Differences In Atrial Fibrillation Research Articles

Abstract 92: Impacts of a Multidisciplinary Brain Heart Team on Patent Foramen Ovale Closure in Patients With Cryptogenic Stroke

Background: The AHA/ASA 2021 Secondary Stroke Prevention Guideline recommends a joint decision by neurology and cardiology for patent foramen ovale (PFO) closure. The impact of a Brain Heart Team (BHT) consisting of interventional cardiologists and vascular neurologists to evaluate PFO closure is unclear. We analyzed whether a BHT implementation led to more guideline recommended PFO closures based on Risk of Paradoxical Embolism (RoPE) score and PASCAL categories across a 15-hospital system. Methods: Data were collected retrospectively between 1/2016 - 2/2023. Baseline demographics, risk factors, method of shunt identification, high-risk shunt features, post PFO atrial fibrillation and stroke rates, RoPE score and PASCAL categorization were abstracted. Non-BHT was defined as absence of vascular neurology involvement. Appropriate PFO closure was defined as RoPE score > 7 and/or PASCAL categories of possible/probable. Chi-squared and t-test were used. Results: Of 174 patients, 108 (62%) were identified as BHT and 66 (38%) as non-BHT. There were no differences in baseline risk factors between BHT and non-BHT besides hyperlipidemia (28.7% vs 53% p < .002) and smoking history (12% vs 31.8% p < .003). BHT patients were younger at age of diagnosis and PFO closure (44.8 yrs ±1.7 vs 56 yrs ±1.2 p=0.003 and 44.7 yrs ±1.9 vs. 56 yrs ±1.3 p=0.004 respectively). There were differences in race/ethnicity (Table 1). More BHT patients had possible/probable PASCAL vs non-BHT (101 [93.5%] vs 44 [66.7%], p <0.001). Patients in BHT had higher mean RoPe scores (7.34 ± 1.55 vs 6.06 ± 2.02 p <0.001). More patients in BHT had a RoPE score > 7 (77 [71.3%] vs 26 [39.4%] p <0.001). There were no differences in atrial fibrillation (5 [4.6%] vs 5 [7.6%] p = 0.635) or stroke after PFO closure (2 [1.9%] vs 2 [3%] p = 1). Conclusion: Implementing a multi-disciplinary approach with a Brain Heart Team leads to more guideline based PFO closures in cryptogenic strokes based on PASCAL and RoPE scores.

Trends and sex differences in atrial fibrillation among patients hospitalized due to asthma: Insights from a nationwide population-based discharge database in Spain, 2016–2021

AimsTo analyze changes in the prevalence of atrial fibrillation (AF) in patients hospitalized due to asthma; to compare hospital outcomes in asthma patients with and without AF, assessing sex differences; to identify variables associated with the presence of AF; and to analyze the factors associated with in-hospital mortality (IHM) among asthma patients with AF. MethodsWe used data from the Registry of Specialized Care Activity-Basic Minimum Data Set to select all patients aged ≥40 years with an asthma diagnosis in Spain, from 2016 to 2021. We stratified the study population according to the presence of AF and sex. ResultsWe identified 65,233 hospitalizations that met the inclusion criteria (14.85 % with AF). The prevalence of AF significantly increased over time, with the male sex being a protective factor for its presentation. IHM were significantly higher in patients with AF. Older age, being a woman, congestive heart failure, renal disease, obstructive sleep apnea, hypertension, and hyperthyroidism were associated with the presence of AF. Advanced age and the presence of cancer and COVID-19 were factors associated with a higher IHM, as well as admission to an intensive care unit and the use of invasive mechanical ventilation. There were no association of sex with the IHM. ConclusionsAF is highly prevalent among subjects hospitalized due to asthma, with this prevalence having increased significantly in Spain over time. The presence of AF in patients with asthma was associated significantly with a higher LOHS and IHM. Sex was not associated with IHM in these patients.

Women have less progression of paroxysmal atrial fibrillation: data from the RACE V study

BackgroundSex differences in atrial fibrillation (AF) are observed in terms of comorbidities, symptoms, therapies received, AF progression and cardiovascular complications.MethodsWe assessed the differences in prevalence and the determinants of AF...

Gender-Based Clinical, Therapeutic Strategies and Prognosis Differences in Atrial Fibrillation.

There are limited data on gender-based differences in atrial fibrillation (AF) treatment and prognosis. We aimed to examine gender-related differences in medical attention in an emergency department (ED) and follow-up (FU) among patients diagnosed with an AF episode and to determine whether there are gender-related differences in clinical characteristics, therapeutic strategies, and long-term adverse events in this population. We performed a retrospective observational study of patients who presented to a tertiary hospital ER for AF from 2010 to 2015, with a minimum FU of one year. Data on medical attention received, mortality, and other adverse outcomes were collected and analyzed. Among the 2013 patients selected, 1232 (60%) were female. Women were less likely than men to be evaluated by a cardiologist during the ED visit (11.5% vs. 16.6%, p = 0.001) and were less likely to be admitted (5.9% vs. 9.5%, p < 0.05). Electrical cardioversion was performed more frequently in men, both during the first episode (3.4% vs. 1.2%, p = 0.001) and during FU (15.9% vs. 10.6%, p < 0.001), despite a lower AF recurrence rate in women (9.9% vs. 18.1%). During FU, women had more hospitalizations for heart failure (26.2% vs. 16.1%, p < 0.001). In patients with AF, although there were no gender differences in mortality, there were significant differences in clinical outcomes, medical attention received, and therapeutic strategies. Women underwent fewer attempts at cardioversion, had a lower probability of being evaluated by cardiologists, and showed a higher probability of hospitalization for heart failure. Being alert to these inequities should facilitate the adoption of measures to correct them.

Atrial pacing minimization in sinus node dysfunction and risk of incident atrial fibrillation: a randomized trial.

High percentages of atrial pacing have been associated with an increased risk of atrial fibrillation. This study is aimed at evaluating whether atrial pacing minimization in patients with sinus node dysfunction reduces the incidence of atrial fibrillation. In a nationwide, randomized controlled trial, 540 patients with sinus node dysfunction and an indication for first pacemaker implantation were assigned to pacing programmed to a base rate of 60 bpm and rate-adaptive pacing (DDDR-60) or pacing programmed to a base rate of 40 bpm without rate-adaptive pacing (DDD-40). Patients were followed on remote monitoring for 2 years. The primary endpoint was time to first episode of atrial fibrillation longer than 6 min. Secondary endpoints included longer episodes of atrial fibrillation, and the safety endpoint comprised a composite of syncope or presyncope. The median percentage of atrial pacing was 1% in patients assigned to DDD-40 and 49% in patients assigned to DDDR-60. The primary endpoint occurred in 124 patients (46%) in each treatment group (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.76-1.25, P = .83). There were no between-group differences in atrial fibrillation exceeding 6 or 24 h, persistent atrial fibrillation, or cardioversions for atrial fibrillation. The incidence of syncope or presyncope was higher in patients assigned to DDD-40 (HR 1.71, 95% CI 1.13-2.59, P = .01). Atrial pacing minimization in patients with sinus node dysfunction does not reduce the incidence of atrial fibrillation. Programming a base rate of 40 bpm without rate-adaptive pacing is associated with an increased risk of syncope or presyncope.

Sex Differences in Atrial Fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The estimated lifetime risk of developing AF is higher in men; however, due to differences in life expectancy, the overall prevalence is higher among women, particularly in the older age group. Sex differences play an important role in the pathophysiology, presentation, and clinical outcomes of AF. Awareness of these differences minimizes the potential for disparities in AF management. Our review summarizes the current literature on sex differences in AF, including the epidemiology, pathophysiology, risk factors, clinical symptomatology, mechanisms, treatment, and outcomes. We also explore the implications of these differences for clinical practice and future research. Women are more likely to present with atypical symptoms, have a higher stroke risk, and have a worse quality of life with AF when compared to men. Despite this, they are less likely to receive rhythm control strategies and anticoagulants. The sex-based differences in AF pathology and management might be a combination of inherent biological and hormonal differences, and implicit bias of the research entities and treating clinicians. Our review stresses the need for further sex-specific research in the pathophysiology of AF and opens a dialogue on personalized medicine, where management strategies can be tailored to individual patient characteristics, including sex.

Sex differences in atrial fibrillation and progression to dementia

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The National Institute of Aging (NIA) is a division of the U.S. National Institutes of Health (NIH) Background Atrial fibrillation (AF) is recognized as an independent risk factor for cognitive disease such as mild cognitive impairment (MCI) and Alzheimer’s disease (AD). Women with AF experience more symptoms and worse outcomes of AF and stroke than men. Greater understanding is needed about whether sex differences exist in AF-related dementia incidence and prevalence. Purpose To address sex differences in AF-related cognitive disease, we examined disease prevalence and progression among adults with and without AF in the U.S. National Alzheimer’s Coordinating Center (NACC) cohort. Methods Data freeze/extraction of NACC data (N= 43,630) took place March 2021. Participants with ≥ 3 annual visits, diagnostic data, and AF status (self-reported or clinically diagnosed) were included. Cognition status was determined at each visit as normal, MCI, or dementia. Five domains evaluated by neuropsychological testing included attention, language, memory, executive functioning, and global cognition. Multinomial logistic regression and Cox proportional hazard model were used to examine association between AF and baseline cognitive diagnosis and time to progression in cognitive diagnosis, respectively. Covariates included age, sex, race, education, BMI, smoking, depression, hypertension, diabetes, hypercholesterolemia, heart failure, stroke, and sleep apnea. Interactions with sex were examined in all models. Results 4,593 participants had AF at baseline. AF participants were 46% female, mean age 78.5, 81% White, 8% Black, 11% other ethnicities. There were significant declines in 3 of 5 cognitive domains (executive function, verbal ability, and memory) among participants with AF compared to those without AF. AF is associated with higher odds of having MCI (OR 3.43 [1.55, 7.55] in females; OR 1.73 [0.81, 3.71] in males) and dementia (OR 3.00 [1.22, 7.38] in females; OR 1.60 [0.87, 2.97] and in males). Among the 13,683 subjects included in the survival analysis, 4066 (30%) progressed from normal cognition to MCI or dementia and 2895 (21%) developed dementia with median follow-up of 3.98 years. Women with AF had higher risk of more rapid disease progression (HR 1.21 [1.04, 1.40]) compared to women without AF, but the association was not significant in men (HR 0.96 [0.83, 1.11]). AF was significantly associated with faster transition from normal cognition to MCI (HR 1.17 [1.03, 1.33]) and from MCI to vascular dementia (HR 2.57 [1.63, 3.95]) but not MCI to AD. Conclusions Women with AF are at higher risk of MCI and dementia with faster transition from normal cognition to MCI and dementia than women without AF or men with and without AF. Future research should focus on early identification of those individuals with AF at highest risk of cognitive disease and development of interventions to prevent or slow AF-related MCI and vascular dementia.

Sex Differences in Atrial Fibrillation and Associated Complications in Hypertensive Patients with Left Ventricular Hypertrophy: The LIFE Study.

There is no consensus on whether biological differences account for the higher risk of stroke seen in females compared to males with atrial fibrillation (AF). Capitalizing on The Losartan Intervention for Endpoint study, a multicenter randomized clinical trial randomizing 9,193 patients and followed for at least four years, we aimed to identify sex differences in the risk of stroke in the presence of AF in patients with hypertension and left ventricular hypertrophy (LVH). 342 Patients had a history of AF, and 669 developed new-onset AF. History of AF and new-onset AF were more prevalent among males (5.0% vs. 2.9% and 3.0% vs. 0.9%) in patients aged 55-63 years, but the relative difference decreased with age. Females with new-onset AF tended to have a higher risk of stroke than males (HR 1.52 [95% CI 0.95-2.43]). However, females with a history of AF did not have a higher risk than males (HR 0.88 [95% CI 0.5-1.6]). In patients with new-onset AF, the relative higher stroke risk in females increased with age. Among patients with a history of AF, stroke risk was comparable and increased with age in both sexes. Among patients with hypertension and LVH, females with new-onset AF had a higher risk of stroke than males, especially in patients above 64 years. However, the risk did not differ between the sexes among patients with a history of AF.

Association of Body Mass Index and Abdominal Obesity with Incidence of Atrial Fibrillation in Heart Failure with Preserved Ejection Fraction.

The association between obesity and atrial fibrillation (AF) incidence in heart failure with preserved ejection fraction (HFpEF) patients is currently unclear. Our analyses and results are based on the whole Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial (placebo and spironolactone). A total of 2138 subjects without baseline AF were included in the trial. Kaplan-Meier (K-M) curves and Cox regression with hazard ratios (HRs) and confidence intervals (CIs) were used to assess the incidence of AF with obesity. Of 2138 HFpEF patients without baseline AF, 1165 were obese (body mass index [BMI]≥30 kg/m2). The K-M curve showed obese patients developed AF more than overweight (25≤ BMI ≤29.9 kg/m2) patients (p=0.013), confirmed by multivariable analysis, while there's no statistical difference between overweight and normal weight (18.5≤ BMI ≤24.9 kg/m2) patients. The occurrence of AF increased by 3% for every kg/m2 increase in BMI (adjusted HR, aHR: 1.03; 95% CI: 1.00-1.06), with a positive linear association (p for nonlinear: 0.145). Obesity was associated with AF incidence (aHR: 1.62; 95% CI: 1.05-2.50) compared with non-obesity (including overweight and normal-weight patients). Abdominal obesity was associated with increased AF incidence (aHR: 1.70; 95% CI: 1.04-2.77), and AF incidence rose by 18% per centimeter in circumference (aHR: 1.18; 95% CI: 1.04-1.34). Obesity and abdominal obesity increase the incidence of AF in HFpEF patients. Further studies need to determine whether there is a difference in AF in response to spironolactone across obese HFpEF pheno groups.

Gender Differences in Atrial Fibrillation: From the Thromboembolic Risk to the Anticoagulant Treatment Response

Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with an increased thromboembolic risk. The impact of the female sex as an independent risk factor for thromboembolic events in AF is still debated. Background and Objectives: The aim of this review is to evaluate the gender-related differences in cardioembolic risk and response to anticoagulants among AF patients. Materials and Methods: The PubMed database is used to review the reports about gender differences and thromboembolic risk in atrial fibrillation. Results: Non-vitamin K oral anticoagulants (NOACs) represent the gold standard for thromboembolic risk prevention in patients with non-valvular atrial fibrillation (NVAF). Despite a similar rate of stroke and systemic embolism (SE) among men and women in NOACs or vitamin K antagonists (VKAs) treatment, the use of NOACs in AF women is associated with a lower risk of intracranial bleeding, major bleeding, and all-cause mortality than in men. Conclusions: The female sex can be defined as a stroke risk modifier rather than a stroke risk factor since it mainly increases the thromboembolic risk in the presence of other risk factors. Further studies about the efficacy and safety profile of NOACs according to sex are needed to support clinicians in performing the most appropriate and tailored anticoagulant therapy, either in male or female AF patients.

Sex Differences in the Regional Analysis of Nonpulmonary Vein Foci and Epicardial Adipose Tissue in Patients With Atrial Fibrillation

The mechanism underlying the sex differences in atrial fibrillation (AF) recurrence following pulmonary vein (PV) isolation is not fully understood. We hypothesized that non-PV foci and epicardial adipose tissue (EAT) play a key role.Methods and Results: Data from 304 consecutive patients (75% males) who underwent contrast-enhanced computed tomography and catheter ablation of AF were reviewed. The EAT around the atrium was measured separately in 4 parts of the atrium. All patients underwent high-dose isoproterenol infusions to assess the non-PV foci. Significantly more non-PV foci and less EAT around the atrium were observed in female patients than in male patients. In males, those with non-PV foci on the left atrial (LA) anterior wall had significantly greater EAT for the same lesions than those without non-PV foci. During a median follow-up of 27 months, the predictors of AF recurrence after first catheter ablation were female sex, presence of non-PV foci, LA diameter, and septal EAT index. A sex-specific analysis revealed that LA diameter was a predictor only in males and that the presence of non-PV foci in the septal region was a strong predictor in males (hazard ratio [HR]: 2.24) and females (HR: 3.65). Sex-specific differences were observed in non-PV foci sites and local EAT and in regard to the predictors of AF recurrence.

Abstract 12847: Atrial Fibrillation and Atrial Flutter: What Are the Substrate Differences Seen in 3D Panoramic Optical Mapping?

Background: Panoramic optical mapping (POM) is an effective tool for 3D visualization and analysis of action potential duration (APD) heterogeneity, a key driver for initiation and persistence of reentry. POM may elucidate cardiac electrophysiological predisposition to develop chaotic arrhythmia such as atrial fibrillation (AF) or organized arrhythmia such as atrial flutter (AFL). Objective: To determine the APD differences in AF and AFL in a transgenic (TG) murine model. Methods: We performed high resolution POM with 4 simultaneous CMOS cameras on 14 Langendorff perfused TG murine hearts (SCN5A mutation at lidocaine binding site F1759A) with spontaneous AF and AFL. We generated serial 2D activation and APD maps in normal sinus rhythm (NSR), while phase movies were created in AF/AFL. All optical maps were then reconstructed in 3D. We averaged the APD80 and APD dispersion values over each atrial chamber and compared the mean differences: i) within AF and AFL across right atrium (RA) and left atrium (LA); and ii) within RA and LA across AF and AFL. Results: AF (n=7) and AFL (n=7) were present at baseline (8/14) or induced by 10Hz burst pacing (6/14). Mean APD80 in RA/LA was: 57.03 ± 4.66 / 50.93± 3.38ms (p&lt;0.05) in AF vs 77.18 ± 4.30 / 58.25 ± 3.88ms (p&lt; 0.01) in AFL, and mean dispersion: 6.23 ± 1.04/ 7.25± 1.71ms in AF vs 5.49 ± 0.80/ 8.42 ± 1.15ms (p&lt;0.01) in AFL. High mean APD80 in the RA with low intra-atrial dispersion in the RA lead to AFL rotational reentry cores, while lower overall APD80 values with high intra-atrial dispersion in the LA resulted in the presence of AF phase singularity points. Conclusion: Development of AF was associated with high intra-atrial APD dispersion in NSR, whereas AFL was associated with high inter-atrial APD dispersion in NSR (1.4-fold higher mean APD80 in the RA). Certain atrial APD dispersion patterns observed in NSR are associated with development of chaotic vs. organized atrial arrhythmias.

Sex differences in presentation of atrial fibrillation: Findings from 30-day ambulatory monitoring in real-world practice

BackgroundWomen are less likely to receive oral anticoagulation or ablation for treatment of atrial fibrillation (AF). Identification of sex differences in arrhythmia characteristics and symptoms may lead to a better understanding of potential reasons for these differences. ObjectivesTo determine sex differences in AF with respect to heart rate, duration, burden, and symptoms in patients undergoing mobile cardiac telemetry (MCT) monitoring. MethodsAll patients who registered for ≤30-day MCT using PocketECG (MediLynx) in the USA in 2017 were included (n = 27,512, 58 % women). PocketECG records and transmits a three-lead ambulatory electrocardiogram (ECG) with real-time beat-to-beat analysis. Sex-related differences were analyzed with Chi2 and Spearmans rho. ResultsFewer women than men were diagnosed with AF lasting ≥30s (13.7 % versus [vs] 19.0 %, p < 0.001). AF burden was lower in women in all age groups <90 years (all p < 0.01). Women were older at the time of AF diagnosis (median 76 vs 73 years, p < 0.001), had faster heart rate during AF (mean: 104.7 ± 26.0 vs 96.7 ± 26.7 bpm, p < 0.001), and shorter AF duration (mean: 96.2 ± 176.0 vs 121.6 ± 189.9 min, p < 0.001). There was a non-significant trend toward more symptoms (such as dizziness, racing heart, fatigue, or palpitations) during AF in women compared to men (46.5 % vs 43.7 %, p = 0.062). ConclusionsAF was less prevalent and occurred at lower burdens in women than men in each age strata. Despite faster heart rates in AF in women, there were no significant sex differences in reported symptoms during AF. Sex differences in therapy cannot be explained by differences in symptoms or rates in AF. Condensed abstractReal-world data on sex differences in AF using a 30-day MCT monitoring device remain scarce. We aim to determine the sex differences in AF with respect to prevalence, burden, heart rate, and symptom in patients undergoing ≤30-day MCT monitoring. Our data analysis suggests that fewer women than men had AF, women were older at diagnosis of AF, and women with AF had higher mean heart rate, shorter mean AF duration, and lower mean AF burden than men. Further studies are needed to examine reasons for sex differences, specifically in relation to AF therapy and its impact on clinical outcomes.

Differences in Left Atrial Size and Function and Supraventricular Ectopy Between Black and White Participants in the ARIC Study.

BackgroundBlack Americans have more atrial fibrillation risk factors but lower atrial fibrillation risk than White Americans. Left atrial (LA) enlargement and/or dysfunction, frequent atrial tachycardia (AT), and premature atrial contractions (PAC) are associated with increased atrial fibrillation risk. Racial differences in these factors may exist that could explain the difference in atrial fibrillation risk.Methods and ResultsWe included 2133 ARIC (Atherosclerosis Risk in Communities) study participants (aged 74±4.5 years[mean±SD], 59% women, 27% Black participants) who had echocardiograms in 2011 to 2013 and wore the Zio XT Patch (a 2‐week continuous heart monitor) in 2016 to 2017. Linear regression was used to analyze (1) differences in AT/day or PAC/hour between Black and White participants, (2) differences in LA measures between Black and White participants, and (3) racial differences in the association of LA measures with AT or PAC frequency. Compared with White participants, Black participants had a higher prevalence of cardiovascular risk factors and disease, lower AT frequency, greater LA size, and lower LA function. After multivariable adjustments, Black participants had 37% (95% CI, 24%–47%) fewer AT runs/day than White participants. No difference in PAC between races was noted. Greater LA size and reduced LA function are associated with more AT and PAC runs; however, no race interaction was present.ConclusionsDifferences in LA measures are unlikely to explain the difference in atrial fibrillation risk between Black and White individuals. Despite more cardiovascular risk factors and greater atrial remodeling, Black participants have lower AT frequency than White participants. Future research is needed to elucidate the protective mechanisms that confer resilience to atrial arrhythmias in Black individuals.

Myocardial infarction with non obstructive coronary arteries (MINOCA) according to definitions of 2020 ESC Guidelines: clinical profile and prognosis

Abstract Background MINOCA's physiopathology, treatment and prognosis are yet to be completely understood. The aim of this study is to compare baseline characteristics and prognosis of MINOCA patients and those of patients with myocardial infarction (MI) and obstructive coronary arteries. Methods We analysed all consecutive patients with MI who underwent coronary angiography admitted in a University Hospital covering a population of 220.000 people during a period of 60 months. The database and the all the patient's angiographies were revised by a group of experts in order to adequate MINOCA to 2020 ESC Guidelines definition and the American Heart Association position paper. Results 680 patients, 68 of whom were MINOCA (10%) with a median of follow up of 31±16 months were analysed (see table 1). We found no differences in both groups' age. Female gender was more prevalent among MINOCA patients. The underlying mechanism in MINOCA was coronary spasm (17.6%), plaque rupture (13.2%), coronary embolism (7.4%), coronary dissection (2.9%), type II infarction (19.1%) or unknown (39.7%). Coronary arteries in MINOCA patients had no obstructions at all in 57.4%, and 30–50% obstruction in 42.6% of the cases. MINOCA patients didn't have higher prevalence of cancer, autoimmune or psychiatric diseases, dyslipidaemia, hypertension or inflammatory analytical parameters. However, we found significant differences in atrial fibrillation, migraine, connective tissue diseases, tobacco use and diabetes. We found no effect of stress in the development of MINOCA (measured with validated STAI and DS-14 scales). Symptoms at admission didn't differ between the two groups, but those with MINOCA had normal ECG more frequently. Prognosis showed relevant differences, as MINOCA patients had less major cardiovascular complications, such as inotropic requirements (0% Vs 4.8%, p=0.04), shock (0% vs 6.6%, p=0.013) and left ventricular dysfunction (11.8 vs 30.2, p=0.015). Furthermore, myocardial injury biomarkers' levels were, significantly lower in MINOCA patients. Death rates tend to be lower both in hospital (0% vs 3.1%, p=0.131) and during follow up (9.1% vs 11.5%, p=0.369). Conclusion Analysing MINOCA patients' clinical profile might help us understanding the underlying physiopathology, prognosis and treatment targets. In these patients, classic cardiovascular risk factors don't appear to be as important as in obstructive patients. At admission, we found no clinical differences that could help making an early diagnosis, even if those with normal ECG and lower levels of myocardial injury biomarkers are more likely to have non-obstructive coronary arteries. These patients seem to have better prognosis and lower myocardial injury than those with obstructive coronary arteries. Further research is needed to provide more evidence on the accurate treatment of these patients. Funding Acknowledgement Type of funding sources: None.

Sex differences in atrial fibrillation: patient-reported outcomes and the persistent toll on women

BackgroundWomen have worse patient-reported outcomes in atrial fibrillation (AF) than men, but the reasons remain poorly understood. We investigated how comorbid conditions, treatment, social factors, and their modification by sex would attenuate sex-specific differences in patient-reported outcomes in AF. MethodsIn a cohort with prevalent AF we measured patient-reported outcomes with the Short-Form-12 (SF-12, an 8-domain quality of life measure), and the AF Effect on QualiTy of Life (AFEQT), an instrument specific to AF, both with range 0-100 and higher scores indicating superior outcomes. We examined sex-specific differences in patient-reported outcomes in multivariable-adjusted regression analyses incorporating demographics, comorbid conditions, treatment, social factors, and their sex-based modification. ResultsIn 339 individuals (age 72±10, 45% women), women (vs. men) reported worse physical functioning on the SF-12 (49.7±39.0 versus 65.0±34.0), social functioning (69.8±31.8 versus 79.7±25.8), and mental health (67.4±20.2 versus 75.0±18.6). These differences were attenuated with adjustment for comorbid conditions and depression. Women had worse composite AFEQT scores (73.8±18.4 versus 78.5±16.6) and symptoms and treatment scores than men with differences remaining significant after multivariable adjustment. There were not significant interactions by sex and the array of covariates when examining differences in patient-reported outcomes between women and men. ConclusionsWe identified sex-specific differences in patient-reported outcomes assessed with general and AF-specific measures. Compared to men, women with AF reported worse overall health-related quality of life, even after consideration of both relevant covariates and their modification by sex. Our research indicates the importance of consideration of sex-based inequities when evaluating patient-reported outcomes in AF.

Revealing the Influences of Sex Hormones and Sex Differences in Atrial Fibrillation and Vascular Cognitive Impairment.

The impacts of sex differences on the biology of various organ systems and the influences of sex hormones on modulating health and disease have become increasingly relevant in clinical and biomedical research. A growing body of evidence has recently suggested fundamental sex differences in cardiovascular and cognitive function, including anatomy, pathophysiology, incidence and age of disease onset, symptoms affecting disease diagnosis, disease severity, progression, and treatment responses and outcomes. Atrial fibrillation (AF) is currently recognized as the most prevalent sustained arrhythmia and might contribute to the pathogenesis and progression of vascular cognitive impairment (VCI), including a range of cognitive deficits, from mild cognitive impairment to dementia. In this review, we describe sex-based differences and sex hormone functions in the physiology of the brain and vasculature and the pathophysiology of disorders therein, with special emphasis on AF and VCI. Deciphering how sex hormones and their receptor signaling (estrogen and androgen receptors) potentially impact on sex differences could help to reveal disease links between AF and VCI and identify therapeutic targets that may lead to potentially novel therapeutic interventions early in the disease course of AF and VCI.

Interventional occlusion of left atrial appendage in patients with atrial fibrillation. Gender-related outcomes in the German LAARGE Registry.

Gender-based differences in atrial fibrillation have been identified, but limited data exist for patients undergoing left atrial appendage occluder (LAAO) implantation. This study reports gender-related periprocedural and 1-year outcomes of the prospective, multicenter German left atrial appendage occlusion registry (LAARGE). LAARGE enrolled 641 patients who were scheduled for LAAO implantation from July 2014 to January 2016 in 38 hospitals in Germany. The data collected included demographics, clinical characteristics, details of implantation, and outcome. Efficacy and safety at 1-year follow-up were assessed by the occurrence of thrombembolic and bleeding events, as well as mortality. Of 638 patients undergoing LAAO implantation 38.9% were female and 61.1% male. Females were older (76.4 ± 8.2 [females] vs. 75.6 ± 7.7 [males], p = .042) and had a higher stroke risk (CHA2 DS2 -VASc score: 4.9 ± 1.5 vs. 4.3 ± 1.5, p < .001). In contrast, males suffered more often from coronary artery (33.1% vs. 53.8%, p < .001) and vascular disease (18.5% vs. 31.0%, p < .001). Technical success was high and similar for both genders (98.4% vs. 97.2%, p = .33). Severe periprocedural complications (6.9% vs. 3.1%, p = .032) occurred more often in females. At 1-year follow-up the rates of all-cause stroke (0.5% vs. 1.3%, p = .65) and severe bleeding (0.0% and 1.0%, p = .29) were low and comparable between the genders. Also, one-year all-cause mortality (9.2% vs. 13.1%, p = .14) did not differ significantly. LAARGE documented in this elderly patient population undergoing LAAO implantation a higher rate of severe periprocedural complications in females. At 1-year follow-up similar efficacy and safety outcomes were observed for both genders.

Atrial Fibrillation: Are Associated Risk Factors Surrogates for an Inflammatory State?

Today’s understanding of the inflammatory process has evolved far beyond what was initially described by Celsus in the 1st Century A.D [1]. Terms like oxidative stress, reactive oxygen species (ROS), cytokines, and fibrosis have been thrown around in everyday scientific discussions for some time now. Well-known pathways of the “inflammatory state” have underpinned many common cardiovascular diseases such as the atherosclerotic process. However, there are less recognized entities where inflammation seems to play a key role in their mechanisms of origin. The concept of inflammation in atrial fibrillation (AF) is not a novel one, but this characteristic of its pathophysiology seems to have been overshadowed by the inherent dangers of its complications. More emphasis has been placed instead on its associated risk factors, which alone, or in combination, contribute to the development of AF. The risk factor burden and the arrhythmia it produces are generally considered uniform in a presentation in most studies. Some researchers, however, allude to ethnic or racial differences in AF [2,3]. This small retrospective study of an Afro-Mestizo Caribbean cohort of patients with AF will corroborate findings of associated risk factors with those commonly encountered globally in predominantly White populations. It will also point out, through numerous bibliographical references, how an “inflammatory state” may be identified in each AF-associated risk factor. If it holds true that the whole is nothing more than a sum of its parts, we should then accept the oversimplified view that AF, like atherosclerosis, is indeed inflammatory in nature. To this end, a fresh focus could be placed on new upstream therapeutic opportunities designed to complement our current downstream interventions, in an effort to prevent the occurrence and recurrence of AF.

Estimation and modeling of the restricted mean time lost in the presence of competing risks.

Survival data with competing or semi-competing risks are common in observational studies. As an alternative to cause-specific and subdistribution hazard ratios, the between-group difference in cause-specific restricted mean times lost (RMTL) gives the mean difference in life expectancy lost to a specific cause of death or in disease-free time lost, in the case of a nonfatal outcome, over a prespecified period. To adjust for covariates, we introduce an inverse probability weighted estimator and its variance for the marginal difference in RMTL. We also introduce an inverse probability of censoring weighted regression model for the RMTL. In simulation studies, we examined the finite sample performance of the proposed methods under proportional and nonproportional subdistribution hazards scenarios. We illustrated both methods with competing risks data from the Framingham Heart Study. We estimated sex differences in atrial fibrillation (AF)-free times lost over 40 years. We also estimated sex differences in mean lifetime lost to cardiovascular disease (CVD) and non-CVD death over 10 years among individuals with AF.