European Heart Rhythm Association Score Research Articles

The one-minute sit-to-stand test is an alternative to the 6-minute walk test in patients with atrial fibrillation: A cross-sectional study and ROC curve analysis

BackgroundThe one-minute sit-to-stand test (1STST) is an easy-to-administer, space and time-saving test for determining functional exercise capacity in cardiac disease. This study aimed to investigate the 1STSt-test-retest reliability and convergent validity and compare its physiological responses to the six-minute walk test (6MWT) in patients with Atrial fibrillation (AF). MethodsForty-five patients with AF were included in this study. Functional exercise capacity was evaluated using the 1STST and 6MWT. For assessing test-retest reliability, the intraclass correlation coefficient and Bland-Altman plots were utilised. Convergent validity was determined by correlation analysis 1 STST and 6MWT, age, European Heart Rhythm Association score, ejection fraction, and quality of life. The cut-off point of 1STST was defined using ROC analysis. ResultsWith an intraclass correlation coefficient value of 0.975 [95 % confidence interval (CI) 0.954–0.986], the 1STST demonstrated excellent-test-retest reliability. Physiological responses after tests were similar in the 1STST and 6MWT (p > 0.05). The number of 1STST repetitions was strongly associated with 6MWT distance (r = 0.809; p < 0.001). A cut-off value of ≤13 repetitions in the number of 1STST repetitions was defined as functional impairment related to an increased risk of clinical events [sensitivity: 100 %, specificity: 84.6 %; AUC:0.94; 95 % CI 0.82 to 0.98; p < 0.001]. ConclusionsThe 1STST is a reliable and valid assessment tool that produced comparable hemodynamic responses to the 6MWT in patients with AF. Considering its feasibility and time efficiency, healthcare professionals can use the 1STST rather than the 6MWT test to measure functional exercise status in a constrained environment for this patient group.

Cluster-specific predictors of early rhythm control in contemporary European cohort of patients with atrial fibrillation: The EHRA-PATHS Project

Abstract Background Early rhythm control (ERC) using antiarrhytmic drugs, electrical cardioversion or catheter ablation for AF within a year from first diagnosis of atrial fibrillation (AF) has been shown to reduce the risk of major adverse outcomes compared to usual care, and the effects of ERC have been suggested to be consistent across all AF subgroups with different risk profiles. We aimed to identify cluster-specific predictors of ERC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort. Methods The EHRA-PATHS AF cohort was derived from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific predictors of ERC were identified using univariate and multivariate logistic regression analyses. Results Of 18,799 patients, AF was diagnosed within 1 year in 8088 (43.0%), and 3913/8088 patients (48.4%) were treated with ERC. Among the three clusters - Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) and Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), see Table, ERC was significantly more often used in Cluster 1 compared with Cluster 2 and Cluster 3 (both P&amp;lt;0.001), and in Cluster 2 compared with Cluster 3. Cluster-specific multivariable predictors of ERC are shown in Table. In all three clusters, asymptomatic AF (EHRA score I) and Northern Europe residence were inversely associated with ERC, while Western Europe residence was positively associated with ERC in Cluster 2 and 3. In Cluster 1, low stroke risk and hypertension were positively associated with ERC, while dilated left atrium (LA) and reduced left ventricular ejection fraction (LV EF) were negative predictors of ERC. In Cluster 2, age ≥80 years, enlarged LA, and CHA2DS2-VASc ≥2 for males and ≥3 for females were negatively associated with ERC. In Cluster 3, age ≥75 years, cardiomyopathy, liver disease, dementia and reduced LV EF were negative predictors of ERC. Conclusion Our study of a large European AF cohort showed that likelihood for ERC was greater in younger and healthier AF patients, as well as in elderly from Western Europe, while ERC was significantly less likely with increasing age and comorbidity (especially cardiovascular diseases). These findings likely reflect the lack of high-quality evidence supporting aggressive ERC in high-risk patients with AF. With increasing body of evidence favouring ERC such patients, a shift towards less selective consideration of ERC in daily practice may be expected.

Acute clinical outcomes of patients with HFpEF undergoing atrial fibrillation ablation

Abstract Aim Robust data show that atrial fibrillation (AF) ablation can improve left ventricular function and prevent cardiovascular complications in patients with heart failure and reduced ejection fraction. The effectiveness and safety of AF ablation in patients with heart failure and preserved ejection fraction (HFpEF) is less well characterized. Methods We retrospectively analyzed 785 consecutive patients with normal left ventricular function undergoing AF ablation in a high-volume center including 251 with AF and HFpEF. We compared baseline parameters, procedural details and procedural complications by heart failure status. Results Patients with HFpEF (n=251/785) were older (median age 70 years vs. 64 years; p &amp;lt; 0.05) and more frequently female (48.2% vs. 32.2%; p &amp;lt; 0.05) compared to patients without HF. Symptom severity was comparable with a median European Heart Rhythm Association score of 2 in both groups (p &amp;gt; 0.05). Arterial (71.7% vs. 59.7%, p &amp;lt; 0.05), diabetes (16.7% vs. 9.4%, p &amp;lt; 0.05) and dyslipidemia (41.4% vs. 27.2%, p &amp;lt; 0.05) were more common in patients with AF and HFpEF. Acute pulmonary vein isolation (PVI) was achieved in all patients using cryoballoon or radiofrequency energy with similar frequency in both groups (cryoballoon ablation: 37.8% vs. 41.6%; p &amp;gt; 0.05). A subgroup of patients in both groups additionally underwent cavotricuspid isthmus ablation for coexistent atrial flutter (26% vs. 20.7%; p &amp;gt; 0.05). Procedure times (119.4 ± 47.7 min vs. 120.2 ± 48.3 min; p &amp;gt; 0.05) and fluoroscopy times (15.8 ± 10.4 min vs. 15.5 ± 7.1 min; p &amp;gt; 0.05) were comparable. Overall complication rates did not differ (12.7% vs. 10.3%; p &amp;gt; 0.05). While the incidence of pericardial tamponades was slightly higher (2% vs. 0%), other severe and minor complications showed no significant differences, including stroke/transient ischemic attack (TIA; 0.4% vs. 0.6%), major life-threatening bleeding (0% vs. 0.2%), vascular complications (1.6% vs. 2.1%), phrenic nerve palsy (0.8% vs. 1.5%), and pulmonary vein stenosis (0.4 vs. 0%). The mean in-hospital stay for the procedure was 2 days in both groups (p &amp;gt; 0.05). In-hospital recurrence rates were similar (12.4% vs. 17%; p &amp;gt; 0.05), as was the need for electrical cardioversion before discharge (5.6% vs. 6.6%; p &amp;gt; 0.05). Conclusion Patients with HFpEF undergoing AF ablation were older, more frequently female, and have more comorbidities than patients without heart failure. Acute procedural success and acute complication rates appear low. These data encourage randomized evaluations of the safety and efficacy of ablation-based rhythm control therapy in patients with AF and HFpEF.

Newly diagnosed heart failure in patients with atrial fibrillation referred for catheter ablation - identifying patients with arrhythmia-induced cardiomyopathy

Abstract Introduction Atrial tachyarrhythmias are primary drivers in the development of arrhythmia-induced cardiomyopathy (AiCM). The restoration of sinus rhythm in patients with an AF (atrial fibrillation) based AiCM results in enhancement of left ventricular ejection fraction (LV-EF). This study aims to assess the prevalence of undiagnosed and unexplained heart failure among patients with AF referred for catheter ablation and seeks to phenotype these patients. Methods Our registry, a prospective, observational clinical cohort that recruits patients with heart rhythm disorders at a large tertiary-care center since March 2021 was interrogated for AF patients. These patients underwent screening for heart failure based on clinical, laboratory, and imaging characteristics. Undiagnosed heart failure at baseline, lack of heart failure medication and absence of known structural heart disease were considered suspicious for AiCM. Results A total of 1225 patients were analyzed. 35.2% were female, median age 67 (IQR 59;75) years, median LV-EF 55.0 (IQR 50;60) % and median N-terminal pro B-type natriuretic peptide (NT-proBNP) 686 (IQR 210;1630) mg/dl. NYHA class I was reported in 28.3% cases, NYHA class II in 32.2%, NYHA class III in 20.2% and NYHA class IV in 2%. At baseline, 263 patients (17.6%) had an LV-EF &amp;lt; 50% of those 110/263 (42%) with suspected AiCM. Patients with suspected AiCM were 67 (IQR 58;76) years old, 40.9% were female, median LV-EF was 41.0 (IQR 35;41) % and NT-proBNP at admission was 1681 (IQR 775;2352) mg/dl. Patients with suspected AiCM had a significantly reduced TAPSE (19 vs. 22 mm; p&amp;lt;0.001), showed generic characteristics of heart failure (NTproBNP: p&amp;lt;0.001, NYHA class: p=0.049), while EHRA score was significantly lower (p=0.006). In contrast, patients with known cardiomyopathy of non-AiCM origin at baseline and EF &amp;lt; 50% (n=153) had significantly higher LAVI (44.8 vs. 38.8 ml/m2; p=0.002), were predominantly male (76.5 vs. 59.1 %; p=0.004) and had lower GFR (60.2 vs. 68.5 ml/min; p=0.002) compared to AiCM patients. Among 29/110 suspected AiCM patients with available TTE at follow-up (within 12 months post-catheter ablation), 26/29 exhibited an improved LV-EF (40% at baseline vs. 54% at FU; p&amp;lt;0.001). 3/3 patients without LV-EF improvement exhibited arrhythmia recurrence. Conclusion Primary AiCM was suspected in 42% of all AF patients with reduced LV function referred for catheter ablation. These patients exhibited a different phenotype compared to the remaining cohort. After catheter ablation, ejection fraction improved in 90% of AiCM patients. These findings call for structured HF screening in clinical routine in AF patients. In the future, validated scores are required to enable early rhythm control for these patients.Proportion of patients with HFrEFCourse of EF after catheter ablation

Echocardiographic follow-up after AV node ablation combined with left bundle branch area pacing for patients with symptomatic atrial fibrillation

Abstract Background AV node ablation combined with permanent pacing is an established therapy for rate control in patients with symptomatic atrial fibrillation (AF) refractory or intolerant to pharmacological rate or rhythm control and not eligible for rhythm control by left atrial catheter ablation. The threshold for performing this so-called "pace-and-ablate" strategy has decreased since the introduction of conduction system pacing, and especially left bundle branch area pacing (LBBAP). Purpose To investigate the change of the left-ventricular (LV) ejection fraction (EF) and left-atrial volume index (LAVI) in patients with symptomatic AF, twelve months after LBBAP and AV-node ablation. Methods Consecutive patients with symptomatic AF intolerant or refractory to pharmacological rate and symptom control and deemed not eligible for left atrial catheter ablation were included. At baseline, the EHRA score was noted and the LVEF and LAVI were measured echocardiographically. Patients were subdivided in a normal baseline LV ejection fraction (LVEF &amp;gt;50%) or diminished baseline LVEF (LVEF &amp;lt;50%) group. After LBBAP, patients underwent AV node ablation in the same procedure or four weeks later. After twelve months, the LVEF and LAVI were reassessed in the entire cohort and the two subgroups. Results Twenty-two patients (68% female, mean age 79±4 years) scheduled for pace-and-ablate therapy were prospectively included. Three (14%) had paroxysmal, sixteen patients (72%) had persistent AF and three patients (14%) long-standing persistent AF. An EHRA class IIb or higher was found in eighteen patients (82%). At baseline, the mean LVEF was 51 ± 7%, the mean LVEDD 47 ± 6 mm and LAVI 54 ± 18 ml/m2. Twelve patients (55%) had a preserved LVEF, whereas ten patients (45%) had an LVEF &amp;lt;50%, fig. 1. After twelve months, the overall ejection fraction increased to 54 ± 5% (p=0.016), fig. 2A. This was mostly attributed to the increase in LVEF to 51 ± 5% in the subgroup with a reduced baseline LVEF (p=0.009 compared to baseline 44 ± 5%), fig. 2A. The LVEF was unaffected in the other group (57 ± 3% vs. 57 ± 4%, p=0.63), fig. 2A. The LAVI was not significantly reduced in the overall cohort or the subgroups (54 ± 18 ml/m2 to 51 ± 19 ml/m2, p=0.16), fig 2B. Conclusion AV node ablation combined with LBBAP results in a significant improvement in LVEF at twelve months follow-up. This is mainly driven by an improvement in LVEF in those patients with a diminished LVEF at baseline. The data suggests that the therapy can reverse a tachycardiomyopathy without inducing a pacing-induced cardiomyopathy. No significant reduction in LAVI was found.Baseline characteristicsChanges in LVEF (A) and LAVI (B)

Evaluation of the Effect of Conversion of Nonvalvular Atrial Fibrillation to Sinus Rhythm on Cardiac Remodeling.

Atrial fibrillation (AF)represents the most prevalent cardiac arrhythmia globally, with a significant burden on mortality and morbidity. While rhythm control strategies, particularly electrical cardioversion (EC), have gained traction in recent years, the precise impact of sinus rhythm (SR) restoration on cardiac reverse remodeling remains a subject of debate. In this study, 23 AF patients underwent elective EC. AF diagnosis was made via ECG by a cardiologist, and candidates for cardioversion were selected by an electrophysiologist. Transthoracic echocardiography (TTE) by utilizing two-dimensional, three-dimensional, and tissue Doppler imaging modalities was performed before cardioversion. Patients who maintained SR after six months underwent a second TTE evaluation. SR was restored successfully in all 23 patients and 15 patients (65.2%) maintained SR after six months. SR group had significantly lower baseline cardiac output (CO)and indexed left ventricular end-systolic volume (LVESVi), and better European Heart Rhythm Association (EHRA) scores after six months. Within the SR group, patients exhibited significant changes in mitral regurgitation, tricuspid regurgitation, EHRA score, LVESVi, stroke volume, left ventricle ejection fraction, left ventricle global longitudinal strain, indexed minimum left atrial volume, left atrial emptying fraction, and left and right atrial diameters. Reduced CO was associated with AF recurrence. Receiver operating curve analysis revealed that CO value can predict six-month AF recurrence with a cut-off point of 2.3. Our study underscores the beneficial effects of SR restoration on cardiac parameters in AF patients post EC. Notably, CO value emerged as a predictor of AF recurrence, emphasizing the importance of comprehensive assessments for predicting long-term outcomes.

Long-Term Results of the Mini Maze Standalone Bi-Atrial Surgical Ablation: A 10-Year Follow-Up.

Background: One way to treat atrial fibrillation is through surgical ablation. However, the literature only provides information on patient follow-up results for up to 5 years. Methods: In order to assess long-term monitoring data over ten years, this retrospective study included 58 patients with paroxysmal or persistent atrial fibrillation who underwent Mini Maze surgical ablation at Santaros Clinics between 1 February 2009 and 1 June 2014. The follow-up time after surgery was 144 ± 48 months. We evaluated the absence of atrial fibrillation, echocardiographic and clinical parameters, and EHRA score. Results: Sinus rhythm remained in 69.4%, 75.5%, 55.6%, and 44.1% of patients with paroxysmal AF, and 68,2%, 59.1%, 50%, and 41.9% of patients with persistent AF (p = 0.681). In the post-operative period, one patient (1.7%) had a transient ischemic attack, and another patient (1.7%) had a thoracotomy for post-operative bleeding. A total of 20% of patients were diagnosed with a post-operative respiratory tract infection. EHRA scores showed that patients' quality of life improved after they underwent Mini Maze surgical ablation. Conclusions: Despite AF recurrences after surgery, quality of life remains better than before surgery, showing that Mini Maze surgery is an effective and safe second-line treatment method for atrial fibrillation.

Increased EHRA Score Predicts Atrial Fibrillation Recurrence in Paroxysmal Atrial Fibrillation Patients Undergoing Cryoablation

Abstract Aim: Atrial fibrillation (AF) recurrence occurs in 20-30% of patients despite cryoablation treatment. We aimed to investigate the importance of CHA2DS2-VASc, TIMI-AF, ATRIA, HASBLED and EHRA scoring systems in identifying patients with late-stage AF recurrence in patients who received cryoablation due to paroxysmal AF (PAF). Materials and Methods: This cross-sectional study included 300 patients who received cryoablation because of PAF. EHRA, CHA2DS2-VASc, TIMI AF, ATRIA and HASBLED scores used in the clinic were calculated for AF burden, stroke and bleeding risk in patients. AF recurrence was defined as detection of AF in 12-lead electrocardiography or observation of AF attack for at least 30 seconds in Holter ECG recording. Patients were divided into 2 groups as patients with and without AF recurrence. Results: In the follow-up of patients who underwent cryoablation due to PAF, AF recurrence was detected in 47 (16%) patients. CHA2DS2-VASc, ATRIA, HASBLED and EHRA scores were significantly higher in the patient group with AF recurrence (p&lt;0.05 for each). TIMI-AF score was similar between the two groups. When logistic regression analysis was performed to identify patients with AF recurrence, variables of HT (OR:3.322, 95% CI:1.659 – 6.620, p=0.001), BMI (OR:1.087, 95% CI:1.011 – 1.169, p=0.024) and EHRA scoring system (OR:3.503, 95% CI:1.680 – 7.306, p=0.001) were determined as independent markers for AF recurrence. Conclusion: The results of our study showed that EHRA scoring system should be used for AF ablation decision, as well as its ability to predict AF recurrence, would be clinically useful.

Surgical ablation of long-standing persistent atrial fibrillation: 1-year outcomes from the CArdioSurgEry Atrial Fibrillation (CASE-AF) registry.

The CArdioSurgEry Atrial Fibrillation (CASE-AF) registry is a prospective, multicentre study for collecting and analysing real-world data of surgical atrial fibrillation (AF) treatment. This study aimed to evaluate outcomes of surgery for long-standing persistent AF at 1 year. In total, 17 centres consecutively include all eligible patients with continuous AF lasting for ≥1 year. Exclusion criteria are missing informed consent or age <18 years. For patient-reported outcomes measures, the European Heart Rhythm Association score was used. No presence of AF (based on ECG findings including Holter ECG and/or implanted devices), no re-ablation, no further cardioversion and no rehospitalization due to AF after a 3-month blanking period defined no AF recurrence at 1 year. From January 2017 to January 2020, a total of 1115 patients were enrolled in CASE-AF. Of them, 202 patients (mean age 69.7 ± 7.8 years, 27.2% female) underwent surgical ablation of long-standing persistent AF (study cohort), mostly accompanied by left atrial appendage closure (n = 180 [89%], resection n = 75 [42%]) and predominantly performed as concomitant (n = 174 [86%]) and left atrial only procedure (n = 144 [71%]). Early mortality (30 days) was 2.0% and morbidity was low. At follow-up (median 14.4 months, interquartile range, 12.7-17.6 months, 100% complete), 106 patients (56%) had no AF recurrence and 93% of them were asymptomatic. AF recurrence was accompanied by AF-related rehospitalization (n = 12, P = 0.003), direct current shock cardioversion (n = 23, P < 0.001), AF ablation (n = 7, P = 0.003) and stroke (n = 3, P = 0.059). Multivariable analysis identified cryoablation, predominantly performed endocardially including additional left atrial (74%) and biatrial (42%) lesions, as a significant factor for freedom from AF recurrence (odds ratio 2.7, 95% confidence interval 1.07-6.79, P = 0.035). According to CASE-AF, surgical ablation of long-standing persistent AF is most effective when concomitantly performed using endocardial cryoablation. Ongoing follow-up allows further elucidation of efficacious treatment strategies.

Clinician-reported EHRA and NYHA scores only moderately reflect patient-reported quality of life in atrial fibrillation and heart failure

Abstract Background In the management of heart failure (HF) and atrial fibrillation (AF), treatment decisions are often made based on the amount and severity of symptoms. It is expected that treating the patients’ symptoms positively impacts the patients’ burden of disease. Clinician-reported symptoms are expected to agree with patient-perceived symptoms. However, patients may value (the impact of) symptoms on their quality of life (QoL) differently to clinicians. Purpose This study aimed to gain insights on how patients perceive the impact of AF and HF on QoL, compared to how clinicians perceive (the impact of) patients’ symptoms. To this end, the clinician-reported severity of symptoms was assessed in relationship with patient-reported QoL within 12 months after diagnosis. Methods Newly diagnosed AF and HF patients were included between November 2014 and January 2023 in four non-academic hospitals situated in the Southeast of the Netherlands. During routine visits to AF- and HF-outpatient clinics trained nurses collected information on among others symptoms and QoL at diagnosis and 12 months of follow-up. Severity of symptoms was determined through a clinician-reported NYHA classification for HF and EHRA score for AF. QoL was assessed through the use of the CareQol questionnaire for HF and AFEQT questionnaire for AF. Medians and interquartile-ranges (IQR) were used to assess symptoms and QoL at diagnosis and 12 months of follow-up. In addition, one-way ANOVA’s were employed to assess difference in symptoms and QoL over a period of 12 months. Results In total, 890 AF patients and 292 HF patients were available for analysis with complete 12 month follow-up information. A moderate correlation was observed between EHRA score and AFEQT at diagnosis and 12 months follow-up (Pearson’s R -0.357 and -0.302, respectively). A comparable correlation was observed between NYHA classification and CareQoL (Pearson’s R 0.290 and 0.491). A clinician-reported improvement in AF or HF symptoms from diagnosis to 12 months follow-up was associated with a patient-reported improvement in QoL (AF: F(762,3) = 25.86, p &amp;lt;.001, and HF: F(256,2) = 8.87, p &amp;lt;.001). When clinicians reported no change or worsening symptoms, no significant changes in QoL were reported by patients. Furthermore, a large variation was observed in patient-reported quality of life, even if clinicians reported no symptoms (i.e. EHRA I / NYHA I) for both AF and HF (Median (IQR); 84.3 (25.1) and 2.49 (1.05), respectively) (Figure 1 &amp; 2). Conclusion In this study only a moderate correlation was observed between clinician-reported symptoms and patient-reported quality of life with large individual variation in patient reported QoL. A clinician-reported worsening of symptoms was not always reflected in a decrease of patients’ QoL. The clinician-reported EHRA and NYHA classification does often not accurately reflect the burden of disease as perceived by patients.

15-month follow-up of catheter ablation for atrial fibrillation in octogenarians

Abstract Background Catheter ablation for atrial fibrillation (AF) in octogenarians poses a challenge due to comorbidities, frailty, and suspected higher complication rates. Data regarding the outcome of catheter ablation in this population is scarce. Purpose Due to the projected increase of octogenarians presenting with AF in the future, we investigated the outcome of catheter ablation in this patient population. Methods We retrospectively analysed octogenarians with symptomatic AF undergoing catheter ablation in a single centre, including first and re-ablation procedures. Catheter ablation involved pulmonary vein isolation (PVI) using radiofrequency (RF), cryoballoon (CB) and pulsed field ablation (PFA) as energy sources and also atrial tachycardia (AT) ablation including linear lesions and/or ablation of complex fractionated atrial electrograms (CFAE). Follow-up (FU) was obtained to assess arrhythmia-free survival after a 90-day blanking period, recurrences after the blanking period, management of recurrences, rhythm at FU, use of antiarrhythmic drugs (AADs) and improvement in symptoms (EHRA symptom scale). Results A total of 126 patients (mean age 82.2 ± 1.9 years, paroxysmal AF n=48, persistent AF n=78, mean CHA2DS2-VASc-Score 4.2 ± 1.5) were included. 57.1% (n=72/126) underwent an index procedure {47.2% (n=34/72) RF PVI, 37.5% (n=27/72) CB PVI, 4.2% (n=3/72) PFA PVI and 11.1% (n=8/72) PVI + AT ablation}. 42.9% (n=54/126) received repeat procedures {20.4% (n=11/54) re-PVI, 42.6% (n=23/54) re-PVI + AT ablation, 37% (n=20/54) AT ablation}. FU of 108 patients after 15.4 ± 3.6 months revealed arrhythmia-free survival after the blanking period in 64.8% (n=70/108). Recurrence after the blanking period was seen in 35.2% (n=38/108). No significant difference in recurrences was shown between index and repeat procedures (32.3%, n=20/62 after index procedures and 36.7%, n=18/49 after repeat procedures, p =0.97). Management of recurrence involved repeat ablation (47%, n=18/38), AADs (16%, n=6/38), cardioversion (21%, n=8/38), pacemaker-implantation/AV-node ablation (5%, n=2/38) and pharmacological rate control (11%, n=4/38). At FU, 88.9% (n=96/108) of patients were in sinus rhythm with 21.3% (n=23/108) receiving AADs, 7.4% (n=8/108) were in AF, 0.9% (n=1/108) in AT and 2.8% (n=3/108) pacemaker-dependant. Symptoms were significantly improved at FU (mean EHRA score at FU= 1.2 ± 0.5, before ablation= 2.4 ± 0.5, p &amp;lt;0.0001). Conclusion Catheter ablation for AF in octogenarians is effective in maintaining sinus rhythm and controlling AF-related symptoms. Longer term success and impact on prognosis in this patient population is unknown and should be investigated further.

Asymptomatic atrial fibrillation among hospitalized patients: clinical correlates and in-hospital outcomes in Improving Care for Cardiovascular Disease in China-Atrial Fibrillation.

The clinical correlates and outcomes of asymptomatic atrial fibrillation (AF) in hospitalized patients are largely unknown. We aimed to investigate the clinical correlates and in-hospital outcomes of asymptomatic AF in hospitalized Chinese patients. We conducted a cross-sectional registry study of inpatients with AF enrolled in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation Project between February 2015 and December 2019. We investigated the clinical characteristics of asymptomatic AF and the association between the clinical correlates and the in-hospital outcomes of asymptomatic AF. Asymptomatic and symptomatic AF were defined according to the European Heart Rhythm Association score. Asymptomatic patients were more commonly males (56.3%) and had more comorbidities such as hypertension (57.4%), diabetes mellitus (18.6%), peripheral artery disease (PAD; 2.3%), coronary artery disease (55.5%), previous history of stroke/transient ischaemic attack (TIA; 17.9%), and myocardial infarction (MI; 5.4%); however, they had less prevalent heart failure (9.6%) or left ventricular ejection fractions ≤40% (7.3%). Asymptomatic patients were more often hospitalized with a non-AF diagnosis as the main diagnosis and were more commonly first diagnosed with AF (23.9%) and long-standing persistent/permanent AF (17.0%). The independent determinants of asymptomatic presentation were male sex, long-standing persistent AF/permanent AF, previous history of stroke/TIA, MI, PAD, and previous treatment with anti-platelet drugs. The incidence of in-hospital clinical events such as all-cause death, ischaemic stroke/TIA, and acute coronary syndrome (ACS) was higher in asymptomatic patients than in symptomatic patients, and asymptomatic clinical status was an independent risk factor for in-hospital all-cause death, ischaemic stroke/TIA, and ACS. Asymptomatic AF is common among hospitalized patients with AF. Asymptomatic clinical status is associated with male sex, comorbidities, and a higher risk of in-hospital outcomes. The adoption of effective management strategies for patients with AF should not be solely based on clinical symptoms.

A pilot study evaluating the role of ivabradine for rate control in patients with rheumatic atrial fibrillation

ObjectivesIvabradine may have a role in rate control of atrial fibrillation (AF) due to effects on HCN channels in AV node. We studied role of Ivabradine in rate control of rheumatic AF. Methods80 patients, rheumatic AF, HR > 100 bpm (age 47 ± 11 yrs, AF duration 6.8 ± 2.9 years, rate 131 ± 16 bpm) on maximally tolerated ββ or CCB's, randomized to Ivabradine or escalated ββ/CCB. Ivabradine started @ 2.5 mg BD; increased to 5 mg BD if inadequate response at 1 week (failure to decrease HR < 10% vs baseline). After Holter at 1 month, dose escalated to 7.5 mg BD if needed. ResultsIvabradine resulted in significantly lower HR (81 ± 10 vs 99 ± 9) at 3 months and 6 months (79 ± 8 vs 94 ± 8, p < 0.001). Absolute reduction in HR: 56 ± 15 vs 31 ± 14 bpm and % change in HR: 41 ± 7 vs 24 ± 9%, both p < 0.00001).At 6 months, Ivabradine group had.1Significantly lower NT Pro BNP (1168 vs 1314 pg/ml), higher 6 min walk distance (410 ± 47 vs 349 ± 54 m, all p < 0.001)2Better symptom class (EHRA score 1: asymptomatic 84% vs 40%), improvement >1 EHRA class; baseline 60% vs 17%3Better LA Strain (22.8 ± 2.8% vs 20.6 ± 2.5%)Ivabradine was well tolerated and there was no drug withdrawal. ConclusionOur data suggest that Ivabradine can be an option for rate control in rheumatic AF.

Atrioventricular nodal ablation is an effective management strategy for atrial fibrillation in patients with hypertrophic cardiomyopathy

Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and can be challenging to manage. Atrioventricular nodal (AVN) ablation may be an effective management strategy for AF in these patients. The purpose of this study was to assess the efficacy of AVN ablation in HCM patients who have failed medical therapy and/or catheter ablation for AF. A multicenter study with retrospective analysis of a prospectively collated HCM registry was performed. AVN ablation patients were identified. Baseline characteristics and device and procedural indications were collected. Symptoms defined by New York Heart Association and European Heart Rhythm Association classification and echocardiographic findings during follow-up were assessed. Fifty-nine patients were included in the study. Indications for AVN ablation were 6 (10.2%) inappropriate implantable cardioverter-defibrillator shock, 35 (59.3%) ineffective rate control, and 18 (30.5%) to regularize rhythm for symptom improvement. During post-AVN ablation follow-up of 79.4 ± 61.1 months, left ventricular ejection fraction (LVEF) remained stable (pre-LVEF 48.9% ± 12.6% vs post-LVEF 50.1% ± 10.1%; P = .29), even in those without a cardiac resynchronization therapy (CRT) device (pre-LVEF 54.3% ± 8.0% vs post-LVEF 53.8% ± 8.0%; P = .65). Forty-nine patients (83.1%) reported an improvement in symptoms regardless of AF type (17/21 [81.0%] paroxysmal vs 32/38 [84.2%] persistent; P = 1.00), presence of baseline left ventricular impairment (22/26 [84.6%] LVEF ≤50% vs 27/33 [81.8%] LVEF ≥50%; P = 1.00) or CRT device (27/32 [84.4%] CRT vs 22/27 [81.5%] no CRT; P = 1.00). Symptoms improved in 16 patients (89.0%) who underwent AVN ablation to regularize rhythm. AVN ablation improved symptoms without impacting left ventricular function in the majority of patients. The data suggest that AVN ablation is an effective and safe management approach for AF in HCM and should be further evaluated in larger prospective studies.

Patient perspectives on same-day discharge following catheter ablation for atrial fibrillation: Results from a patient survey as part of the monocentric FAST AFA trial.

Same-day discharge (SDD) following catheter ablation (CA) of atrial fibrillation (AF) was already introduced in selected facilities in Europe but a widespread implementation has not yet succeeded. Data on patients' perspectives is lacking. Therefore, we conducted a survey to address patients' beliefs towards SDD and identify variables that are associated with their evaluation. As part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing left atrial CA for AF were asked to participate in the survey consisting of a study-specific questionnaire, the AF knowledge scale and pre-defined PROMs. The study cohort was stratified based on SDD willingness and a logistic regression analysis was used to identify predictors for patients' valuation. Between 07/26/2021-07/01/2022, 256 of 376 screened patients consented to study participation of whom 248 (mean age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%) and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, expressed concerns included uncertainties with occurring complaints (50.6%), and the insufficient recognition (47.8%) and treatment (48.9%) of complications. EHRA class at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not. We provide a detailed survey expressing patients' beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts.

Analysis of factors associated with anxiety in patients with atrial fibrillation and their caregivers

Objective: To explore the risk factors of anxiety in patients with atrial fibrillation and their caregivers. Methods: From September 2020 to March 2021, patients with atrial fibrillation and one primary family member as caregiver of each patient from Beijing Anzhen Hospital were enrolled. Basic data of patients and their caregivers were collected, and anxiety of patients and caregivers were evaluated by Generalized Anxiety Disorder-7 scale (GAD-7). A total of 374 patients with atrial fibrillation and their caregivers were included in this study. Multivariate logistic regression analysis was used to analyze the risk factors of anxiety of patients and their caregivers. Results: The mean age of the patients was (58.3±10.6) years, and 124 (33.2%) were female. The caregivers were (53.6±11.6) years old, and 247 (66%) were female. 69 (18.4%) patients and 38 (10.2%) caregivers had mild anxiety (GAD-7:5-9 scores), 13 (3.5%) patients and 9 (2.4%) caregivers had moderate or higher anxiety (GAD-7:10-21 scores). Multivariate analysis showed that the risk factors of anxiety in patients with atrial fibrillation included EHRA score≥3 (OR=1.73,95%CI:1.03-2.89,P=0.039) and female sex (OR=1.90,95%CI:1.06-3.40,P=0.032). EHRA score of patients≥3 (OR=2.11,95%CI:1.05-4.24, P=0.036) or anxiety of patients (OR=2.76,95%CI:1.36-5.60,P=0.005) were associated with higher anxiety of caregivers. Moreover, age of≥65 years old (OR=3.97,95%CI:1.68-9.38,P=0.002), female sex (OR=3.83,95%CI:1.64-8.93,P=0.002) and number of comorbidities of caregivers≥2 (OR=2.57,95%CI:1.03-6.41,P=0.043) were also associated with anxiety of caregivers. Conclusions: Patients with severe symptoms have a higher proportion of anxiety, and their caregivers are more likely to experience anxiety. Anxiety rate is higher in caregivers of patients with anxiety.

Changes in cardiac output, rhythm regularity, and symptom severity after electrical cardioversion of atrial fibrillation

Objectives Symptoms in atrial fibrillation (AF) range from none to disabling. The physiological correlates of AF symptoms are not well characterized. This study investigated the association between physiological parameters and symptom severity before and after electrical cardioversion (EC) of AF. Design We studied 44 patients with persistent AF (age 66.2 ± 7.9 years, 16% females) 4 ± 2 days before and 5 ± 2 days after EC. Physiological parameters included cardiac output (CO; non-invasive inert gas rebreathing), heart rate (HR), RR variability and resting and ambulatory blood pressure (BP). Symptoms and quality of life (QoL) were assessed by the modified European Heart Rhythm Association score (mEHRA), the Atrial Fibrillation Effect on Quality of Life (AFEQT) and the Symptom Checklist for frequency and severity of symptoms (SCL). Results 28 of 44 patients were still in sinus rhythm (SR) at post EC evaluation. Those in SR had a decreased HR (-15.4 ± 13.1 bpm, p < 0.001), and an increased CO (+0.8 ± 0.7 L/min, p < 0.001) as compared to those with recurrent AF. Changes in CO after EC correlated with symptom improvement as scored by AFEQT (r = 0.36; p < 0.05), AFEQT symptoms subscore (r = 0.46; p < 0.01), SCL for frequency (r = 0.62; p < 0.01) and severity (r = 0.33; p < 0.05) of symptoms, and the mEHRA score (r = 0.50; p < 0.01). A decrease in RR variability showed similar correlations with these measures of symptom improvement. Conclusions Improvements in symptoms and quality of life experienced by patients after electrical conversion of atrial fibrillation are correlated with an increase in CO and a decreased RR variability.

Comparison of quality-of-life following cryoballoon versus radiofrequency catheter ablation of symptomatic atrial fibrillation - a subanalysis of the FREEZE cohort study

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Catheter ablation of symptomatic atrial fibrillation (AF) is an established treatment option. Cryoballoon (CBA) and radiofrequency ablation (RFA) have demonstrated comparable high rates of freedom from atrial arrhythmia recurrence. Comparative data on quality of life (QoL) outcomes with respect to the used energy source are scarce. Purpose To compare QoL changes following CBA versus RFA in symptomatic AF. Methods This is a sub-analysis of the prospective multi-center FREEZE Cohort Study (ClinicalTrials.gov, NCT01360008). QoL changes were assessed by EQ-5D-3L self-report questionnaire and by EHRA symptom score at baseline and follow-up. Five dimensions of QoL were compared between the treatment groups: "mobility", "self-care", "usual activities", "pain/discomfort", and "anxiety/depression". Changes of Visual Analogue Scale (EQ-VAS) and general physical condition (GPC) were assessed. Results From 2011 to 2016, a total of N=4,189 patients were included, and N=2,110 (50.4%) - CBA N=1,590 (75%) and RFA N=529 (25%) - completed all QoL questionnaires. Differences between groups were observed. Mean age was 61.4±10.4 (CBA) and 63.2±10.4 (RFA) years (p&amp;lt;0.001), and 72.8%, and 65.4% of patients demonstrated paroxysmal AF (p&amp;lt;0.01), respectively. EHRA symptom score was &amp;gt;/= II in 89.7% versus 92.9% of patients in CBA and RFA group at baseline (p&amp;lt;0.0001). The median follow-up duration was 422 (CBA) and 482 days (RFA), p&amp;lt;0.0001. At follow-up, atrial arrhythmia recurrence was documented in 45.0% and 56.9% of patients in the CBA and RFA group (p&amp;lt;0.0001), and EHRA Score &amp;gt;/= II was documented in 23.7% and 32.0% of patients (p&amp;lt;0.001), respectively. Repeat ablation was less frequently performed in the CBA group (7.9% vs. 22.3%, p&amp;lt;0.001). Ablation was rated as „overall successful" by 69.5% and 53.7% of the patients in in the CBA and RFA group, respectively (p&amp;lt;0.0001). Significant differences in QoL dimensions from baseline to follow-up were observed between the groups (see Figure): Patients in the CBA group showed a statistically significant greater improvement for the QoL dimension "pain/discomfort", „general physical condition", EQ-VAS, and EQ-5D-Score as compared to the RFA group (all p&amp;lt;0.001). No differences between the groups were found for the dimensions "mobility", "self-care", "usual activities", and "anxiety/depression". Conclusion Catheter ablation in symptomatic AF was associated with a significant improvement of AF symptoms, "pain/discomfort", "anxiety/depression", and GPC in both groups. However, there was only a small benefit of ablation on „mobility", „self-care", and „usual activities". Interestingly, in the CBA group patients reported significantly more frequently amelioration of "pain/discomfort" and „general physical condition". This finding was confirmed by a higher EQ-VAS and EQ-5D-Score as well as a higher level of satisfaction in the CBA group, and might be related to the lower recurrence rate.

Usefulness of the systemic immune inflammation index to predict atrial fibrillation recurrence after cryoablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Catheter-based atrial fibrillation (AF) ablation is an effective and reliable therapy in the treatment of patients with symptomatic and drug-refractory atrial fibrillation [1, 2]. Several factors and noninvasive clinical markers have been investigated to predict the success rate of catheter ablation[3, 4]. Inflammation is a well-established risk factor in the pathogenesis, initiation and perputuation of AF and in the recurrence of AF following ablation procedures [ 5]. The systemic immune inflammation index (SII) has emerged as a new predictor of inflammation and is determined using the following equation: neutrophil (N) × platelet (P) ÷ lymphocyte (L)[6]. The predictive value of this index on routine blood tests have been examined and suggested to be a powerful and independent prognostic factor of several cardiovascular diseases. [7, 8]. The current study sought to assess whether there is a relationship between SII level and recurrence of AF after catheter ablation. Methods This study was a single center and non-randomized study conducted at our city hospital Department of Cardiology. From January 2019 to March 2021 a total of 370 consecutive patients with symptomatic AF who underwent cryoablation were enrolled. The study population consisted of patients (mean age 56.1±12.3 years, 50.5% male) with drug-resistant symptomatic AF who underwent initial PV isolation with cryoballoon technique for documented AF. The patients were divided into two groups according to receurrence development Results After a mean follow-up period of 25.0±6.7 months, early recurrence was developed in 36 (9.7%) patients and recurrence after blanking period was observed in 77 patients (20.8%) patients. According to multivariate Cox proportional hazard regression analysis, pre-ablation SII level (HR: 2.32, 95% CI: 1.35–3.98, P: 0.002), left ventricular ejection fraction (HR: 0.96, 95% CI: 0.93–0.99, P : 0.020) and EHRA Score (HR: 2.04, 95% CI: 1.34–3.10, P : 0.001) were independent predictors of AF recurrence after cryoablation. In ROC curve analysis, using a cut-off level of 532, the pre-ablation SII level predicted AF recurrence with a sensitivity of 71.4% and a specificity of 67.9% (AUC: 0.88, 95% CI: 0.67–0.80; P &amp;lt;0.001) (Figure 1). In addition, correlation analysis revealed that there was a positive correlation of pre-procedural SII level with pre-procedural hsCRP level (r: 0.340, P &amp;lt;0.001). Figure 2 represent the Kaplan–Meier curves for the freedom from AF recurrence according to SII cut-off level of 532 (log-rank, P &amp;lt; 0.001). Conclusions Our findings revealed that, in patients with paroxysmal and/or persistent AF undergoing cryoablation, increased pre-ablation SII levels were associated with a higher rate of AF recurrence. As a readily available, low-cost and easy to access marker of inflammation, pre-ablation SII level has well-predicted AF recurrence after cryoballoon-based ablation.

The prognostic value of quality of life in atrial fibrillation on patient value

BackgroundIn this study, the prognostic value of AF-related quality of life (AFEQT) at baseline on Major Adverse Cardiovascular Events (MACE) and improvement of perceived symptoms (EHRA) was assessed. Furthermore, the relationship between QoL and AF-related hospitalizations was assessed.MethodsA cohort of AF-patients diagnosed between November 2014 and October 2019 in four hospitals embedded within the Netherlands Heart Network were prospectively followed for 12 months. MACE was defined as stroke, myocardial infarction, heart failure and/or mortality. Subsequently, MACE, EHRA score improvement and AF-related hospitalizations between baseline and 12 months of follow-up were recorded.ResultsIn total, 970 AF-patients were available for analysis. In analyses with patients with complete information on the confounder subset 36/687 (5.2%) AF-patients developed MACE, 190/432 (44.0%) improved in EHRA score and 189/510(37.1%) were hospitalized during 12 months of follow-up. Patients with a low AFEQT score at baseline more often developed MACE (OR(95%CI): 2.42(1.16–5.06)), more often improved in EHRA score (OR(95%CI): 4.55(2.45–8.44) and were more often hospitalized (OR(95%CI): 4.04(2.22–7.01)) during 12 months post diagnosis, compared to patients with a high AFEQT score at baseline.ConclusionsAF-patients with a lower quality of life at diagnosis more often develop MACE, more often improve on their symptoms and also were more often hospitalized, compared to AF-patients with a higher quality of life. This study highlights that the integration of patient-reported outcomes, such as quality of life, has the potential to be used as a prognostic indicator of the expected disease course for AF.