphonates and atrial fibrillation/flutter (AF) in women. This relationship in men, including those with sleep-disordered breathing (SDB), remains unclear. This study evaluated the relationship between bisphosphonate use and prevalent (nocturnal) and incident (clinically relevant) AFin a population of community-dwelling older men. A total of 2,911 male participants (mean age, 76 years) of the prospective observational Osteoporotic Fractures in Men Study sleep cohort with overnight in-home polysomnography (PSG) constituted the analytic cohort. Nocturnal AF from ECGs during PSG and incident AF events were centrally adjudicated. The association of bisphosphonate use and AF was examined using multivariable-adjusted logistic regression for prevalent AF and Cox proportional hazards regression for incident AF. A total of 123 (4.2%) men were current bisphosphonate users. Prevalent nocturnal AF was present in 138 participants (4.6%). After multivariable adjustment, there was a significant association between current bisphosphonate use and prevalent AF (OR, 2.33; 95%CI, 1.13-4.79). In the subset of men with moderate to severe SDB, this association was even more pronounced (OR, 3.22; 95%CI, 1.29-8.03). However, the multivariable-adjusted relationship between bisphosphonate use and incident AF did not reach statistical significance (adjusted hazard ratio, 1.53; 95%CI, 0.96-2.45). These results support an association between bisphosphonate use and prevalent nocturnal AF in community-dwelling older men. The data further suggest that those with moderate to severe SDB may be a particularly vulnerable group susceptible to bisphosphonate-related AF. Similar associations were not seen for bisphosphonate use and clinically relevant incident AF.

MP022: Anticoagulation use in patients with atrial fibrillation/flutter in Canadian emergency departments since the introduction of the novel anticoagulants

Introduction: Despite strong evidence that antithrombotic drugs in atrial fibrillation/flutter (AF) patients reduce stroke risk, previous emergency department (ED) pre-novel anticoagulant (NOAC) studies have shown that most discharged patients are not optimally treated. This study sought to determine baseline antithrombotic management in AF patients, and appropriate antithrombotic prescription upon ED discharge since the introduction of NOACs. Methods: Consecutive AF patients discharged by the ED physician from three academic EDs in Toronto, Canada were retrospectively identified using ECG data. Primary AF was defined as AF in patients ≥18 years without congenital heart disease or other acute medical conditions. All management and disposition decisions were left to the discretion of the emergency doctor. Results: From July 2012 to October 2014, 691 patients with primary AF were identified. Of these, 34.4% (n=238) had new onset AF and 66.4% (n=459) were discharged home directly from the ED. Of those with previously known AF (n= 453), 44.2% (n=200) were on anticoagulation at ED arrival (warfarin 59.5%, dabigatran 23.0%, rivaroxaban 11.5%); 25.6% (n=116) on antiplatelets, and 29 (6.4%) on both. Based on 2012 Canadian AF guidelines, 60.1% of those who should have received anticoagulation were receiving it. In discharged patients meeting de novo criteria for anticoagulation (n=130), 20.0% (n=26) were started on anticoagulation and 23.1% (n=30) on antiplatelets. In patients with CHADS2 score ≥ 2 (n=61), 26.2% (n=16) were started on anticoagulation. Warfarin (73.1%) was most commonly prescribed followed by dabigatran (15.4%) and rivaroxaban (11.5%). Age was the only inverse independent predictor for appropriate anticoagulation (OR 0.92 per 5 year of age 95% CI 0.89-0.95, p &lt;0.0001) i.e. older patients were less likely to be anticoagulated. The CHADS2 score was not an independent predictor of appropriate anticoagulation. Conclusion: Our study shows a persistent gap in the antithrombotic treatment of ED AF patients irrespective of their risk.

LO004: Short-term risk of arrhythmias among syncope patients presenting with atrial fibrillation/flutter to Canadian emergency departments

Introduction: Short-term risk of arrhythmia or death among emergency department (ED) syncope patients with atrial fibrillation/flutter (AFF) has not been reported in the literature. Our objectives were to assess the incidence and the independent risk of 30-day arrhythmia or death for syncope patients with AFF after ED disposition. Methods: We conducted a prospective study at 6 Canadian academic EDs to include adults with syncope. We collected demographic, clinical and ECG characteristics while our outcome assessments were completed by medical records review and by telephone follow-up of patients after 30 days. Primary outcome was arrhythmia or death within 30-days after ED disposition and secondary outcomes included non-arrhythmic cardiac and non-cardiac outcomes. We performed descriptive and logistic regression analyses. Results: We enrolled 4,266 patients: mean age 53.4 years, 55.4% females, and 8.5% with AFF. After excluding those with outcomes in the ED, lost to follow-up and those with other non-sinus rhythms, 3,417 patients in the sinus and 280 patients in the AFF groups were analyzed. The incidence of arrhythmia or death was significantly higher in the AFF group (Relative Risk 5.1; 95% CI 3.1-8.4; p&lt;0.0001) but there were no significant differences in secondary outcomes between the groups. The unadjusted odds ratio for 30-days arrhythmia or deaths among ED syncope patients with AFF was 5.4 (95% CI 3.2- 9.2). After adjusting for important baseline risk factors by multivariable analysis, the odds ratio for arrhythmia or death in patients with AFF was 1.5 (95% CI 0.8-2.7). Conclusion: The risk of AFF for 30-day arrhythmia or death among syncope patients after ED disposition is higher but is attenuated when adjusted for important patient characteristics. Future research should assess long-term outcomes among syncope patients with AFF to guide follow-up after ED discharge.

Abstract 210: Association between Paroxysmal Supraventricular Tachycardia and Ischemic Stroke in Patients Without Atrial Fibrillation

Introduction: Paroxysmal supraventricular tachycardia (PSVT) is viewed as a benign heart-rhythm disorder. However, recent studies suggest that atrial dysrhythmias other than atrial fibrillation/flutter (AF) may signify an increased stroke risk. Hypothesis: PSVT is associated with subsequent ischemic stroke in patients without documented AF. Methods: We obtained inpatient and outpatient claims data from 2010-2011 in a 5% sample of Medicare beneficiaries ≥66 years of age. We included only patients with a pacemaker or defibrillator, since such patients often undergo interrogation of heart rhythm. Patients with AF or stroke before or at the time of device implantation were excluded. Our predictor variable was PSVT. The primary outcome was ischemic stroke and the secondary outcome was embolic stroke. All diagnoses were ascertained from ICD-9-CM codes using previously validated algorithms. We used Kaplan-Meier survival analysis and the log-rank test to compare outcomes in patients with and without PSVT, which was modeled as a time-varying covariate. Patients were censored at the time of incident AF, stroke, death, or on December 31, 2011. Cox proportional hazards analysis was used to assess the relationship between PSVT and stroke while adjusting for demographic characteristics and vascular risk factors. Results: Among 42,152 eligible patients with a median 1.8 years of follow-up, 2,245 (5.3%) had PSVT and 1,007 (2.4%) developed a stroke. The incidence of stroke after a PSVT diagnosis (2.17% per year; 95% confidence interval [CI], 1.45-3.24%) was significantly higher than in patients without PSVT (0.95% per year; 95% CI, 0.87-1.03%; P &lt; 0.001). After adjustment for demographic characteristics and vascular risk factors, PSVT was associated with a higher hazard of stroke (hazard ratio [HR], 2.0; 95% CI, 1.3-3.0). This association appeared stronger for embolic stroke (HR, 3.6; 95% CI, 1.1-11.8). Conclusions: In Medicare beneficiaries with implantable pacemakers or defibrillators, PSVT was associated with ischemic stroke, especially embolic stroke, in the absence of documented AF. These results build on recent findings that disturbances of atrial rhythm and function other than AF may be a previously unrecognized stroke risk factor.

The BTK Inhibitor, Bgb-3111, Is Safe, Tolerable, and Highly Active in Patients with Relapsed/ Refractory B-Cell Malignancies: Initial Report of a Phase 1 First-in-Human Trial

The BTK Inhibitor, Bgb-3111, Is Safe, Tolerable, and Highly Active in Patients with Relapsed/ Refractory B-Cell Malignancies: Initial Report of a Phase 1 First-in-Human Trial

Abstract 14223: Atrial Fibrillation, Clinical Outcomes, and Post-discharge Natriuretic Peptide Trajectory Among Patients Hospitalized for Heart Failure: Findings From the ASTRONAUT Trial

Introduction: Heart failure (HF) clinical trials have used change in NT-proBNP as a surrogate endpoint, but the influence of atrial fibrillation/ flutter (AFF) on this endpoint is unclear. We investigated the association of AFF with change in NT-proBNP and clinical outcomes following HF hospitalization. Methods: Characteristics and outcomes of 1,358 patients from the ASTRONAUT trial were compared by presence/ absence of AFF on baseline ECG. Patients with history of AFF but without AFF on ECG were excluded. Full factorial repeated measures design using AFF and study randomization was used to predict NT-proBNP changes from baseline to 1, 6, and 12 months. Survival analysis was used to examine the correlation between AFF and outcomes. Results: Patient characteristics and outcomes are displayed in the Table. Among placebo patients, AFF was associated with higher NT-proBNP level at all time points, but larger reductions from baseline levels (p for interaction &lt;0.01). These differences became non-significant after accounting for other clinical characteristics. The ability of aliskiren to lower NT-proBNP over time differed by AFF status (p for interaction &lt;0.01, Figure). After adjustment for patient characteristics, AFF was not associated with cardiovascular mortality/ HF hospitalization or all-cause death at 12 months (all p≥0.15). Conclusions: Absolute levels and change from baseline in NT-proBNP over time differ in HF patients with and without AFF. The ability of a study drug to lower NT-proBNP may depend on the AFF prevalence in the population. AFF was not independently associated with clinical outcomes in this cohort.