Episodes Of Paroxysmal Atrial Fibrillation Research Articles

Temporal association between atrial fibrillation and ischemic stroke: Systematic review and meta-analysis.

Paroxysmal atrial fibrillation (PAF) is strongly associated with ischemic stroke. Continuous cardiac implantable electronic devices (CIEDs) can assess PAF episodes over prolonged periods. Studies that attempted to find a temporal association between PAF and ischemic stroke were inconclusive. Thus, we performed a systematic review and meta-analysis to assess this relationship. This study aimed to assess the temporal association between AF episodes and stroke within 30 days of the arrhythmic episode. The secondary outcome is a temporal association within a 90-day period. A total of 2804 studies that discussed the temporal relationship between PAF and ischemic stroke were screened, and 7 studies were included in the meta-analysis. Among the 4041 patients included in these studies, there were 138 patients with device detected PAF episodes and stroke. Four studies used a 30-day window for temporality and the pooled odds ratio (OR) showed a significant association (OR 4.11 (95% CI 1.03-16.40)). The three studies reporting on AF and stroke within a 90-day window did not find a significant temporal relationship (OR 0.43 (95% CI 0.13-1.41)). Finally, the pooled result of those seven studies did not show a significant association (OR 1.51 (95% CI 0.44-5.17)). This meta-analysis supports a temporal relationship between PAF and ischemic stroke within a 30-day window. Establishing this relationship is important for individualized risk prediction and targeted anticoagulation treatment. The data will be made available upon reasonable request.

The Risk of Atrial Fibrillation in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objective: To evaluate the role of acute exacerbation of COPD in the risk of atrial fibrillation. Study Design: Cross sectional study design.Place and Duration of Study: The study was conducted at Bakhtawar Amin Hospital Multan and Recep Tayyip Erdogan Hospital Muzaffargarh, Pakistan from March 2022 to March 2023.Methods: The patients with acute, hypercapnic chronic obstructive pulmonary disease(COPD) exacerbation were included in the study. A total of 200 patients were analyzed. Baseline data including demographic and clinical details, blood tests, ABG, systolic and diastolic blood pressure, ECG, pulmonary function test, and transthoracic echocardiography were recorded.Results: Of 200 patients, 40(20%) had an episode of paroxysmal atrial fibrillation (AF). Atrial fibrillation was more prevalent in cases with lower FEV1 (P<.05). In addition, it was also more common in cases with higher PaCO2 (P<.05). Atrial Fibrillation was significantly higher in cases with larger LA diameters (34.1 ± 2.3 mm vs 46.1 ± 2.3 mm, P<.05), area (22.8 ± 4.1 cm2 vs 34.1 ± 5.1 cm2, P<.05) and higher PASP (36.1 mmHg ± 2.2 vs 46.4 mmHg ± 3.7, P<.05). RA area was larger in patients with AF and COPD compared to those without AF (25.6 ± 5.1cm2 vs 30.2 ± 6.4 cm2, P<0.05). These findings suggest COPD patients are at increased risk of AF and require measures to reduce the risk. These data will be helpful for further investigation and development of strategies to prevent AF morbidities in COPD patients.Conclusion: In patients with acute exacerbations of chronic obstructive pulmonary disease, blood gas fluctuations, hemodynamic alterations, and abnormal pulmonary functions can lead to an increased risk of atrial fibrillation. How to cite this: Razzaq MA, Atif M, Ullah U, Mehmood M, Irfan M, Sardar K. The Risk of Atrial Fibrillation in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Life and Science. 2024; 5(2): 132-137. doi: http://doi.org/10.37185/LnS.1.1.487

Sympathetic toggled paroxysmal atrial fibrillation and recurrent premature atrial contractions in ambulatory patients

BackgroundAutonomic nerve activity is important in the mechanisms of paroxysmal atrial fibrillation (PAF). ObjectiveTo test the hypothesis that a single burst of skin sympathetic nerve activity (SKNA) can toggle on and off PAF or premature atrial contraction (PAC) clusters. MethodsWe performed neuECG recording over 7 days in patients with PAF. ResultsIn Study 1, we found 8 patients (7 men, 1 woman, 62±8 years) had 124 episodes of PAF. An SKNA burst toggled both on and off PAF in 8 (6.5%) episodes (Type 1), toggled on but not off in 12 (9.7%) episodes (Type 2), and toggled on a PAC cluster, followed by PAF in 4 (3.2%) episodes (Type 3). The duration of these PAF episodes was < 10 min. The remaining 100 (80.6%) episodes were associated with active SKNA bursts throughout PAF (Type 4) and lasted longer than Type 1 (p=0.0185) and Type 2 (p=0.0027) PAF. There were 47 PAC clusters. Among them, 24 (51.1%) were toggled on and off, and 23 (48.9%) were toggled on but not off by an SKNA burst. In Study 2, we found 17 patients (9 men, 8 women, 58±12 years) with < 10 min PAF (4, 8, 0, and 31 of Types 1-4, respectively). There were significant circadian variations of all types of PAF. ConclusionsA single SKNA burst can toggle short-duration PAF and PAC cluster episodes on and off. The absence of continued SKNA after the onset might have affected the maintenance of these arrhythmias.

Ventricular response as a predictor of the termination of sustained paroxysmal atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained atrial arrhythmia. Accurate detection of the timing and possibility of AF termination is vital for optimizing rhythm and rate control strategies. The present study evaluated whether the ventricular response (VR) in AF offers a distinctive electrocardiographic indicator for predicting AF termination. Patients experiencing sustained paroxysmal AF for more than 3h were observed using 24-h ambulatory Holter monitoring. VR within 5min before AF termination (VR 0-5min, BAFT) was compared with VR observed during the 60th to 65th min (VR 60-65min, BAFT) and the 120th to 125th min (VR 120-125min, BAFT) before AF termination. Maximum and minimum VRs were calculated on the basis of the average of the highest and lowest VRs across 10 consecutive heartbeats. Data from 37 episodes of paroxysmal AF revealed that the minimum VR0-5min, BAFT (64±20bpm) was significantly faster than both the minimum VR120-125min, BAFT (56±15bpm) and the minimum VR60-65min, BAFT(57±16bpm, p<.05). Similarly, the maximum VR0-5min, BAFT (158±49bpm) was significantly faster than the maximum VR120-125min, BAFT (148±45bpm, p<.05). In the daytime, the minimum VR0-5min, BAFT (66±20bpm) was significantly faster than both the minimum VR60-65min, BAFT (58±17bpm) and minimum VR120-125min, BAFT(57±15bpm, p<.05). However, the mean and maximum VR0-5min, BAFT in the daytime were similar to the mean and maximum VR120-125min in the daytime, respectively. At night, the minimum, mean, and maximum VR0-5min, BAFT were similar to the minimum, mean, and maximum VR120-125min, respectively. Elevated VR rates during AF episodes may be predictors for the termination of AF, especially during the daytime and in patients with nondilated left atria. These findings may guide the development of clinical approaches to rhythm control in AF.

Acute antiarrhythmic effects of SGLT2 inhibitors–dapagliflozin lowers the excitability of atrial cardiomyocytes

In recent years, SGLT2 inhibitors have become an integral part of heart failure therapy, and several mechanisms contributing to cardiorenal protection have been identified. In this study, we place special emphasis on the atria and investigate acute electrophysiological effects of dapagliflozin to assess the antiarrhythmic potential of SGLT2 inhibitors. Direct electrophysiological effects of dapagliflozin were investigated in patch clamp experiments on isolated atrial cardiomyocytes. Acute treatment with elevated-dose dapagliflozin caused a significant reduction of the action potential inducibility, the amplitude and maximum upstroke velocity. The inhibitory effects were reproduced in human induced pluripotent stem cell-derived cardiomyocytes, and were more pronounced in atrial compared to ventricular cells. Hypothesizing that dapagliflozin directly affects the depolarization phase of atrial action potentials, we examined fast inward sodium currents in human atrial cardiomyocytes and found a significant decrease of peak sodium current densities by dapagliflozin, accompanied by a moderate inhibition of the transient outward potassium current. Translating these findings into a porcine large animal model, acute elevated-dose dapagliflozin treatment caused an atrial-dominant reduction of myocardial conduction velocity in vivo. This could be utilized for both, acute cardioversion of paroxysmal atrial fibrillation episodes and rhythm control of persistent atrial fibrillation. In this study, we show that dapagliflozin alters the excitability of atrial cardiomyocytes by direct inhibition of peak sodium currents. In vivo, dapagliflozin exerts antiarrhythmic effects, revealing a potential new additional role of SGLT2 inhibitors in the treatment of atrial arrhythmias.

Propafenona Bağlı Gelişen Takotsubo Kardiyomiyopatisi: Sadece Bir Tesadüf mü, Yeni Bir Nedensel İlişki mi?

Propafenone is a class 1C antiarrhythmic drug that blocks sodium channels and is used in the treatment of arrhythmia. Because of its rapid effect on terminating paroxysmal episodes of atrial fibrillation, it can be used as a pill-in-the-pocket. In patients with structural heart disease, it is less preferred due to cardiotoxic effects in long-term use. Although propafenone use is known to cause several cardiovascular side effects, the development of Takotsubo cardiomyopathy is unknown. Propafenone toxicity at standard doses is a rare condition. Propafenone plasma concentrations may increase through inhibition of cytochrome P450 2D6 and complete inhibition of 2D6 metabolism can increase propafenone levels by up to 3 to 10 times. In this case report, we aimed to present a 37-year-old female patient who developed Takotsubo cardiomyopathy and cardiogenic shock after the first dose of propafenone use and recovered with medical treatment.

Short-term paroxysmal atrial fibrillation detection with intra- and inter-patient paradigm based on R-R intervals

Paroxysmal Atrial Fibrillation (PAF) may lead to the decline of atrial mechanism and hemodynamic disturbance, which is the major risk factor for stroke, myocardial infarction, heart failure and other diseases. Although a number of methods have been developed to detect PAF, they rely on long ECG signals. Furthermore, most studies are only for the intra-patient test, ignoring individual specificity. Therefore, this paper proposes an automatic detection algorithm based on the combination of RR interval time-domain and nonlinear features to detect short-term PAF. The proposed features reflect the underlying physiological phenomenon of highly irregular ventricular activity caused by atrial unstable conduction. These include changes in morphological features and intrinsic changes in the cardiac dynamic system, which can capture subtle changes in early short-term PAF episodes and attenuate specificity between individuals. Finally, the random forest algorithm was used to detect the MIT-BIH Atrial Fibrillation Database and MIT-BIH Arrhythmia Database with intra-patient and inter-patient paradigm. The results show that the two databases’ algorithm accuracy in different paradigms of intra-patient and inter-patient have achieved more than 99.50% and 95.50%, respectively. Therefore, the proposed algorithm has a potential application for clinical monitoring.

Catheter ablation of persistent atrial fibrillation: circumferential pulmonary vein ablation with or without a linear lesion at the left atrial roof for (12-year follow-up)

Abstract Background Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation. Circumferential pulmonary vein ablation is still the standard approach in these patients. However, the results are not very favourable and more complex ablation strategies are the subject of current controversy. Therefore, we have evaluated the effect of an additional linear lesion at the roof of the left atrium on the long-term outcome. Methods A total of 300 patients (155 men, 145 women; mean age 72 years (SD ± 18 years)) with symptomatic persistent atrial fibrillation underwent a circumferential pulmonary vein ablation procedure in combination with an additional linear lesion at the roof of the left atrium (group A). After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, 6, 12, 24, 36, 48, 60, 72, 84, 96, 102, 108, 120, 132, 138 and 144 months after the ablation procedure. The long-term follow-up data was compared to 300 patients who underwent circumferential pulmonary vein ablation without an additional linear lesion at the roof of the left atrium (group B). Results The ablation procedure could be performed as planned in all patients. Sixfty-six out of 300 patients (22.0 %) in group A and 69 out of 300 patients (23.0 %) in group B experienced an arrhythmia recurrence within the first 3 months after ablation requiring an electrical cardioversion. At 144-month follow-up, analysis of a 168-hour ECG recording revealed no evidence for an arrhythmia recurrence in 171/300 patients (57.0 %) in group A and in 141/300 patients (47.0 %) in group B. In 87/300 patients (29.0 %) in group A and 78/300 patients (26.0 %) in group B, only short episodes of paroxysmal atrial fibrillation were documented. In 42 patients (14.0 %) in group A, a recurrence of persistent atrial fibrillation (&amp;gt; 48 hours) was revealed by the long-term recordings (group B: 81 patients (27.0 %)). The lower arrhythmia recurrence rate in group A was partially due to a lower incidence of atypical atrial flutter after catheter ablation. The rate of repeat ablation procedures was significantly lower in group A than in group B. There were no major complications. Conclusions Catheter ablation of persistent atrial fibrillation comprising a circumferential pulmonary vein ablation and an additional linear lesion at the roof of the left atrium provides more favourable results than circumferential pulmonary vein ablation alone. The effect is more pronounced during long-term than during short-term follow-up.

An objective approach to identifying individual atrial fibrillation triggers: A simulation study

Background and Objective:Growing evidence shows that certain acute exposures, especially alcohol, may trigger episodes of paroxysmal atrial fibrillation (AF). However, there is a lack of methods for assessing the relation between triggers and AF episodes in individual patients. The present paper proposes an approach to identifying AF triggers based on the assumption that the post-trigger AF burden is larger than the pre-trigger AF burden during the analysis time interval. Method:For the purpose of identification, a measure of relational strength between pre- and post-trigger burden is introduced, accounting for the cumulative effect of the triggers contained in the observation interval. The proposed approach is explored for different types of AF episode pattern, generated using the alternating, bivariate Hawkes model, whose conditional intensity function is designed to account for the effect of alcohol. In total, 7200 different AF patterns were generated for different numbers of AF triggers and alcohol units. Results:The simulation study demonstrates that, depending on the pattern type, the relational strength increases 3–6 times with alcohol consumption in comparison with no consumption. Conclusions:The proposed approach to identifying triggers in individual patients with paroxysmal AF should facilitate the implementation of longitudinal studies for the objective assessment of trigger effect on AF occurrence.

Increased Left Atrial Stiffness is Significantly Associated with Paroxysmal Atrial Fibrillation in Diabetic Patients.

Atrial fibrillation (AF) and diabetes mellitus (DM) are common pathogenic diseases. Diabetes is an independent risk factor for AF, and coexisting AF is a risk factor for the diabetic pa-tient's progression. The purpose of this study was to see if two-dimensional-speckle tracking echocardiography (2D-STE) might provide valuable criteria for determining the risk of AF in diabetic patients. This retrospective study compared 30 adult diabetic patients with documented paroxysmal atrial fibrillation (PAF) with 30 age- and sex-matched diabetic patients without PAF. Inclusion criteria were: age ≥18 years, sinus rhythm, diabetes mellitus type 2, and the ability to sign the informed consent. Exclusion criteria included: moderate or severe valvular disease, previous myocardial infarction, left ventricular ejection fraction (LVEF) <50%, congenital heart disease, a history of cardiac surgery, paced atrial or ventricular rhythm, inadequate echocardiography imaging. The medical history, clinical, biochemical data and the results of the transthoracic cardiac ultrasound examination were registered during their evaluation at the outpatients cardiology clinics. The mean age of the patients was 62.5±1.7 years, 60% were men. Diabetic patients who experienced PAF episodes demonstrated significantly impaired left atrial (LA) deformation patterns, with decreased LA strains and increased LA stiffness (p < 0.05). The present study demonstrates that LA strains and LA stiffness are significantly associated with the occurrence of PAF in diabetic patients. As 2D-STE of the LA is more sensitive than routine echocardiographic examination, it should be performed in patients suspected of being suffering from PAF.

Impact of low-dose Brain-Derived Neurotrophic Factor (BDNF) on atrial fibrillation recurrence.

Atrial fibrillation is the most common arrhythmia worldwide and is associated with significant morbidity and mortality. Despite the effectiveness of catheter-based ablation, periprocedural complication and recurrences remain a concern. In this context, we aim to appraise the potential impact of brain-derived neurotrophic factor (BDNF) on reducing episodes of paroxysmal atrial fibrillation (PAF). 22 patients with an established diagnosis of PAF and without structural heart disease were considered. Every patient received 20 drops of GUNA-BDNF administered in the morning. During the 24 months of follow-up, the arrhythmic burden was measured by the average monthly duration of PAF episodes. At the end of the follow-up period (24 months), data from 22 patients, of whom 17 men and five women, were analyzed. The arrhythmic burden, measured in terms of average monthly duration of PAF episodes, was found significantly reduced after the administration of low dose BDNF (9.5 vs. 65.3 minutes per month, P<0.001). A total of 17 out of 22 patients saw their arrhythmic burden eliminated or consistently reduced, furthermore two patients underwent a drastic reduction of the average monthly duration of AF (more than 200 minutes compared to the baseline). Only four patients, despite the administration of BDNF, still experienced an arrhythmic burden of 20 minutes or more. Considering the age groups, the major reduction was observed in people aged 70 or more, who were also the most represented in the sample. These results are coherent with the poor literature currently available. BDNF low dose therapy has shown to have an impacting role in reducing the arrhythmic burden and recurrences of AF, with a particular effectiveness in patients over 70 and without structural heart disease. We should welcome this work, despite it limitations. Further clinical and molecular studies are needed before-considering BDNF low dose as a tool against PAF.

Bayesian Network Meta-analysis of Randomized Controlled Trials on the Efficacy of Antiarrhythmics in the Pharmacological Cardioversion of Paroxysmal Atrial Fibrillation.

Since atrial fibrillation (AF) is one of the major arrhythmias managed in hospitals worldwide, it has a major impact on public health. The guidelines agree on the desirability of cardioverting paroxysmal AF episodes. This meta-analysis aims to answer the question of which antiarrhythmic agent is most effective in cardioverting a paroxysmal AF. A systematic review and Bayesian network meta-analysis, searching MEDLINE, Embase, and CINAHL, were performed, including randomized controlled trials (RCTs) enrolling a population of unselected adult patients with a paroxysmal AF that compared at least two pharmacological regimes to restore the sinus rhythm or a cardioversion agent against a placebo. The main outcome was efficacy in restoring sinus rhythm. Sixty-one RCTs (7988 patients) were included in the quantitative analysis [deviance information criterion (DIC) 272.57; I2 = 3%]. Compared with the placebo, the association verapamil-quinidine shows the highest SUCRA rank score (87%), followed by antazoline (86%), vernakalant (85%), tedisamil at high dose (i.e., 0.6 mg/kg; 80%), amiodarone-ranolazine (80%), lidocaine (78%), dofetilide (77%), and intravenous flecainide (71%). Taking into account the degree of evidence of each individual comparison between pharmacological agents, we have drawn up a ranking of pharmacological agents from the most effective to the least effective. In comparing the antiarrhythmic agents used to restore sinus rhythm in the case of paroxysmal AF, vernakalant, amiodarone-ranolazine, flecainide, and ibutilide are the most effective medications. The verapamil-quinidine combination seems promising, though few RCTs have studied it. The incidence of side effects must be taken into account in the choice of antiarrhythmic in clinical practice. PROSPERO: International prospective register of systematic reviews, 2022, CRD42022369433 (Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022369433 ).

P236 THE EARLY USE OF A PARTICULAR HEMODIALYTIC FILTER DURING SCA–STEMI COMPLICATED BY MULTIORGAN FAILURE

Abstract A 66–year–old man, hypertensive, obese and avid smoker, in apparent good health until, due to the onset of typical chest pain associated with vomiting and algid sweating, he went to the PS where a diagnosis of acute coronary syndrome with ST–segment elevation was made. As per the guidelines, antithrombotic therapy was administered and transfer to the HUB center was arranged to perform urgent coronarography; thrombotic occlusion of the I M.O. branch was revealed and treated with angioplasty and drug–eluting stent implantation. On admission to the NICU, the patient presented hypotensive, tachycardic and with repeated episodes of rectorrhagia and vomiting intermingled with blood. Cardiac echocolorDoppler showed mild reduction in global kinesthesia (FE 45%) with hypo–akinesis of the inferior and lateral walls, circumferential pericardial effusion that was not hemodynamically significant, dilated and fixed inferior vena cava with mild increase in systolic pulmonary artery pressure. On suspicion of gastro–intestinal ischemic damage, supported by the clinical and laboratory findings (creatinine increase with anuria for more than 12 hours and severe signs of hepato–pancreatic insufficiency) CT scan with mdc was performed showing hepato–renal hypoperfusion. Therefore, on suspicion of multi–organ dysfunction syndrome, renal replacement therapy was started in CVVHD mode with filter for clearance of medium molecular weight molecules (cut–off 40 kDa) to reduce possible cytokine and myoglobin damage. Already from the first hours of treatment, there was a rapid and exponential improvement in clinical–laboratory parameters with resumption of diuresis. During hospitalization, two episodes of paroxysmal atrial fibrillation treated with electrical and pharmacological cardioversion were detected; given a CHA2DS2VASc score 3 and a HAS–BLED score 2, triple antithrombotic therapy was initiated. At follow–up, there was improvement in echocardiographic parameters (minimal residual pericardial dislodgement and inferior vena cava of normal caliber and respiratory collapsibility) and clinical–laboratory.

Diagnostic Yield of Extended Cardiac Patch Monitoring in Cryptogenic Stroke Patients (P11-5.032)

<h3>Objective:</h3> To evaluate the diagnostic yield of detecting atrial fibrillation (AF) and/or atrial flutter (AFL) with extended cardiac patch monitoring in our cryptogenic stroke population. <h3>Background:</h3> Cryptogenic stroke accounts for 15–40% of yearly strokes with increased incidence in younger patients. It is standard of care at our comprehensive stroke center located in the stroke belt to discharge cryptogenic stroke patients with a 14-day continuous cardiac monitoring patch (Zio) to evaluate for paroxysmal AF/AFL. <h3>Design/Methods:</h3> We propose to conduct a retrospective chart review from January 2019 to June 2022 (3.5 years) of all adult stroke patients with a discharge diagnosis of ischemic stroke using the Get With The Guidelines stroke database at our institute. We will be analyzing all cryptogenic stroke patients who were discharged with a Zio patch. The following data points will be collated; demographics, baseline stroke risk factors, left atrium volume, Zio patch results including wear time, analyzed time, AF burden, duration the first episode of AF detected, patient events, and other irregular arrhythmias. Our preliminary data from January 2021 to June 2022 (18 months), observed 270 cryptogenic stroke discharges. Out of which, 165 met the eligibility criteria and were discharged with a Zio patch. <h3>Results:</h3> AF/AFL was detected in 14 patients (8.5%). The mean duration before the first episode of paroxysmal AF (PAF) was 3.7 days and the median duration was 1.5 days. 43 percent of PAF occurred after 48 hours. <h3>Conclusions:</h3> The preliminary data demonstrated a relatively low yield of AF/AFL detection with Zio patch monitoring in our cryptogenic stroke population. We plan to complete the prespecified data collection period to achieve a larger sample size and further analyze independent risk factors for AF/AFL detection and patient compliance. <b>Disclosure:</b> Dr. Rice has nothing to disclose. Dr. Lucioni has nothing to disclose. Mr. Aiello has nothing to disclose. Dr. Ranasinghe has nothing to disclose.

587 LEFT ATRIAL APPENDAGE OCCLUSION: A REAL SOLUTION TO CARDIOEMBOLIC RISK OF ATRIAL FIBRILLATION?

Abstract 82-year-old woman comes to our clinical observation for worsening exertional dyspnea, with ECG evidence of atrial fibrillation (AF) with high ventricular response. Past medical history: previous right breast carcinoma treated in 1998 with quadrantectomy, radiotherapy and hormone therapy. Previous ischemic transitory attack. Hypertension. Dyslipidemia. The patient reports the first episode of paroxysmal AF in 2016, for which anticoagulant therapy with new oral anticoagulants NOACs was started for CHA2DS2VASc=6. During anticoagulant therapy episode of ocular haemorrhage for which the patient discontinued therapy with NOACs and used low-molecular-weight heparin LMWH "as needed" in the course of arrhythmic relapses. In July and August 2019 relapses of symptomatic paroxysmal AF. Multiple attempts to take different anticoagulants (Rivaroxaban, Edoxaban) poorly tolerated. The patient undergoes catheter ablation by isolation of the pulmonary veins (considered first line according to ESC guidelines for the control of symptoms in patients with paroxysmal AF) and percutaneous left atrial appendage occlusion (LAAO), with indication of anticoagulation therapy for at least 4 weeks after the procedure (Apixaban 2.5 mg bid, reduced dose due to the presence of age&amp;gt;80 years and weight&amp;lt;60 kg). At the entrance to our hospital, an ECG is performed with a finding of total arrhythmia from AF with a high ventricular response (HR 130 bpm), conducted with left bundle branch block (LBBB); cardiac echo-Doppler ultrasound is performed with a slight reduction in left ventricular systolic function (EF 45%), second degree diastolic dysfunction with increased filling pressures, moderate mitral valve insufficiency, severe left atrial dilatation (LAVi 125 ml/m2), moderate tricuspid valve insufficiency with moderate pulmonary arterial hypertension (PAPS 55 mmHg), right atrial dilatation, circumferential pericardial detachment, dilated inferior vena cava hyporeactive with breath acts. At blood tests: BNP 1022 pg/ml, sodium 145 mmol/l, potassium 3.5 mmol/l, creatinine 1.17 mg/dl with eGFR 43 ml/min/1.73mq. Rate control therapy with ß-blockers and Digoxin and diuretic therapy with Furosemide and Canrenone is set, with improvement of symptoms and clinical conditions. Anticoagulant therapy with LMWH is also undertaken but the patient shows poor adherence. After home discharge, the patient goes back to the emergency room for dyspnea. Further cardiac echo-Doppler ultrasound is performed with evidence of thrombotic formation in the left atrium of the size of 30×25 mm. Therapeutic dosage LMWH therapy is started with subsequent Warfarin embrication according to INR, obtaining complete resolution of the thrombotic formation. A systematic review of device-related thrombosis (DRT) after left atrial appendage occlusion (LAAO) proved that the overall incidence of DRT was 3.9% and the median time from procedure to diagnosis of DRT was 1.5 months. According to currently reported cases, most DRTs occur within one year after LAAO. This particular clinical case of DRT three years after LAAO underlines the importance of accurate assessment of the patient's risk profile: LAAO is a valid alternative to anticoagulant therapy in patients at high risk of bleeding but with low embolic risk profile. It's known that high CHA2DS2VASc values ​​and reduced cardiac function are recognized risk factors for thrombus formation, such as patient compliance with antithrombotic therapy. Surely additional studies are needed to determine if the current practice of antithrombotic regimens and duration after LAAO is sufficient.

Long‐term monitoring with an implantable loop recorder detects multiple episodes of paroxysmal atrial fibrillation after electrical cardioversion in a Warmblood horse

SummaryAtrial fibrillation (AF) is a pathological arrhythmia affecting performance horses and is termed paroxysmal (pAF) when self‐terminating to sinus rhythm. Little is known about pAF as its sporadic nature makes it difficult to diagnose. Therefore, continuous electrocardiographic monitoring devices, such as implantable loop recorders (ILR), are necessary to detect the time of onset and episode duration. This case report presents the detection of pAF in a 9‐year‐old Warmblood horse after successful transvenous electrical cardioversion (TVEC). An ILR continuously monitored the heart rhythm over 28 months and detected 12 episodes of pAF of which two episodes were associated with reduced performance, while others occurred asymptomatically at rest. The estimated episode duration ranged from 6 min to 46.5 h. The antiarrhythmic drug sotalol (2 mg/kg bwt BID PO) was given prior to TVEC and then for 4 weeks. As episodes continued to occur, sotalol was prescribed for another 4 weeks, 6 months after TVEC. Continuous monitoring after TVEC allows for detection of AF recurrence and identification of AF burden, approximate time of onset and possible identification of trigger events. Early diagnosis and antiarrhythmic treatment may prevent a progression to persistent AF.

Abstract 15258: An Unobvious Benefit of the Coexistence of Arterial Hypertension and Atrial Fibrillation - Results of Nationwide Cross-Sectional Study From Central and Eastern Europe

Introduction: Poland represents the region of Central and Eastern Europe with high cardiovascular risk and a rapidly aging population with an ever-increasing prevalence of arterial hypertension (AH) and atrial fibrillation (AF). Our study describes the epidemiology of these conditions and factors associated with AF in the elderly. Methods: In a representative sample of 3014 Poles aged 65 years and over (mean age 77.5 years old, 49.1% women) questionnaire data, blood pressure measurements and blood samples were taken. Hypertension was defined as mean SBP ≥140mmHg or DBP ≥90mmHg or treatment of hypertension. Each patient was screened for AF by continuous ECG monitoring for up to 30 days using a validated ECG vest. Results: Overall prevalence of AH was 80.9% and overall prevalence of AF was 19.2%. Both conditions coexisted in 16.7% of participants and AF with no AH was observed in only 2.5% of participants. Hypertension was significantly more common in patients with AF than in these without AF (87.1% vs 79.4%, p&lt;0.05). Mean systolic blood pressure and pulse pressure were significantly lower in the AF population (139.7 mmHg vs 142.6 mmHg, p&lt;0.05, 61.3 mmHg vs 63.9 mmHg, p&lt;0.05 respectively). In hypertensive patients the AF was more often paroxysmal than persistent/permanent (11.9% vs 8.8%, p&lt;0.05), but the episodes of paroxysmal AF lasted longer than in patients without AH (14.9 hours vs 7.6 hours in men, p&lt;0.05; 11.2 hours vs 3.5 hours in women, p&lt;0.05). Participants with coexisting AF and AH were more often aware of both AF (79.9% vs 69.2%, p&lt;0.05) and AH (88.9% vs 84.1%, p&lt;0.05). Significant factors associated with AF occurrence in hypertensive patients were heart failure (OR 2.91), male gender (OR 1.94), elevated NT-proBNP level (OR 1.73), diabetes (OR 1.44), hyperthyroidism (OR 1.44), obesity (OR 1.34), chronic kidney disease (OR 1.32), ischemic heart disease (OR 1.31) and age (OR 1.04). Conclusions: Hypertension and atrial fibrillation are widespread in the elderly population and coexist in one in six people aged 65 years and older. This coexistence is associated with better blood pressure control and disease awareness.

Identifying patients with paroxysmal atrial fibrillation from sinus rhythm ECG using random forests

Paroxysmal atrial fibrillation (PAF) is a cardiac arrhythmia which is often challenging to diagnose because patients may be asymptomatic, and episodes are usually intermittent. In this paper we describe a method for identifying patients with a history of PAF using electrocardiogram (ECG) recordings during sinus rhythm. We analyzed, on a beat-to-beat basis, the P-waves in the sinus rhythm ECGs of 69 patients with a history of PAF and 59 healthy individuals. From each subject’s P-waves, we calculated key electrocardiographic metrics, including some which are proposed here for the first time. Using means testing and feature selection methods, we discerned the features which were most useful for classification, and trained a Random Forest which identified PAF patients. Our approach achieved a 93.45% accuracy, sensitivity of 95.21%, and specificity of 91.40% using P-wave integral and novel amplitude and slope-based features which ranked highest in importance compared to other metrics from the literature. In particular, descriptive statistics of P-wave amplitudes, slopes, and integrals, were effective for identifying subjects with PAF history vs. healthy individuals. Our method has a high sensitivity and discrimination ability, with an AUC=0.9669 which is superior to others’, and can thus be potentially valuable for the early identification of patients who are prone to episodes of PAF, even as part of the standard cardiological checkup that most adults undergo periodically.

LA strain helps identifying the cardioembolic etiology of transient ischemic attacks

Abstract Background Patients who have transient ischemic attacks (TIA) often suffer from asymptomatic and paroxysmal atrial fibrillation (AF). Due to the fact that AF is located in the atria, we sought to determine whether abnormalities in left atrial (LA) structure and function could help identify the cardioembolic cause of TIA in patients with sinus rhythm but with documented episodes of paroxysmal AF. Methods The research included 190 individuals with TIA and classified them into two groups based on the presence (group I) or absence (group II) of confirmed paroxysmal AF. The diagnosis of paroxysmal AF was established by an assessment of medical records. To prevent assessing atrial stunning, cardiac ultrasonography was conducted in sinus rhythm at least 14 days following the initiation the TIA. Results The results indicated that patients in group I were older, more often female, had a history of stroke or TIA, and had a higher CHA2DS2-VASc score. Additionally, they exhibited increased LA volumes, a decreased LA emptying fraction, and markedly altered LA deformation patterns. Three factors were found as being independently associated with paroxysmal AF using multivariate logistic regression: age, LA reservoir strain, and LA emptying fraction (P&amp;lt;0.0001). The variables had as cut-off values: age &amp;gt;55 years, LA reservoir strain&amp;lt;−17%, and LA emptying fraction &amp;lt;51%. Conclusion The current research establishes that LA strains are independently associated with paroxysmal AF in patients with TIA and may aid in determining the cardioembolic origin of these events. Our findings have considerable clinical implications because, until now, LA 2D-STE was not included in the usual evaluation of TIA patients, but it may be the ideal next step in this regard. Funding Acknowledgement Type of funding sources: None.

Subclinical sinus node dysfunction in patients with atrial fibrillation-Insight from ultrahigh-resolution mapping of human sinoatrial exits.

Even a short duration of paroxysmal episodes of atrial fibrillation (AF) is associated with sinus node (SN) remodeling and a reduced SN reserve or dysfunction. The number of earliest atrial activation sites (EASs) during sinus rhythm decreases according to the decrease in the SN reserve. We sought to evaluate the EASs during sinus rhythm using an ultrahigh-density mapping system. This study included 35 patients (supraventricular tachycardia [SVT]/paroxysmal atrial fibrillation [PAF]/persistent atrial fibrillation [PsAF] = 5/21/9) who underwent ultrahigh-resolution endocardial mapping of the SN area at rest and during β-stimulation. The number of EASs was determined by the Lumipoint™ algorithm. The number of EASs was greatest in SVT patients both at rest (SVT/PAF/PsAF = 1.4 ± 0.8/1.0 ± 0/1.0 ± 0, p = .04) and during β-stimulation (SVT/PAF/PsAF = 2.6 ± 1.0/1.3 ± 0.6/1.0 ± 0, p < .01). The number significantly increased with β-stimulation as compared to baseline in the PAF patients (p = .02), but not in the PsAF patients. The brain natriuretic peptide (BNP) level was significantly higher in AF than SVT patients (SVT/PAF/PsAF = 12.3 [10.1-14.5]/25.7 [14.8-36.0]/73.4 [57.6-140] pg/ml, p < .01). In the PAF patients, the BNP level was significantly higher in those with unicentric EASs than multicentric EASs during β-stimulation (28.1 [19.1-46.5] vs. 13.1 [9.4-26.9] pg/ml, p = .03), and the optimal cutoff point for the BNP level predicting unicentric EASs was 21.8 pg/ml (sensitivity 82.6%; specificity 85.7%). AF patients have a smaller number of EASs and poorer response to β-stimulation than non-AF patients. An elevated BNP level might predict subclinical SN dysfunction in patients with PAF.