Concurrent Atrial Fibrillation Research Articles

Management of cerebral amyloid angiopathy and atrial fibrillation: We are still far from precision medicine

The use of anticoagulation therapy could prove to be controversial when trying to balance ischemic stroke and intracranial bleeding risks in patients with concurrent cerebral amyloid angiopathy (CAA) and atrial fibrillation (AF). In fact, CAA is an age-related cerebral vasculopathy that predisposes patients to intracerebral hemorrhage. Nevertheless, many AF patients require oral systemic dose-adjusted warfarin, direct oral anticoagulants (such as factor Xa inhibitors) or direct thrombin inhibitors to control often associated with cardioembolic stroke risk. The prevalence of both CAA and AF is expected to rise, due to the aging of the population. This clinical dilemma is becoming increasingly common. In patients with coexisting AF and CAA, the risks/benefits profile of anticoagulant therapy must be assessed for each patient individually due to the lack of a clear-cut consensus with regard to its risks in scientific literature. This review aims to provide an overview of the management of patients with concomitant AF and CAA and proposes the implementation of a risk-based decision-making algorithm.

Immunotherapy induced endocrinopathies: "pembrolizumab-induced pancreatitis presenting as diabetic ketoacidosis with concurrent hyperthyroidism-related atrial fibrillation"

Immunotherapy induced endocrinopathies: "pembrolizumab-induced pancreatitis presenting as diabetic ketoacidosis with concurrent hyperthyroidism-related atrial fibrillation"

Deep learning evaluation of echocardiograms to identify occult atrial fibrillation

Atrial fibrillation (AF) often escapes detection, given its frequent paroxysmal and asymptomatic presentation. Deep learning of transthoracic echocardiograms (TTEs), which have structural information, could help identify occult AF. We created a two-stage deep learning algorithm using a video-based convolutional neural network model that (1) distinguished whether TTEs were in sinus rhythm or AF and then (2) predicted which of the TTEs in sinus rhythm were in patients who had experienced AF within 90 days. Our model, trained on 111,319 TTE videos, distinguished TTEs in AF from those in sinus rhythm with high accuracy in a held-out test cohort (AUC 0.96 (0.95–0.96), AUPRC 0.91 (0.90–0.92)). Among TTEs in sinus rhythm, the model predicted the presence of concurrent paroxysmal AF (AUC 0.74 (0.71–0.77), AUPRC 0.19 (0.16–0.23)). Model discrimination remained similar in an external cohort of 10,203 TTEs (AUC of 0.69 (0.67–0.70), AUPRC 0.34 (0.31–0.36)). Performance held across patients who were women (AUC 0.76 (0.72–0.81)), older than 65 years (0.73 (0.69–0.76)), or had a CHA2DS2VASc ≥2 (0.73 (0.79–0.77)). The model performed better than using clinical risk factors (AUC 0.64 (0.62–0.67)), TTE measurements (0.64 (0.62–0.67)), left atrial size (0.63 (0.62–0.64)), or CHA2DS2VASc (0.61 (0.60–0.62)). An ensemble model in a cohort subset combining the TTE model with an electrocardiogram (ECGs) deep learning model performed better than using the ECG model alone (AUC 0.81 vs. 0.79, p = 0.01). Deep learning using TTEs can predict patients with active or occult AF and could be used for opportunistic AF screening that could lead to earlier treatment.

Outcomes and care quality metrics for people living with rheumatic heart disease and atrial fibrillation in Uganda

Atrial fibrillation (AF) is a common complication of rheumatic heart disease (RHD) and is challenging to treat in lower-resourced settings in which RHD remains endemic. We characterized demographics, treatment outcomes, and factors leading to care retention for participants with RHD and AF in Uganda. We conducted a retrospective analysis of the Uganda national RHD registry between June 2009 and May 2018. Participants with AF or atrial flutter were included. Demographics, survival, and care metrics were compared with participants without AF. Multivariable logistic regression was used to identify factors associated with retention in care among participants with AF. A total of 1530 participants with RHD were analyzed and 293 (19%) had AF. The median age was 24 (interquartile range 14-38) years. Mortality was similar in both groups (adjusted hazard ratio 1.183, P = .77) over a median follow-up of 203 (interquartile range 98-275) days. A total of 79% of AF participants were prescribed anticoagulation, and 43% were aware of their target international normalized ratio. Retention in care was higher in participants with AF (18% vs 12%, P < .01). Factors associated with decreased retention in care include New York Heart Association functional class III/IV (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.30-0.76) and distance to nearest health center (adjusted OR 0.94, 95% CI 0.90-0.99). Anticoagulation prescription was associated with enhanced care retention (adjusted OR 1.86, 95% CI 1.24-2.79). Participants with RHD and AF in Uganda do not experience higher mortality than those without AF. Anticoagulation prescription rates are high. Although retention in care is poor among RHD participants, those with concurrent AF are more likely to be retained.

Single-lead electrocardiogram Artificial Intelligence model with risk factors detects atrial fibrillation during sinus rhythm.

Guidelines recommend opportunistic screening for atrial fibrillation (AF), using a 30 s single-lead electrocardiogram (ECG) recorded by a wearable device. Since many patients have paroxysmal AF, identification of patients at high risk presenting with sinus rhythm (SR) may increase the yield of subsequent long-term cardiac monitoring. The aim is to evaluate an AI-algorithm trained on 10 s single-lead ECG with or without risk factors to predict AF. This retrospective study used 13 479 ECGs from AF patients in SR around the time of diagnosis and 53 916 age- and sex-matched control ECGs, augmented with 17 risk factors extracted from electronic health records. AI models were trained and compared using 1- or 12-lead ECGs, with or without risk factors. Model bias was evaluated by age- and sex-stratification of results. Random forest models identified the most relevant risk factors. The single-lead model achieved an area under the curve of 0.74, which increased to 0.76 by adding six risk factors (95% confidence interval: 0.74-0.79). This model matched the performance of a 12-lead model. Results are stable for both sexes, over ages ranging from 40 to 90 years. Out of 17 clinical variables, 6 were sufficient for optimal accuracy of the model: hypertension, heart failure, valvular disease, history of myocardial infarction, age, and sex. An AI model using a single-lead SR ECG and six risk factors can identify patients with concurrent AF with similar accuracy as a 12-lead ECG-AI model. An age- and sex-matched data set leads to an unbiased model with consistent predictions across age groups.

Abstract 12665: Hospital Outcomes of Breast Cancer Patients With Concurrent Atrial Fibrillation

Background: It was estimated that 4% of newly diagnosed breast cancer patients had new onset of atrial fibrillation (AF). Data on the impact of AF on the in-hospital outcomes of breast cancer patients are scarce. Objective: This study aimed to determine and assess the in-hospital outcomes of breast cancer patients with concurrent AF. Methods: Using the all-payer, nationally representative Nationwide Readmissions Database, our study included patients aged 18 years or older with a diagnosis of breast cancer between 2017 and 2020. We categorized the cohort into two groups depending on the occurrence of AF during hospitalization. The primary endpoint of our study was the in-hospital outcomes and complications of breast cancer patients with and without concurrent AF. Results: 284,226 breast cancer patients were included in this study; 32,289 (11.4%, 76.5 ± 10.1 years of age) with concurrent AF and 251,937 (88.6%, 62.7 ± 14.0 years of age) without. Those with concurrent AF were associated with higher odds of early mortality (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.12- 1.27, p&lt;0.01), prolonged index hospital stay (aOR: 1.11; CI: 1.06- 1.16, p&lt;0.01), and non-home discharge (aOR: 1.42; CI: 1.35- 1.48, p&lt;0.01). The length of hospital stay was longer in the group with concurrent AF than those without concurrent AF (mean 6.3 days vs. 5.7 days, p&lt;0.01). During hospitalization, those with concurrent AF had higher odds of developing acute heart failure (aOR: 1.54; CI: 1.37- 1.74, p&lt;0.01), cardiogenic shock (aOR: 1.42; CI: 1.04- 1.93, p=0.03), pulmonary edema (aOR: 1.26; CI: 1.06- 1.49, p=0.01), and cerebral infarction (aOR: 1.51; CI: 1.21- 1.89, p&lt;0.01). Conclusion: Breast cancer patients with concurrent AF had worse in-hospital outcomes and complications than those without concurrent AF. Figure In-Hospital Outcomes and Complications of Breast Cancer Patients with Concurrent Atrial Fibrillation versus without Concurrent Atrial Fibrillation.

Abstract 16885: Progression of Aortic Valve Stenosis in Atrial Fibrillation versus Sinus Rhythm: Implications for Clinical Practice and Severe Aortic Stenosis Diagnosis

Introduction: Rate of aortic stenosis (AS) progression in patients with concurrent atrial fibrillation (AF) has not been previously described. Objectives: To describe changes over time in aortic valve area (AVA) and associated hemodynamics during AS progression in patients in AF versus sinus rhythm (SR). Methods: Patients with AVA ≤ 1 cm 2 and preserved left ventricular ejection fraction ≥50% were identified from the Mayo Clinic Echocardiographic Laboratory Database. Serial echocardiograms prior to the development of AVA ≤ 1 cm 2 (Time 0) were examined. Inverse probability weighting was used for statistical analysis. Results: A total of 166 patients were included (SR=79 and AF=87), mean age 78.1 ± 7.8 years, females 31%. The rates of AVA reduction (-0.14±0.01 vs -0.12±0.01 cm2/year, p=0.31) and increase in trans-aortic peak velocity (+0.23 ± 0.02 vs +0.22 ± 0.02 m/sec, p=0.55) and mean gradient (MG) (3.9 ± 0.3 vs 3.8 ± 0.4 mmHg, p=0.83) did not differ between AF and SR (Figure 1). However, AF was associated with systematically lower forward stroke volume index (SVi), peak velocity and MG for the same AVA compared to SR (p&lt;0.04 for all) throughout AS progression. When AVA reached 1 cm 2 , SVi (38.8±6.6 vs 45.7 ±8.9, p=0.02), peak velocity (3.9 ± 0.6 vs 4.1 ± 0.6 m/sec, p=0.04) and MG (36.6±10.9 vs 41±12.8 mmHg, p=0.03) were lower in AF compared to SR. Conclusions: The rate of AS progression was not different in AF versus SR. However, forward flow was systematically lower in AF resulting in discordant AS during AS progression and when AVA reached 1 cm 2 . Doppler velocity and MG criteria for severe AS appear to be lower in AF versus SR which has implications for timely diagnosis of severe AS and patient management.

Association Between Atrial Fibrillation and Diabetes-Related Complications: A Nationwide Cohort Study.

This study aimed to investigate the associations between concurrent atrial fibrillation and diabetes-related complications among patients with diabetes. This nationwide observational cohort study used the health checkup database from the Korean National Health Insurance Service. Patients diagnosed with diabetes who underwent health checkups between 2009 and 2012 were investigated. The patients with atrial fibrillation were matched in a 1:5 ratio with those without atrial fibrillation using propensity scores. Study outcomes included macrovascular, microvascular (diabetic retinopathy and diabetic nephropathy), and diabetic foot complications. The risks of clinical outcomes were measured using hazard ratios (HRs) with 95% CIs. A total of 65,760 patients with diabetes were analyzed (54,800 without atrial fibrillation and 10,960 with atrial fibrillation). After well-balanced propensity score matching, atrial fibrillation was associated with significantly higher risks of macrovascular complications (HR 1.12, 95% CI 1.09-1.16), diabetic nephropathy (HR 1.23, 95% CI 1.16-1.30), and diabetic foot complications (HR 1.13, 95% CI 1.09-1.17) compared with no atrial fibrillation, while the risk of diabetic retinopathy was comparable (HR 0.99, 95% CI 0.96-1.03). Patients with atrial fibrillation had a significantly higher risk of diabetic foot amputation (HR 4.12, 95% CI 1.98-8.56). Among patients with diabetes, concurrent atrial fibrillation was associated with increased risks for diabetes-related macrovascular complications, diabetic nephropathy, and diabetic foot. Such patients require holistic management to reduce the risk of adverse outcomes.

Atrial Myopathy Quantified by Speckle-tracking Echocardiography in Mice.

Emerging evidence suggests that atrial myopathy may be the underlying pathophysiology that explains adverse cardiovascular outcomes in heart failure (HF) and atrial fibrillation. Lower left atrial (LA) function (strain) is a key biomarker of atrial myopathy, but murine LA strain has not been described, thus limiting translational investigation. Therefore, the objective of this study was to characterize LA function by speckle-tracking echocardiography in mouse models of atrial myopathy. We used 3 models of atrial myopathy in wild-type male and female C57Bl6/J mice: (1) aged 16 to 17 months, (2) Ang II (angiotensin II) infusion, and (3) high-fat diet+Nω-nitro-L-arginine methyl ester (HF with preserved ejection fraction, HFpEF). LA reservoir, conduit, and contractile strain were measured using speckle-tracking echocardiography from a modified parasternal long-axis window. Left ventricular systolic and diastolic function, and global longitudinal strain were also measured. Transesophageal rapid atrial pacing was used to induce atrial fibrillation. LA reservoir, conduit, and contractile strain were significantly reduced in aged, Ang II and HFpEF mice compared with young controls. There were no sex-based interactions. Left ventricular diastolic function and global longitudinal strain were lower in aged, Ang II and HFpEF, but left ventricular ejection fraction was unchanged. Atrial fibrillation inducibility was low in young mice (5%), moderately higher in aged mice (20%), and high in Ang II (75%) and HFpEF (83%) mice. Using speckle-tracking echocardiography, we observed reduced LA function in established mouse models of atrial myopathy with concurrent atrial fibrillation inducibility, thus providing the field with a timely and clinically relevant platform for understanding the pathophysiology and discovery of novel treatment targets for atrial myopathy.

Successful treatment of concurrent acute migraine headache and atrial fibrillation with benzodiazepine administration

Migraine and atrial fibrillation (AF) are common disorders in the general population in which autonomic nervous system takes role in the pathophysiological mechanism of both diseases. Migraine is a primary headache disease that is associated with significant debilitating symptoms and disability especially among young individuals and AF is associated with excess risk of morbidity and mortality. Interaction between migraine and AF has been a major interest since years at a pathophysiological and clinical level. Benzodiazepines (BZDs) are a class of psychotropic drugs that act through gamma amino butyric acid-A receptors located in the central nervous system. BZDs are widely used for their anxiolytic, anticonvulsant, sedative-hypnotic and muscle relaxant effects. Herein, we describe a case of a patient presenting with concurrent acute migraine headache and AF attack and successful treatment of both conditions simultaneously with intravenous administration of BZD.

Association of Length of Stay With the Clinical Trajectory of Hospitalized Patients With Atrial Fibrillation: Staying Less Is More?

Data predicting the length of stay (LOS) in patients with concurrent atrial fibrillation (AF) are scarce. This study aimed to investigate the potential predictors for prolonged LOS andits prognostic value. In this observational post hoc analysis of the MISOAC-AF (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation) randomized trial logistic regression analyses were conducted to identifythe parameters associated with prolonged LOS (defined as >7days according to diagnostic accuracy analyses). Kaplan-Meier and Cox regression analyses were performed to generate survival curves and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for the primary end point of all-cause mortality and for the secondaryend points during a median 3.7-year follow-up. Of the 1,057 patients studied, 462 (43.7%) were hospitalized for ≥7days. Heart failure with reduced ejection fracture (aHR 1.75, 95% CI 1.17 to 2.63), permanent AF (aHR 1.72, 95% CI 1.29 to 2.31), history of coronary artery disease (aHR 2.32, 95% CI 1.59 to 3.39), and advanced or end-stage chronic kidney disease (aHR 1.54, 95% CI 1.15 to 2.06) were independently associated with prolonged hospitalization. Prolonged LOS was independently linked with increasedall-cause mortality rates (aHR 1.68, 95% CI 1.25 to 2.26), cardiovascular mortality (aHR 1.92, 95% CI 1.36 to 2.72), major bleeding (aHR 3.07, 95% CI 1.07 to 8.78), and the composite outcome of cardiovascular death or rehospitalization (aHR 1.31, 95% CI 1.04 to 1.66). Each extra day of LOS wasan independent predictor of all-causemortality(aHR 1.03, 95% CI 1.02 to 1.04). Hospitalized patientswith concurrent AF carry a substantial morbidity burden being prone to extended LOS. A jointed approach seems reasonable to reduce the LOS in patients with AF.

Abstract P157: IMPACT OF CONCURRENT ATRIAL FIBRILLATION ON HYPERTENSIVE EMERGENCIES:

Introduction: In patients suffering from hypertension, the presence of concurrent atrial fibrillation tends to escalate the risk of severe conditions and worsen outcomes. This study, aimed to delve into the impact that a simultaneous diagnosis of atrial fibrillation can have on patients admitted for hypertensive emergencies during the initial year of the COVID-19 pandemic. Methods: We examined data from the 2020 National Inpatient Sample to identify patients primarily admitted due to a hypertensive emergency. We used ICD-10 codes to distinguish between those with and without concurrent atrial fibrillation. We employed logistic and linear regression analyses and accounted for potential confounders. We deemed the results as statistically significant when the 2-tailed p-value was less than 0.05. Results: During 2020, there were a total of 1,221,535 admissions for hypertensive emergencies. Notably, 470,440 (38.5%), involved patients concurrently diagnosed with atrial fibrillation. After adjusting for variables such as age, race, gender, the size and geographic location of the hospital, insurance coverage, income level, and existing comorbidities, patients hospitalized for hypertensive emergencies, who were also diagnosed with atrial fibrillation, demonstrated an elevated risk of in-hospital mortality (aOR 1.25, 95% CI 1.18-1.32). This patient group was also more likely to require the initiation of mechanical ventilation (aOR 1.06, 95% CI 1.03-1.09), vasopressor therapy (aOR 1.71, 95% CI 1.52-1.92), and mechanical circulatory support (aOR 1.71, 95% CI 1.32-2.21). Intriguingly, despite the increased risks in these areas, these patients displayed a reduced rate of hemodialysis initiation (aOR 0.82, 95% CI 0.79-0.86). Conclusion: Atrial fibrillation seemingly has a critical influence on the in-hospital outcomes of patients admitted for hypertensive emergencies, generally leading to more unfavorable results. Given the anticipated increased prevalence of atrial fibrillation in an aging population, understanding its pathophysiology and potential contribution to the complexity of diseases in patients with severe hypertension represents a crucial area for further investigation.

Improved prognosis with integrated care management including early rhythm control and healthy lifestyle modification in patients with concurrent atrial fibrillation and diabetes mellitus

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with concurrent atrial fibrillation (AF) and diabetes mellitus (DM) [AF-DM] have a high risk of cardiovascular and diabetes-related complications, but are less engaged in a comprehensive treatment approach. Purpose We evaluated the association of early rhythm control (ERC), lifestyle modification (LSM), and a combination of ERC and LSM with cardiovascular or diabetes-related complication risk in patients with AF-DM. Methods From the National Health Information Database, 47,940 patients diagnosed with AF-DM in 2009–2016 were included. We defined ERC as rhythm control therapy within two years of AF diagnosis and LSM as adherence to ≥2 of the healthy behaviors among non-current smoking, non-drinking, and regular exercise. We compared the primary (ischemic stroke) and secondary (macro- and microvascular complications, glycemic emergency, and all-cause death) outcomes in four groups: non-ERC and non-LSM (group 1), LSM only (group 2), ERC only (group 3), and both ERC and LSM (group 4). Results Of total, 10,617 (22%), 26,730 (55.8%), 2,903 (6.1%), and 7,690 (16.0%) were classified into groups 1 to 4, in sequence. The mean duration from AF diagnosis to ERC was 25.6±75.5 days. During 4.0 (interquartile range: 2.5–6.2) years’ follow-up, groups 2 and 3 were associated with 23% and 33% lower risks of stroke than group 1, respectively. Group 4 was associated with the lowest risk of stroke: hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51–0.67, p&amp;lt;0.001. Regarding secondary outcomes, the lowest risks were also observed in group 4; macro- and microvascular complications, glycemic emergency, and all-cause death had HRs (95% CIs) of 0.63 (0.56–0.70), 0.88 (0.82–0.94), 0.72 (0.62–0.84), and 0.80 (0.73–0.87), respectively, all p&amp;lt;0.001. Conclusions For AF-DM patients, ERC and LSM exert a synergistic effect in preventing cardiovascular and diabetes-related complications with the greatest lowered risk of stroke. A comprehensive treatment approach should be pursued in AF-DM patients.

CE-452776-4 ATRIAL FIBRILLATION IS ASSOCIATED WITH HIGHER INPATIENT MORTALITY AS COMPARED WITH SINUS TACHYCARDIA IN PATIENTS WITH CARDIOGENIC SHOCK

Cardiogenic shock (CS) is commonly associated with a compensatory atrial stress response like sinus tachycardia (ST) or atrial fibrillation (AF). However, there is paucity of data comparing inpatient outcomes in patients with cardiogenic shock presenting with AF versus ST. To compare the impact of AF and ST on in-hospital outcomes in patients admitted with cardiogenic shock. We queried the National Inpatient Sample database to identify primary hospitalizations of CS using ICD-9/ICD-10 CM codes between 2009 and 2019. The study cohort was further divided into three groups based on the concurrent diagnosis of AF, ST, and a comparator group of no AF/ST. Our cohort included a total of 1,376,187 hospitalizations with a diagnosis of CS. Multivariate analysis showed CS hospitalizations with AF as compared with ST, had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.03-1.11) p=0.0005], CRT implantation [aOR 2.38 (1.88-3.03) p<0.001] and AV node ablation [aOR 3.22 (2.63-4.00) p<0.001]. Patients hospitalized with CS without concurrent AF/ST vs concurrent AF had significantly higher odds of all-cause in-hospital mortality [aOR 1.07 (1.06-1.08) p<0.001] and utilization of mechanical circulatory support [aOR 1.33 (1.31-1.34) p<0.001] but lower odds of CRT [aOR 0.76 (0.73-0.80) p<0.001] and AV node ablation [aOR 0.38 (0.37-0.40) p<0.001]. Our data suggest that patients admitted for CS and AF have worse outcomes including higher inpatient mortality, compared to those with CS and ST. However, compared to those without ST or arrhythmias, AF patients had a lower in-hospital mortality. These data are hypothesis generating and merit further study to better inform management of patients with CS and atrial arrhythmias.

PO-05-167 THE BIDIRECTIONAL ASSOCIATION BETWEEN ATRIAL FIBRILLATION AND MYOCARDIAL INFARCTION IN THE FRAMINGHAM HEART STUDY

Atrial fibrillation (AF) and myocardial infarction (MI) are major contributors to disease burden. Studies suggest a bidirectional association between AF and MI. 1) To assess the bidirectional association between MI and AF, 2) to describe temporality between MI and AF among Framingham Heart Study participants with new-onset AF/MI, 3) to examine the association between interim/prevalent MI/AF and mortality among new-onset AF/MI cases. For aim 1, we included participants aged ≥45 years attending exams between 1960-2019. Multivariable-adjusted Cox proportional hazards models were used to calculate hazards ratios (HR) and 95% confidence intervals (CI) for the association between prevalent/interim MI/AF and incident AF/MI. Interim AF/MI were included as time-varying variables. For aims 2 and 3, we included all participants aged ≥45 years developing AF/MI from 1960-2019. In new-onset AF cases, we assessed percentages of prevalent MI, concurrent MI (diagnosed on the same day), and no MI, at time of AF diagnosis. Multivariable-adjusted HRs (95% CIs) were calculated for the association between prevalent/interim MI and mortality among participants with new-onset AF. We performed corresponding analyses for new-onset MI cases, using AF as exposure. In 10,334 participants free of MI at baseline (56% female, mean age 54±7 years), incidence rates of MI according to AF status are shown in table. The risk of incident MI was higher with interim compared to no AF (table). In 10,488 participants free of AF at baseline (55% female, mean age 54±7 years), incidence rates of AF according to MI status are displayed in table. The risk of incident AF was higher with prevalent and interim MI compared to no MI (table). In the 1,847 participants developing AF during 1960-2019 (46% female, mean age 75±11 years), 15% had prevalent MI, 2% had concurrent MI, and 84% had no MI, at time of AF diagnosis. In the 1,091 participants developing MI (42% female, mean age 70±11 years), 9% had prevalent AF, 3% had concurrent AF, and 89% had no AF, at time of MI diagnosis. In participants with new-onset AF or MI, prevalent and interim MI or AF were associated with significantly greater mortality compared to only AF or MI (table). The risk of incident AF was greater in participants with MI compared to no MI. The risk of incident MI was higher in participants with AF compared to no AF. Co-existing AF and MI were associated with a greater mortality compared to only AF or MI.Tabled 1(PO-05-167)Study SampleExposureOutcomeIncidence Rate per 1,000 person-years (95% CI)Hazards Ratio (95% CI)P-valueAF-free participants (N=10,488)Prevalent MIIncident AF23 (19-27)1.72 (1.41-2.11)<0.0001Interim MI50 (42-60)4.36 (3.51-5.42)<0.0001No MI8 (7-8)1.00 (ref)--MI-free participants (N=10,334)Prevalent AFIncident MI11 (8-15)1.33 (0.95-1.87)0.10Interim AF20 (16-26)2.75 (2.06-3.66)<0.0001No AF5 (4-5)1.00 (ref)--New-onset AF cases (N=1,847)Prevalent MIAll-cause mortality159 (139-180)1.36 (1.17-1.58)<0.0001Interim MI202 (161-252)2.25 (1.71-2.98)<0.0001No MI103 (97-109)1.00 (ref)--New-onset MI cases (N=1,091)Prevalent AFAll-cause mortality191 (153-236)1.60 (1.26-2.02)<0.0001Interim AF170 (147-192)2.53 (2.09-3.07)<0.0001No AF78 (72-84)1.00 (ref)-- Open table in a new tab

PO-01-214 DEEP LEARNING EVALUATION OF ECHOCARDIOGRAMS TO IDENTIFY OCCULT ATRIAL FIBRILLATION

Atrial fibrillation (AF) can often be missed by routine screening given its frequently paroxysmal and asymptomatic presentation. Deep learning algorithms can identify patients with paroxysmal AF from sinus electrocardiograms. Transthoracic echocardiograms (TTEs) may provide additional structural information complementary to ECGs that could also be used to help identify occult AF. We sought to determine whether deep learning evaluation of echocardiograms of patients in normal sinus rhythm could predict concurrent atrial fibrillation. We identified patients who had TTE performed between 6/2004 and 6/2021. Cases were defined as patients who had a TTE in normal sinus rhythm (NSR) with AF documented on ECG within 90 days before/after the TTE. Controls had a NSR TTE (by report and confirmed by lack of noted mitral A wave velocity) and no documented AF within 90 days by ECG or ICD diagnosis. We trained a video-based convolutional neural network using TTE parasternal long axis (PLAX) videos to predict concurrent AF. Model performance was compared to AF prediction by logistic regression using clinical variables (age, sex, heart failure, hypertension, cerebrovascular disease, peripheral arterial disease, diabetes, height, weight, smoker), CHADS2VASc score, and left atrial (LA) size on TTE. Model was trained on 57,681 TTEs of patients who were on average 66.2 years old (SD 16.9), 44.9% female, with a mean CHADS2VASc score of 3.1 (SD 2.1) and LA area of 19.7cm2 (SD 5.8). When tested on a held-out sample of 7,283 TTEs, the model predicted the occurrence of atrial fibrillation within 90 days of a sinus TTE with an AUC of 0.71 (0.69-0.73). Using the max accuracy threshold, the PPV was 0.20 and the NPV was 0.95. The model performed better than predicting AF using clinical risk factors (AUC 0.67), LA area (AUC 0.63), and CHADS2VASc (AUC 0.61). A deep learning model predicted the occurrence of atrial fibrillation from TTEs moderately well, better than clinical variables or LA size alone. This may open up additional opportunities for screening patients for occult AF.

Time trends in atrial fibrillation-related stroke during 2001-2020 in Sweden: a nationwide, observational study.

Great efforts have been made to improve stroke prevention in atrial fibrillation (AF) patients. Meanwhile, incidence of AF is increasing, which may affect the share of AF-related stroke on all strokes. We aimed to examine the temporal trends in the incidence of AF-related ischemic stroke between 2001 and 2020, if it varied by use of novel oral anticoagulant drugs (NOAC), and if the relative risk of ischemic stroke associated with AF changed over time. Data from the total Swedish population aged ≥70 years during the period 2001-2020 were used. Annual incidence rate (IR) was calculated for overall and AF-related ischemic stroke which was defined as first-ever ischemic stroke with AF diagnosed up to 5 years before, on the same day, or within 2 months after the stroke event. Cox regression models were performed to examine if the hazard ratio (HR) between AF and stroke changed over time. While IR of ischemic strokes declined during 2001-2020, IR of AF-related ischemic stroke remained stable between 2001 and 2010 but showed a consistent decline between 2010 and 2020. The HR of ischemic stroke within 3 years from an AF diagnosis came down from 2.39 (95% confidence interval: 2.31-2.48) to 1.54 (1.48-1.61) over the study period, which was largely explained by a substantial increase in the use of NOAC among AF patients after 2012. Yet, by the end of 2020, 24% of all ischemic strokes had a preceding or concurrent AF diagnosis, which is slightly higher than in2001. Even though both the absolute and relative risk of AF-related ischemic stroke declined over the past 20 years, every fourth ischemic stroke in 2020 still had a preceding or concurrent AF diagnosis. This represents a great potential for future gains in stroke prevention among AF patients. Swedish Research Council and Loo and Hans Osterman Foundation for Medical Research.

A rare case of Carotid Dissection seen in Vascular Eagle Syndrome (P3-5.024)

<h3>Objective:</h3> NA <h3>Background:</h3> Vascular eagle syndrome occurs when an elongated styloid process causes impingement to a carotid artery. Four percent of the general population have an elongated styloid process; only four percent are symptomatic. Clinical manifestations occur due to angulation in the middle or end of the styloid, in which turning the head might compress the carotid artery or even tear the vessel itself. Some manifestations include syncope from irritation of the sympathetic plexus, restriction in blood flow, transient ischemic attack, and carotid dissection. <h3>Design/Methods:</h3> NA <h3>Results:</h3> This is an 82-year-old man who presented due to sudden onset of left-sided hemiparesis, urinary incontinence, and aphasia upon awakening. His medical history was significant for recent atrial fibrillation with a pacemaker (not on anticoagulation), hypertension, and hyperlipidemia. Neurological examination revealed left pronator drift, hemisensory neglect on simultaneous tactile stimulation, and a positive left plantar reflex. Computed tomography angiogram (CTA) head and neck revealed a short segment nonflow-limiting dissection of the right mid-cervical internal carotid artery. Magnetic resonance imaging (MRI) of the brain showed multiple areas of cortical and subcortical hyperintense diffusion and T2 foci involving the right frontoparietal and insular cortex most consistent with late acute infarct. Further review showed an elongated styloid process impinging on the right carotid artery. Due to this patient’s age and risk factors, he was not a candidate for surgical intervention. He was started on a heparin drip and bridged to warfarin for secondary stroke prevention for both extracranial cervical dissection and concurrent atrial fibrillation. Stent placement at a later date would be considered if he failed medical therapy. <h3>Conclusions:</h3> An elongated styloid process should be considered in an atraumatic, symptomatic cervical dissection presenting with ischemic infarcts. There is limited data regarding management of vascular eagle syndrome and should be studied further to compare medical management versus surgical intervention. <b>Disclosure:</b> Dr. Kokikian has nothing to disclose. Dr. Ly has nothing to disclose. Dr. Al-Khoury has nothing to disclose.

Trends and in-hospital cardiac complications in patients with atrial fibrillation undergoing allogeneic stem cell transplant: A National Inpatient Sample analysis (2002-2019).

Cardiovascular comorbidities increase the risk of transplant-associated complications. However, the impact of atrial fibrillation (AF) as an independent risk factor remains limited. The National Inpatient Sample (NIS) database was queried using the International Classification of Diseases codes to identify patients admitted for allogeneic stem cell transplant (ASCT). The patients were then subclassified into with and without AF. Subsequently, a multivariate logistic regression model was constructed to account for patient demographics, comorbidities, and hospital characteristics to evaluate the impact of AF on the primary outcome of interest: all-cause mortality, and secondary outcomes of interest that included common hospitalization complications. The data for 77 157 cases of ASCT were collected between 2002 and 2019. Among these 5086 (6.6%) cases had concurrent AF. Multivariate logistic regression revealed patients undergoing ASCT with AF had almost a three times higher risk of all-cause mortality (odds ratio = 2.99 [95% confidence interval: 2.73-3.28]; p < .01). AF patients also had a higher risk for cardiac arrest, cardiogenic shock, acute kidney injury, and need for hemodialysis (all p < .01). AF causes a higher risk of death and cardiovascular complications among patients undergoing ASCT. This signifies the importance of pretransplant consultation and optimization for cardiovascular comorbidities to improve hospitalization outcomes.

Improved prognosis with integrated care management including early rhythm control and healthy lifestyle modification in patients with concurrent atrial fibrillation and diabetes mellitus: a nationwide cohort study

BackgroundPatients with concurrent atrial fibrillation (AF) and diabetes mellitus (DM) [AF-DM] have a high risk of cardiovascular and diabetes-related complications, but are less engaged in a comprehensive treatment approach. We evaluated the association of early rhythm control (ERC), lifestyle modification (LSM), and a combination of ERC and LSM with cardiovascular or diabetes-related complication risk in patients with AF-DM (type 2).MethodsFrom the National Health Information Database, 47,940 patients diagnosed with AF-DM in 2009–2016 were included. We defined ERC as rhythm control therapy within two years of AF diagnosis and LSM as adherence to ≥ 2 of the healthy behaviors among non-current smoking, non-drinking, and regular exercise. We compared the primary (ischemic stroke) and secondary (macro- and microvascular complications, glycemic emergency, and all-cause death) outcomes in four groups: non-ERC and non-LSM (group 1), LSM only (group 2), ERC only (group 3), and both ERC and LSM (group 4).ResultsOf total, 10,617 (22%), 26,730 (55.8%), 2,903 (6.1%), and 7,690 (16.0%) were classified into groups 1 to 4, in sequence. The mean duration from AF diagnosis to ERC was 25.6 ± 75.5 days. During 4.0 (interquartile range: 2.5–6.2) years’ follow-up, groups 2 and 3 were associated with 23% and 33% lower risks of stroke than group 1, respectively. Group 4 was associated with the lowest risk of stroke: hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.51–0.67, p < 0.001. Regarding secondary outcomes, the lowest risks were also observed in group 4; macro- and microvascular complications, glycemic emergency, and all-cause death had HRs (95% CIs) of 0.63 (0.56–0.70), 0.88 (0.82–0.94), 0.72 (0.62–0.84), and 0.80 (0.73–0.87), respectively, all p < 0.001.ConclusionsFor AF-DM patients, ERC and LSM exert a synergistic effect in preventing cardiovascular and diabetes-related complications with the greatest lowered risk of stroke. A comprehensive treatment approach should be pursued in AF-DM patients.