Concurrent Atrial Fibrillation Research Articles

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<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. 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.

Prescribing Trends of Oral Anticoagulants in US Patients With Cirrhosis and Nonvalvular Atrial Fibrillation.

Background Many patients with cirrhosis have concurrent nonvalvular atrial fibrillation (NVAF). Data are lacking regarding recent oral anticoagulant (OAC) usage trends among US patients with cirrhosis and NVAF. Methods and Results Using MarketScan claims data (2012-2019), we identified patients with cirrhosis and NVAF eligible for OACs (CHA2DS2-VASc score ≥2 [men] or ≥3 [women]). We calculated the yearly proportion of patients prescribed a direct OAC (DOAC), warfarin, or no OAC. We stratified by high-risk features (decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease, or end-stage renal disease). Among 32 487 patients (mean age=71.6 years, 38.5% women, 15.1% with decompensated cirrhosis, mean CHA2DS2-VASc=4.2), 44.6% used OACs within 180 days of NVAF diagnosis, including DOACs (20.2%) or warfarin (24.4%). Compared with OAC nonusers, OAC users were less likely to have decompensated cirrhosis (18.6% versus 10.7%), thrombocytopenia (19.5% versus 12.5%), or chronic kidney disease/end-stage renal disease (15.5% versus 14.0%). Between 2012 and 2019, warfarin use decreased by 21.0% (32.0% to 11.0%), whereas DOAC use increased by 30.6% (7.4% to 38.0%), and among all DOACs between 2012 and 2019, apixaban was the most commonly prescribed (46.1%). Warfarin use decreased and DOAC use increased in all subgroups, including in compensated and decompensated cirrhosis, thrombocytopenia, coagulopathy, chronic kidney disease/end-stage renal disease, and across CHA2DS2-VASc categories. Among OAC users (2012-2019), DOAC use increased by 58.9% (18.7% to 77.6%). Among DOAC users, the greatest proportional increase was with apixaban (61.2%; P<0.001). Conclusions Among US patients with cirrhosis and NVAF, DOAC use has increased substantially and surpassed warfarin, including in decompensated cirrhosis. Nevertheless, >55% of patients remain untreated, underscoring the need for clearer treatment guidance.

Thrombotic and bleeding outcomes following the perioperative interruption of anticoagulation among patients with nonvalvular atrial fibrillation and active cancer

BackgroundPatients with cancer are at an increased risk of developing atrial fibrillation (AF) and often need to undergo procedures or surgery that requires periprocedural interruption of anticoagulation. Anticoagulated patients with cancer might be at increased risk of postprocedural thromboembolic and bleeding complications. Data on postprocedural outcomes among patients with concurrent active cancer and AF are sparse. ObjectiveTo assess the 30-day risk of postoperative thromboembolic and major bleeding complications after the periprocedural interruption of anticoagulation among patients with AF and active cancer. MethodsWe conducted a single-center retrospective cohort study in patients with active cancer and AF who required periprocedural interruption of anticoagulation for invasive procedures between August 2015 and May 2019. The primary endpoints were the 30-day postoperative risks of arterial thromboembolism (ATE) and major bleeding. The secondary endpoints included the 30-day risks of venous thromboembolism, clinically relevant nonmajor bleeding, and overall mortality. ResultsTwo hundred sixty-four patients undergoing 302 periprocedural interruptions were included in our study. The 30-day risk of ATE was 0.7% (95% CI, 0.1%-2.4%), and the 30-day risk of major bleeding was 1.7% (95% CI, 0.6%-3.9%). The 30-day risks of venous thromboembolism and clinically relevant nonmajor bleeding were 0.7% (95% CI, 0.1%-2.4%) and 4.3% (95% CI, 2.5%-7.3%), respectively. The overall risk of mortality at 30 days was 1.3% (95% CI, 0.4%-3.4%). There was one fatal postoperative stroke. ConclusionsPatients with AF and active cancer in this study were at relatively low risk for ATE and postoperative bleeding complications when patients were managed according to commonly applied perioperative management recommendations.

Role of cerebral microbleeds in acute ischemic stroke and atrial fibrillation.

Cerebral microbleeds (CMBs) are commonly detected in the brains of patients with acute ischemic stroke (AIS). With the development of neuroimaging, clinicians are paying more attention to the presence of CMBs. CMBs were found to significantly increase the risk of intracranial hemorrhagic transformation and hemorrhage in patients with AIS, especially in patients with concurrent atrial fibrillation (AF). Additionally, the presence of CMBs is thought to be a symbol of a high risk of recurrent ischemic stroke (IS). A few researchers have found that the presence of CMBs has no significant effect on the prognosis of patients with AIS. Therefore, the current views on the role of CMBs in the prognoses of patients with IS are controversial. The use of anticoagulants and other drugs has also become a dilemma due to the special influence of CMBs on the prognosis of these patients. Due to the large number of patients with AF and CMBs, many studies have been conducted on the effects of CMBs on these patients and subsequent pharmacological treatments. However, at present, there are no relevant guidelines to guide the secondary preventive treatment of patients with stroke, CMBs, and AF. In this paper, we summarized the role of CMBs in AIS combined with AF and relevant preventive measures against the recurrence of stroke and the occurrence of intracerebral hemorrhage to help clarify the specifics of drug therapies for this group of patients.

Unfavourable outcomes in patients with heart failure with higher preserved left ventricular ejection fraction.

Newly introduced drugs for heart failure (HF) have been reported to improve the prognosis of HF with preserved ejection fraction (HFpEF) in the lower range of left ventricular ejection fraction (LVEF). We hypothesized that a higher LVEF is related to an unfavourable prognosis in patients with HFpEF. We tested this hypothesis by analysing the data from a prospective multicentre cohort study in 255 patients admitted to the hospital due to decompensated HF (LVEF > 40% at discharge). The primary endpoint of this study was a composite outcome of all-cause death and readmission due to HF, and the secondary endpoint was readmission due to HF. LVEF and the mitral E/e' ratio were measured using echocardiography. In multicovariate parametric survival time analysis, LVEF [hazard ratio (HR) = 1.046 per 1% increase, P = 0.001], concurrent atrial fibrillation (AF) (HR = 3.203, P < 0.001), and E/e' (HR = 1.083 per 1.0 increase, P < 0.001) were significantly correlated with the primary endpoint. In addition to these covariates, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use was significantly correlated with the secondary endpoint (HR = 0.451, P = 0.008). Diagnostic performance plot analysis demonstrated that the discrimination threshold value for LVEF that could identify patients prone to reaching the primary endpoint was ≥57.2%. The prevalence of AF or E/e' ratio did not differ significantly between patients with LVEF ≥ 58% and with 40% < LVEF < 58%. A higher LVEF is independently related to poor prognosis in patients with HFpEF, in addition to concurrent AF and an elevated E/e' ratio. ACEI/ARB use, in contrast, was associated with improved prognosis, especially with regard to readmission due to HF. https://www.umin.ac.jp/ctr/index.htm. UMIN000017725.

Prevalence of atrial fibrillation and procedural outcome in patients undergoing catheter ablation for premature ventricular complexes.

Atrial fibrillation (AF) and premature ventricular complexes (PVC) are common arrhythmias. We aimed to investigate AF prevalence in patients with PVC and its impact on PVC ablation outcomes. Consecutive patients undergoing PVC ablation at a single institution between 2016 and 2019 were included and prospectively followed for 2 years. Patients with severe valvular heart disease, hyperthyroidism, malignancy, alcohol use disorder and advanced renal/hepatic diseases were excluded. Twelve-lead electrocardiograms were used to diagnose AF and assess PVC morphology. All PVCs were targeted for ablation using 4-mm irrigated-tip catheters at standardized radiofrequency power guided by 3-D mapping and intracardiac echocardiography. Patients were followed with remote monitoring, device interrogations and office visits every 6 months for 2 years. Detection of any PVCs in follow-up was considered as recurrence. A total of 394 patients underwent PVC ablation and 96 (24%) had concurrent AF. Patients with PVC and AF were significantly older (68.2 ± 10.8 vs. 58.3 ± 15.8 years, p < .001), had lower LV ejection fraction (43.3 ± 13.3% vs. 49.6 ± 12.4%, p < .001), higher CHA2 DS2 -VASc (2.8 ± 1.3 vs. 2.0 ± 1.3, p < .001) than those without. PVCs with ≥2 morphologies were detected in 60.4% and 13.7% patients with vs without AF (p < .001). At 2-year follow-up, PVC recurrence rate was significantly higher in patients with vs without AF (17.7% vs. 9.4%, p = .02). AF was documented in 1/4 of patients undergoing PVC ablation and was associated with lower procedural success at long-term follow-up. This was likely attributed to older age, worse LV function and higher prevalence of multiple PVC morphologies in patients with concurrent AF.

Abstract 12871: Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Hypertrophic Cardiomyopathy

Introduction: Patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) are at increased stroke risk in comparison to those without HCM. The role of left atrial appendage occlusion (LAAO) in these patients is unclear. Methods: In this retrospective cohort study, we identified patients with HCM and AF using the National Readmission Dataset from 2016-19. Patients were stratified based on LAAO status. The primary efficacy outcome was a composite of any stroke (ischemic and hemorrhagic), TIA, and all-cause mortality. The primary safety outcome was a composite of major bleeding and pericardial complications. Individual components of the primary outcomes were secondary outcomes. Patients were matched using inverse probability of treatment weighting. Cox-proportional hazard regression was applied to calculate hazard ratio (HR) with 95% confidence interval (CI) on matched cohorts. Results: We identified 71,980 patients with HCM and AF. Of these, 1,351 (1.9%) patients underwent LAAO. Those who underwent LAAO were significantly younger than those who did not (67.5±10.1 years vs. 70.0±13.1 years, p&lt;0.001) and were more likely to be male (54.6% vs. 45.4%). LAAO was associated with a lower risk of the primary efficacy outcome (2.5% vs. 5.4%, HR: 0.38; 95% CI: 0.17-0.88; p=0.024) and the primary safety outcome (2.9% vs. 6.8%, HR: 0.39; 95% CI: 0.23-0.66, p=0.001). LAAO associated with reduced major bleeding (1.6% vs. 6.0%, HR 0.34, 95% CI 0.18-0.64, p=0.001), GI bleeding (0.2% vs. 1.3%, HR 0.22; 95% CI: 0.06-0.79, p=0.02), blood transfusions requiring admission (2.10% vs. 4.90%, HR 0.37, 95% CI 0.19-0.73, p=0.004), and admissions for bleeding (0.50% vs. 2.30%, HR 0.20, 95% CI 0.07-0.58, p=0.003). Pericardial complications were similar in both groups. Conclusion: LAAO was associated with a lower risk of stroke and major bleeding in patients with HCM and AF. Future prospective studies on the safety and efficacy of LAAO in concurrent AF and HCM are needed.

Risk of stroke or systemic embolism in patients with degenerative mitral stenosis with or without atrial fibrillation: A cohort study.

BackgroundAtrial fibrillation (AF) is associated with an increased risk of stroke and the combination of AF and mitral stenosis (MS) is associated with a higher risk. In developed nations, degenerative mitral stenosis (DMS) constitutes a sizeable proportion of patients with MS. Current international guidelines do not offer recommendations regarding anticoagulation in these patients. The objective of this study was to describe the incidence of stroke or systemic embolism in patients with DMS with or without prevalent AF.MethodsA cohort study of DMS patients from 1997 to 2018, using data from the Danish health registries. The cohort was stratified based on AF prevalence and prior ischemic stroke. The primary outcome was a diagnosis of ischemic stroke or systemic embolism after 1 year of follow-up from time of DMS diagnosis.ResultsThe study included 1162 patients with DMS, of which 421 had prevalent AF. The incidence rate of stroke or systemic embolism after 1 year of follow-up was highest in the DMS without AF group (7.58 vs. 6.63 per 100 person-years). In both groups, DMS without AF and DMS with AF, the incidence rate was highest in patients with prior thromboembolic events (29.61 vs. 5.15 and 19.53 vs. 5.15, respectively).ConclusionsThe incidence rate of stroke or systemic embolism was highest in DMS patients without AF. Current Danish guidelines recommend DMS patients should be treated with anticoagulation only with concurrent AF, yet our results call for additional research to establish if DMS patients without AF could benefit from stroke prevention therapy.

Premature ventricular complexes are not independently associated with concurrent paroxysmal atrial fibrillation on mobile cardiac telemetry

Abstract Background Premature ventricular complexes (PVCs) on 24hECG predict incident atrial fibrillation in long-term prospective studies, but whether PVCs detected on ambulatory monitoring indicate a risk of concurrent paroxysmal atrial fibrillation is unknown. Objectives To determine whether PVCs predict paroxysmal atrial fibrillation on ≤30-day ambulatory mobile cardiac telemetry (MCT). Methods US patients aged 17–100 years with 2–30 full days of ambulatory full-disclosure ECG using a mobile cardiac telemetry device, without atrial fibrillation on their first day of recording, were included. The association between PVC frequency on recording day 1 and and the outcome of atrial fibrillation ≥30 seconds during subsequent recording days was analysed using age and sex adjusted logistic regression models and restricted cubic splines, with additional adjustment for premature atrial contractions (PACs). Results The study population included 18,220 patients with a mean age 64 years; 58% were female. Median monitoring duration was 19 days (interquartile range 9–29). PVC and PAC frequency were moderatly correlated, Spearmans rho 0.359, p&amp;lt;0.0001. Using logistic regression analyses adjusted for age, sex and recording duration, PVCs were associated with atrial fibrillation detection (Figure 1a), but in models additionally adjusted for PAC frequency there was no remaining effect of PVC frequency on atrial fibrillation risk (Figure 1b). Conclusions A finding of PVCs, in the absence of PACs, on 24hECGs does not imply increased risk of concurrent paroxysmal atrial fibrillation detected on ≤30 day MCT. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Hjärt-Lungfonden, Swedish Society for Medical Research

To compare efficacy and safety of direct oral anticoagulants in patients with concurrent atrial fibrillation and bioprosthetic heart valve repair or replacement: a systematic review and meta-analysis

Abstract Background Use of direct oral anticoagulants (DOACs) is contraindicated in patients with mechanical valves. However data on their use in patients with atrial fibrillation (AF) and bioprosthetic valves (BV) is still limited. Purpose To assess the safety and efficacy of DOACs versus Vitamin K antagonist (VKA) in patients with AF after BV repair or replacement. Methods We performed a comprehensive review of electronic databases (PubMed, Embase, Scopus, Cochrane) using MeSH terms and keywords for DOACs, AF and BVs from inception through December 2021. Randomized clinical trials (RCT) or observational studies that reported clinical outcomes comparing DOACs versus VKA in patients with AF and BVs were eligible for inclusion. Ten articles were reviewed for full text. Primary outcome was a composite of all cause stroke or systemic embolic event. Secondary outcomes included major bleeding and all-cause mortality. Subgroup analysis stratified by study design was performed. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using Mantel-Haenszel method with DerSimonian-Laird estimator for tau2 for random effects model. Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis was performed using RevMan 5.4.1 software. Results Ten studies (5 RCTs, 5 observational studies) with a total of 5,333 patients (DOACs n=2434; VKA n=2899) were included. Aortic, mitral and mixed BV repair or replacement were 74.2%, 25.6% and 0.02% respectively. The mean age was 72.6±11.9 years. The mean follow-up was 15.7±12.9 months. Type of DOACs included apixaban (n=553, 22.7%), rivaroxaban (n=893, 36.7%), dabigatran (n=151, 6.2%) and edoxaban (n=837, 34.4%). There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.79; CI: 0.56–1.11; p&amp;gt;0.05; I2=12%) or secondary outcomes of major bleeding (RR: 0.84; CI: 0.64–1.11; p&amp;gt;0.05; I2=45%), and all-cause mortality (RR: 0.84; CI: 0.64–1.11; p&amp;gt;0.05; I2=29%) between DOACs compared with VKA. Conclusion In patients with AF and BV, DOACs are non-inferior to VKA for risk of stroke or systemic embolism, major bleeding, and all-cause mortality. Thus, DOACs can serve as a viable alternative to VKAs which have a narrow therapeutic index, multiple drug interactions, and require frequent monitoring. Funding Acknowledgement Type of funding sources: None.

Detection of Atrial Fibrillation in a Large Population Using Wearable Devices: The Fitbit Heart Study.

Morbidity from undiagnosed atrial fibrillation (AF) may be preventable with early detection. Many consumer wearables contain optical photoplethysmography (PPG) sensors to measure pulse rate. PPG-based software algorithms that detect irregular heart rhythms may identify undiagnosed AF in large populations using wearables, but minimizing false-positive detections is essential. We performed a prospective remote clinical trial to examine a novel PPG-based algorithm for detecting undiagnosed AF from a range of wrist-worn devices. Adults aged ≥22 years in the United States without AF, using compatible wearable Fitbit devices and Android or iOS smartphones, were included. PPG data were analyzed using a novel algorithm that examines overlapping 5-minute pulse windows (tachograms). Eligible participants with an irregular heart rhythm detection (IHRD), defined as 11 consecutive irregular tachograms, were invited to schedule a telehealth visit and were mailed a 1-week ambulatory ECG patch monitor. The primary outcome was the positive predictive value of the first IHRD during ECG patch monitoring for concurrent AF. A total of 455 699 participants enrolled (median age 47 years, 71% female, 73% White) between May 6 and October 1, 2020. IHRDs occurred for 4728 (1%) participants, and 2070 (4%) participants aged ≥65 years during a median of 122 (interquartile range, 110-134) days at risk for an IHRD. Among 1057 participants with an IHRD notification and subsequent analyzable ECG patch monitor, AF was present in 340 (32.2%). Of the 225 participants with another IHRD during ECG patch monitoring, 221 had concurrent AF on the ECG and 4 did not, resulting in an IHRD positive predictive value of 98.2% (95% CI, 95.5%-99.5%). For participants aged ≥65 years, the IHRD positive predictive value was 97.0% (95% CI, 91.4%-99.4%). A novel PPG software algorithm for wearable Fitbit devices exhibited a high positive predictive value for concurrent AF and identified participants likely to have AF on subsequent ECG patch monitoring. Wearable devices may facilitate identifying individuals with undiagnosed AF. URL: https://www. gov; Unique identifier: NCT04380415.

Advanced Interatrial Block Predicts Recurrence of Atrial Fibrillation and Ischemic Stroke in Elderly Patients With Hypertension.

Background: This study aimed to investigate whether advanced interatrial block (IAB) is a predictor of recurrent atrial fibrillation (AF) and/or ischemic stroke in elderly patients with AF and hypertension. Methods and objectives: Five hundred and sixteen elderly inpatients (mean age 85.53 ± 9.08 years; 5.43% women) with concurrent paroxysmal AF and hypertension were enrolled in this retrospective observational study. Data on comorbidity, medication, digital electrocardiograms (ECG), and outcomes were obtained from the medical records and follow-up examinations. IAB was classified as partial IAB or advanced IAB according to 12-lead surface ECG analysis on admission. Advanced IAB was defined as a maximum P wave duration of >120 ms with biphasic (±) morphology in leads II, Ⅲ, and aVF by two blinded investigators. The endpoints were recurrent AF and ischemic stroke. Results: We enrolled 120 patients (23.26%) with partial IAB and 187 (36.24%) with advanced IAB. The mean follow-up duration was 19 months. A total of 320 patients (62.02%) developed AF recurrence, and 31 (6.01%) experienced ischemic stroke. Significant predictors of advanced IAB in multivariate analysis were older age (>80 years), increased left atrial diameter (>40 mm), and being overweight (body mass index >25 kg/m2). In the multivariable comprehensive Cox regression analyses, partial IAB was associated with AF recurrence. Advanced IAB was an independent predictor of increased risk of AF recurrence and ischemic stroke. Conclusion: Both partial and advanced IAB are associated with AF recurrence in elderly patients with hypertension. Furthermore, advanced IAB is an independent predictor of ischemic stroke.