Evidence Of Atrial Fibrillation Research Articles

RESTING HEART RATE AND MORTALITY RISK IN HYPERTENSIVE PATIENTS WITH NO ATRIAL FIBRILLATION

Objective: The recent ESH Guidelines include elevated resting heart rate (RHR) as an independent risk factor among the established and suggested novel risk factors that influence cardiovascular risk in patients with hypertension, indicating sympathetic overdrive. Increased fitness affects both mortality and RHR. However, the association between RHR and mortality risk, adjusted for cardiorespiratory fitness, age, comorbidities and medication has not been fully explored. Design and method: We evaluated the association between RHR and mortality in 422,702 hypertensive patients (mean age 62.5 ± 8.6 years) with no evidence of atrial fibrillation during the entire follow-up. All completed a standardized exercise treadmill test (ETT), with no evidence of overt heart disease prior to and at the time of the ETT. To assess the risk in a wide and clinically relevant spectrum, we established 6 RHR categories per 10 heartbeat intervals ranging from <=60 to >100 beats. We used multivariable Cox regression to assess the RHR-mortality association. We adjusted the models for age, body mass index, cardiac risk factors, exercise capacity, and medications (including b-blockers). Results: During the median follow-up of 10.6 years, providing 4,551,327 person-years, there were 107,863 deaths with an average annual rate of 23.7 events per 1,000 person-years. We noted approximately 7% increase in risk for each 10 heart beats. Mortality risk was significantly elevated at a RHR of >80 beats/min (HR; 1.15, CI; 1.12 - 1.17; p <0.006) and increased progressively to 41% (HR; 1.41, CI; 1.36 - 1.45; p <0.001) for those with a RHR of >100 beats/min. Similar trends were noted for subjects aged <60; 60-69; and >=70 years and those treated with b blockers. In all assessments, mortality risk was consistently overestimated when fitness was not considered. Conclusions: We noted a progressive increase in mortality risk with increased RHR at >80 bpm in hypertensive patients with no AF. The association was independent of comorbidities, and medications.

Cryoballoon pulmonary vein isolation as first-line treatment of typical atrial flutter: long-term outcomes of the CRAFT trial.

CRAFT was an international, multicentre, randomised controlled trial across 11 sites in the United UK and Switzerland. Given the evidence that pulmonary vein triggers may be responsible for atrial flutter (AFL) as well as atrial fibrillation (AF), we hypothesised that cryoballoon pulmonary vein isolation (PVI) would provide greater symptomatic arrhythmia reduction than cavotricuspid isthmus (CTI) ablation, whilst also reducing the subsequent burden of AF. Twelve-month outcomes were previously reported. In this study, we report the extended outcomes of the CRAFT study to 36months. Patients with typical AFL and no evidence of AF were randomised 1:1 to cryoballoon PVI or radiofrequency CTI. All patients received an implantable loop recorder (ILR) for continuous cardiac rhythm monitoring. The primary outcome was time-to-symptomatic arrhythmia recurrence > 30s. Secondary outcomes included time-to-first-AF episode ≥ 2min. The composite safety outcome included death, stroke and procedural complications. A total of 113 patients were randomised to cryoballoon PVI (n = 54) or radiofrequency CTI ablation (n = 59). Ninety-one patients reconsented for extended follow-up beyond 12months. There was no difference in the primary outcome between arms, with the primary outcome occurring in 12 PVI vs 11 CTI patients (HR 0.97; 95% CI 0.43-2.20; p = 0.994). AF ≥ 2min was significantly less frequent in the PVI arm, affecting 26 PVI vs 36 CTI patients (HR 0.48; 95% CI 0.29-0.79; p = 0.004). The composite safety outcome occurred in 5 PVI and 6 CTI patients (p = 0.755). Cryoballoon PVI shows similar efficacy to radiofrequency CTI ablation in reducing symptomatic arrhythmia recurrence in patients presenting with isolated typical AFL but significantly reduces the occurrence of subsequent AF.

Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy

Atrial cardiopathy is associated with stroke in the absence of clinically apparent atrial fibrillation. It is unknown whether anticoagulation, which has proven benefit in atrial fibrillation, prevents stroke in patients with atrial cardiopathy and no atrial fibrillation. To compare anticoagulation vs antiplatelet therapy for secondary stroke prevention in patients with cryptogenic stroke and evidence of atrial cardiopathy. Multicenter, double-blind, phase 3 randomized clinical trial of 1015 participants with cryptogenic stroke and evidence of atrial cardiopathy, defined as P-wave terminal force greater than 5000 μV × ms in electrocardiogram lead V1, serum N-terminal pro-B-type natriuretic peptide level greater than 250 pg/mL, or left atrial diameter index of 3 cm/m2 or greater on echocardiogram. Participants had no evidence of atrial fibrillation at the time of randomization. Enrollment and follow-up occurred from February 1, 2018, through February 28, 2023, at 185 sites in the National Institutes of Health StrokeNet and the Canadian Stroke Consortium. Apixaban, 5 mg or 2.5 mg, twice daily (n = 507) vs aspirin, 81 mg, once daily (n = 508). The primary efficacy outcome in a time-to-event analysis was recurrent stroke. All participants, including those diagnosed with atrial fibrillation after randomization, were analyzed according to the groups to which they were randomized. The primary safety outcomes were symptomatic intracranial hemorrhage and other major hemorrhage. With 1015 of the target 1100 participants enrolled and mean follow-up of 1.8 years, the trial was stopped for futility after a planned interim analysis. The mean (SD) age of participants was 68.0 (11.0) years, 54.3% were female, and 87.5% completed the full duration of follow-up. Recurrent stroke occurred in 40 patients in the apixaban group (annualized rate, 4.4%) and 40 patients in the aspirin group (annualized rate, 4.4%) (hazard ratio, 1.00 [95% CI, 0.64-1.55]). Symptomatic intracranial hemorrhage occurred in 0 patients taking apixaban and 7 patients taking aspirin (annualized rate, 1.1%). Other major hemorrhages occurred in 5 patients taking apixaban (annualized rate, 0.7%) and 5 patients taking aspirin (annualized rate, 0.8%) (hazard ratio, 1.02 [95% CI, 0.29-3.52]). In patients with cryptogenic stroke and evidence of atrial cardiopathy without atrial fibrillation, apixaban did not significantly reduce recurrent stroke risk compared with aspirin. ClinicalTrials.gov Identifier: NCT03192215.

Isthmus-dependent right atrial flutter : Clinical course after isthmus ablation

Ablation of the cavotricuspid isthmus (CTI) to create bidirectional isthmus blockade is the most effective way to achieve rhythm control in typical atrial flutter. Compared with drug therapy, ablation reduces cardiovascular mortality, all-cause mortality, stroke risk, and the risk of cardiac decompensation. Concomitant arrhythmia of atrial flutter is atrial fibrillation (AF); therefore the duration of oral anticoagulation should be adapted according to the risk of stroke and bleeding. Acombined procedure of CTI ablation and pulmonary vein isolation (PVI) in patients with typical atrial flutter but without evidence of AF should be evaluated individually especially in patients aged > 54years depending on (cardiac) comorbidities. The comprehensive diagnostic view should keep in mind not only arrhythmias but also possibly underlying coronary artery disease.

PO-03-133 BOTH OVERUSE AND UNDERUSE OF ORAL ANTICOAGULATION POST-ATRIAL FIBRILLATION ABLATION IN A LARGE HEALTHCARE SYSTEM

Guidelines recommend that decisions regarding oral anticoagulation (OAC) post ablation for atrial fibrillation (AF) should be based solely on the patient’s stroke risk profile, regardless of the outcomes of the procedure. The adherence to this recommendation in clinical practice has not been examined. To provide real-world data about adherence to anticoagulation guidelines after AF ablation. We included patients undergoing AF ablation in one of 8 hospitals of Northwell Health between 2014 and 2022. We excluded patients without continuous OAC for at least 2 months post-ablation and without a complete 3- and 12-month follow-up. Adherence to OAC guidelines was defined as continuing OAC for males with CHA2DS2-VASc≥2 and females with CHA2DS2-VASc≥3 and discontinuing OAC for the rest. A subgroup analysis of patients based on their CHA2DS2-VASc scores (0, 1, 2, and ≥3) was performed. Exploratory clinical endpoints included AF recurrence, stroke/transient ischemic attack, bleeding events, and all-cause mortality. Out of 900 patients, 69 (7.7%) and 187 (20.1%) discontinued OAC at 3- and 12-months post-ablation, respectively (Figure 1). Among patients who discontinued OAC at 12 months, 91 (48.6%) met indication for OAC. In contrast, among those without OAC indication, 36 (54.5%) patients remained on OAC at 12 months. Patients who discontinued OAC were younger with mostly paroxysmal AF and fewer comorbidities; lending to lower CHA2DS2-VASc scores (all p< 0.001). Specifically, 64.7%, 46.6%, 22.3% and 10.6% of patients with CHA2DS2-VASc of 0, 1, 2, and ≥3 respectively, discontinued OAC at 12 months (Table 1). Among those who discontinued OAC, 6 (13.0%), 32 (18.5%), 48 (13.2%), and 106 (10.5%) had AF recurrence and 0 (0%), 1 (2.3%), 0 (0%), and 1 (2.2%) had a stroke in CHA2DS2-VASc 0, 1, 2, and ≥3 groups, respectively. The most common reasons for discontinuation were patient preference, contraindications, and physician-patient shared decision-making. OAC was discontinued in approximately 20% of all patients undergoing catheter ablation at 1 year. Of these, roughly half had an ongoing indication for OAC. On the other hand, approximately half of patients with very low thromboembolic risk remain on OAC despite no evidence of AF recurrence.Tabled 1Table 1CHA2DS2-VASc0 (n=34)1 (n=133)2 (n=215)≥3 (n=518)Anticoagulation off (%)64.746.622.310.6AF Recurrence (%)17.624.122.520.6Stroke/TIA (%)01.01.22.2All-cause death (%)00.80.92.7Any bleeding (%)00.80.91.3 Open table in a new tab

PO-01-140 ATRIAL FIBRILLATION AND SEPTIC SHOCK: A FIVE-YEAR RETROSPECTIVE OBSERVATIONAL STUDY OF ANTICOAGULATION USAGE, BLEEDING AND STROKE RATES

Anticoagulation (AC) for atrial fibrillation (AF) is a cornerstone of management, and the benefit of mitigating stroke risk is accompanied by an increased risk of bleeding. The risk and benefit of AC in septic shock remains unclear as this disruptive hyperinflammatory state leads to multi-organ dysfunction, which can include coagulopathies. To further understand the risk of bleeding and stroke in patients with AF and septic shock, we aimed to study the rates of these events in addition to AC usage for this population between 2016 and 2020. In this retrospective observational study, we used ICD-10 coding to identify patients with AF and septic shock. Initial query found 604 patients. 52 were excluded for the absence of AF and 24 were excluded for requiring AC for other reasons. Admission for septic shock and evidence of AF on electrocardiogram were confirmed through chart review. Bleeding was defined using the Bleeding Academic Research Consortium (BARC) classification system. For 528 patients, mean age was 64.8 years, 325 (61.6%) were male, and 203 (38.4%) were female. 314 died (59.5%) and 227 (43%) had new-onset AF. Mean CHA2DS2-Vasc and HAS-BLED scores were 3.2 and 2.6, respectively. AC was started for 195 patients (36.9%), not started for 289 (54.7%), and continued for 43 (8.1%). AC was stopped for 74/195 (38.3%) patients after starting AC and for 20/43 (46.5%) patients after continuing AC. 157 had bleeding episodes (29.7%): 9 BARC 1 (1.7%), 46 BARC 2 (8.7%), 63 BARC 3a (11.9%), 20 BARC 3b (3.8%), 6 BARC 3c (1.1%), 5 BARC 4 (0.9%), 3 BARC 5a (0.6%), and 5 BARC 5b (0.9%). After starting AC, 70/195 (35.9%) patients bled, and this included all fatal bleeding cases. Bleeding occurred in 11/43 (25.6%) patients after continuing AC and 76/289 (26.3%) patients after not starting AC. 8 (1.5%) patients had a stroke: 4 hemorrhagic and 4 ischemic. 3 hemorrhagic strokes occurred after starting AC and 1 occurred after not starting AC. 1 ischemic stroke occurred after starting AC and 3 after not starting AC. In patients with AF and septic shock, we found that bleeding occurred more often and with the highest severity after starting AC. The rate of bleeding when not starting AC may indicate an increased baseline risk associated with sepsis. Notably, the rate of ischemic stroke was relatively low, which may suggest that bleeding risk may outweigh the benefit of stroke prevention in this population. Further studies are needed to optimize AC strategies for these patients.

Abstract WP182: Diastolic Dysfunction With Elevated Left Ventricular Filling Pressures Is Associated With Embolic Stroke Of Undetermined Source And Atrial Fibrillation Detection After Ischemic Stroke

Introduction: Diastolic dysfunction, particularly with elevated left ventricle filling pressure (LVFP) is known to be a strong independent predictor of all-cause mortality and major cardiac events. There is limited data on the role of diastolic function in ischemic stroke. We hypothesize that diastolic dysfunction with elevated LVFP is more likely to be present in patients with Embolic stroke of undetermined source (ESUS) compared to non-cardioembolic stroke and is associated with AF on cardiac monitoring in the ESUS group. Methods: This is a single center retrospective study that included adult patients with a diagnosis of acute ischemic stroke from 2014 to 2016. We excluded patients with confirmed cardioembolic stroke and those with indeterminate diastolic function. ESUS was defined as no ipsilateral stenoses ≥ 50%, cardiac telemetry for at least two weeks without evidence of atrial fibrillation or atrial flutter, and a LVEF ≥ 30%. A transthoracic echocardiogram was performed and interpreted by cardiologists. Baseline patient characteristics and clinical variables were compared among patients with and without diastolic dysfunction. Potential associations between diastolic dysfunction, ESUS and AF detection in ESUS patients were assessed using logistic regression. Results: There were 509 patients, the mean age was 64.19, 54.81% were male, and 146 had LVFP data. Diastolic dysfunction overall was not associated with ESUS (adjusted OR 1.44, 95% CI 0.91-2.28, p = 0.125) or AF detection on cardiac monitoring (adjusted OR 1.87, 95% CI 0.75-4.70, p = 0.183). However, diastolic dysfunction and elevated LVFP was associated with ESUS subtype (adjusted OR 2.26, 95% CI 1.03-4.93, p = 0.041) and AF detection on cardiac monitoring (adjusted OR 3.58, 95% CI 1.07-12.01, p = 0.039). Conclusion: Our study suggests that diastolic dysfunction with elevated LVFP is associated with ESUS stroke subtype and AF detection on cardiac monitoring. Therefore, the presence of diastolic dysfunction with elevated LVFP may identify a population of stroke patients more likely to have ESUS, particularly in the setting of occult AF. Studies are needed to confirm our findings and test the safety and efficacy of anticoagulation in patients with ESUS and diastolic dysfunction with elevated LVFP.

PS-C28-10: HYPERTENSIVE CARDIOMYOPATHY AS MOST FREQUENT ECHOCARDIOGRAPHIC FINDING IN PATIENTS HOSPITALIZED FOR ISCHEMIC STROKE.

Objective: In Spain occurs about 120,000 strokes per year. Initial study usually requires echocardiography to rule out cardioembolic source. We describe most common echocardiographic features in neurological patients and traditional risk factors in them. Methods: From August 2020 to August 2021, 502 consecutive Neurology echocardiograms were analysed, collecting data in SPSS for subsequent descriptive and analytical statistical analysis. Results: 45% were women. Most frequent study reason was ischemic stroke (66%), followed by transient ischemic attack (TIA) (11%), haemorrhagic stroke (2%) and miscellaneous (fever, cardiac enzyme release, dyspnoea, coma) (15%). Highest frequent risk factor was hypertension (HBP) (70%), followed by obesity (51%), dyslipidaemia (46%), diabetes (32%), and kidney failure (15%). Atrial fibrillation (AF) had been documented in 13%, while De novo AF was discovered in an additional 14.5%. Systemic inflammation disorders were present in 19% and hypercoagulability in 9%. 10% had suffered a previous stroke (90% ischemic), and 2.6% TIA. About treatment 27% had antiaggregation drugs on stroke moment and 12% were anticoagulated (5.6% VKA and 6.6% DOAC). In echo images, absence of structural heart disease was the most frequent finding (49%), followed by LA dilatation (48%) and ventricular hypertrophy &gt; 13 mm (34%), both characteristic of hypertensive heart. 5% showed valve disease (more frequent mitral regurgitation) and 5% Cor pulmonale. Cardiomyopathy was found in 3% (Dilated 2.6%). Patent foramen ovale, and aneurysm of the interatrial septum were rare (1% each). Ostium secundum type ASD only one case (0.2%). In the follow-up 5% had a new event (stroke or TIA) in next 12 months and additional 4.4% evidence of AF was found, this variable being related to left atrial dilatation in statistical analysis. Conclusions: In our sample of patients with ischemic stroke the abnormal finding most recurrent was hypertensive heart disease (HBP, LA dilatation, and LVH). LA dilation was related to the development of AF during follow-up, this relationship being statistically significant (p &lt; 0.001) by chi-square test. The percentage of de novo AF discovered in the same stroke episode (14.5%) is noteworthy. The ineffectiveness of antiaggregation (27% took it) and that anticoagulation does not completely eliminate risk either. Presence of structural anomalies such ASD, PFO or thrombus was rare (less than 1%).

Assessment of Relationship between Serum NT-proBNP Levels with Clinical Features and Prognosis in Acute Ischemic Stroke Patients.

We aimed to assess N-terminal pro brain-type natriuretic peptide (NT-proBNP) levels in acute ischemic stroke (AIS) patients according to clinical and radiological features and to investigate its relationship with short term clinical outcomes. In our study, 107 patients with AIS were evaluated prospectively. Of all, 56 patients had no evidence of atrial fibrillation (AF) (sinus rhythm [SR] group) (52.3%), 24 patients had paroxysmal AF (pAF group) (22.4%), and the other 27 patients had chronic AF (cAF group) (25.3%). Demographic datas, clinical characteristics, laboratory and radiological findings, CHA2DS2 -VASc scores, NIHSS (National Institute of Health Stroke Scale) and modified Rankin Scale (mRS) scores on admission and at the third month evaluations were recorded. Good functional outcome at 3 months was defined as modified Rankin score (mRS) 2 or less. According to the TOAST (Trial of Org 10172 in Acute StrokeTreatment) and OCSP (Oxfordshire Community Stroke Project) study, ischemic stroke subtyping was performed. Serum NT-proBNP levels were estimated in 107 stroke patients and 24 age- and sex-matched control subjects. Venous blood samples were obtained for serum NT-proBNP measurement within the first 48 hours of the patient group. Mean age of the 107 AIS patients was 68 ± 15.22 years and 58.9% of them were women. Compared to controls, the SR, pAF and cAF groups had higher plasma NT-proBNP levels (P < 0.001) and also NT-proBNP values were significantly higher in the pAF and cAF group than SR groups (P < 0.001). NT-proBNP values were significantly higher in cardioembolic (CE) (n = 57) group than in large artery atherosclerosis (LAA) (n = 20) and small vessel disease (SVD) (n = 30) groups (P < 0.001). NT-proBNP levels of noncardioembolic SR (n = 49) (P = 0.080), LAA and SVD groups (P = 0.103) were higher than the control group but the difference was not statistically significant. There was a positive correlation between NT-proBNP level and third month mRS scores in CE group (r = 0.491). NT-proBNP will contribute to predict cardioembolic and pAF groups and estimate the prognosis.

RF23 | PSAT301 Plasmapheresis and Extracorporeal Membrane Oxygenation (ECMO) for Treatment of Thyroid Storm with Multiorgan Failure

Abstract Introduction Thyroid storm is a life-threatening condition with a high morbidity and mortality rate. It can lead to severe end organ damage including liver injury, which can preclude the use of thionamides. Therapeutic plasma exchange can be a lifesaving option for treatment of thyroid storm in such cases. Multiorgan failure can also necessitate the use of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Case Presentation A 34-year-old woman with a history of Graves’ disease, untreated for several years, presented to the emergency department with fatigue, palpitations, dyspnea, and edema which developed over 1 month. Labs showed suppressed thyroid stimulating hormone (TSH) with significantly elevated free T4 of 10.8 ng/dL (normal 0.89-1.76 ng/dL). She had evidence of atrial fibrillation and heart failure. She was started on treatment with propylthiouracil, propranolol, and hydrocortisone and then Lugol's iodine was added. However, she quickly deteriorated with worsening mentation, dyspnea, and hypotension. She progressed to multiorgan failure including significant liver injury likely due to ischemic hepatitis. Thus, thianomides could not be used any further. She was started on cholestyramine; hydrocortisone and Lugol's iodine were continued.An echocardiogram revealed global hypokinesis with a left ventricular ejection fraction of 20%. Beta blockers were discontinued due to hypotension. The cardiogenic shock worsened despite aggressive medical therapy requiring initiation of veno-arterial (V-A) ECMO. She also required CRRT due to renal failure.Plasmapheresis was initiated for treatment of thyroid storm and she received 4 treatments with normalization of free T4: 1.48 ng/dL and T3 levels: 3.4 ng/dL (normal 2.3-4.2 ng/dL). Her condition subsequently improved and she was decannulated from the ECMO device after 5 days. She was then able to receive definitive treatment with thyroidectomy 11 days following admission. The patient was discharged in improved condition after a 10-week hospital course. Discussion Thyroid storm is a rare complication of thyrotoxicosis with a mortality rate of 10-30%. Treatment classically involves inhibiting the synthesis, release, and peripheral conversion of thyroid hormone as well as supportive management. Major causes of mortality in thyroid storm, present in our patient, include cardiogenic shock, arrhythmia, and multiorgan failure. Cardiac and hepatic failure can preclude the use of beta blockers and thionamides, which may necessitate the use of extracorporeal treatments, such as plasmapheresis for clearance of high burden of circulating thyroid hormone; V-A ECMO and CRRT for end organ damage. These therapeutic measures were used in our patient and led to a favorable outcome. This case highlights the successful use of these extracorporeal treatments as a bridge to thyroidectomy when standard medical treatment is contraindicated or unsuccessful. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:42 p.m. - 12:47 p.m.

Digoxin vs. beta-blocker therapy in atrial fibrillation: analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry

Abstract Background There is a long-standing and unresolved controversy over the effects of digoxin on mortality. Furthermore, there is scarce evidence comparing the use of digoxin to beta-blocker in the general population with atrial fibrillation (AF). In this study, we aimed to evaluate the effects of digoxin over beta-blocker therapy among patients with AF. Methods Patients from the EORP-AF General Long-Term Registry with AF who were treated with either digoxin or beta-blocker were included. All patients were over 18 years old and had documented evidence of AF within 12 months prior to enrolment. The outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality and number of patients with unplanned hospitalisation (total and AF-related). These were recorded until the last known follow-up available. Results Of 6377 patients, 549 (8.6%) and 5828 (91.4%) were treated with digoxin and beta-blockers, respectively. Patients in the digoxin group were older (73 vs. 71 years, p&amp;lt;0.001) with reduced renal function (eGFR 65.4 vs. 68.7 mL/min/1.73m2, p=0.002), and had (in general) greater burden of comorbidities in terms of chronic kidney disease, chronic obstructive pulmonary disease, heart failure, hypertension and peripheral artery disease. Nonetheless, the use of anticoagulation therapy was comparable between both groups (p=0.112). Over 24 months follow-up, there were 550 (8.6%) all-cause mortality and 1304 (23.6%) patients with unplanned emergency hospitalisation. Digoxin use was associated with increased all-cause mortality (hazard ratio [HR] 1.90 [95% CI, 1.48–2.44]), both from CV and non-CV causes (CV: HR 2.21 [95% CI, 1.49–3.26]); non-CV: HR 1.70 [95% CI, 1.04–2.79]). There was no statistical difference in terms of unplanned emergency hospitalisation (HR 0.99 [95% CI, 0.80–1.21]) and AF-related hospitalisation (HR 0.78 [95% CI, 0.58–1.06]) between both groups. Using multivariable cox regression analysis, digoxin compared to beta-blocker therapy was independently linked to increased all-cause mortality (HR 1.52 [95% CI, 1.11–2.09]) and CV mortality (HR 1.82 [95% CI, 1.11–2.97]), but was not related to non-CV mortality (HR 1.31 [95% CI, 0.71–2.41]), emergency hospitalisation (HR 0.91 [95% CI, 0.71–1.16]) or AF-related hospitalisation (HR 0.88 [95% CI, 0.62–1.24]), after adjustment for known risk factors. Conclusion We demonstrated that the use of digoxin was independently associated with excess all-cause mortality, driven by CV death, but was non-inferior to beta-blocker in terms of preventing unplanned emergency or AF-related hospitalisation, after accounting for important risk factors. Funding Acknowledgement Type of funding sources: None.

Patent foramen ovale closure in non-lacunar cryptogenic ischemic stroke: where are we now?

Patent foram ovale (PFO) is the most common anatomical cause of an interarterial shunt. It is usually asymptomatic but may cause paradoxical embolism and is a risk factor for non-lacunar cryptogenic cerebral ischemia in young adults. Although the first clinical trials did not show a significant superiority of PFO closure in the secondary prevention of cerebral ischemia as compared with standard antithrombotic treatment, six subsequent randomized clinical trials (CLOSURE I, PC Trial, RESPECT, CLOSE, REDUCE, and DEFENSE-PFO) performed in a sample of cryptogenic stroke in patients aged 60 years or younger provided evidence of a significant reduction of recurrent cerebral ischemia after percutaneous PFO closure. However, the use of percutaneous PFO closure cannot be generalized to the entire population of patients with cerebral ischemia and PFO, but it is indicated in highly selected patients with non-lacunar cryptogenic cerebral infarction with a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation, as well as in association with antithrombotic treatment for an optimal secondary prevention of cerebral ischemia.

HFpEF score discriminates severity of cardiovascular profile in asymptomatic treated hypertensive patients: the campania salute network

Abstract Background The heart failure with preserved ejection fraction (HFpEF) score is easy to use and potentially useful to discriminate HFpEF from noncardiac causes of dyspnea. HFpEF score may be expressed also as probability to have HFpEF. Purpose We investigated whether a high HFpEF score can identify specific cardiovascular (CV) profile in treated hypertensive patients even without dyspnea. Methods From September to December 2019, we consecutively enrolled treated hypertensive patients without dyspnea, with normal left ventricular (LV) ejection fraction (&amp;gt;50%), and chronic kidney disease of no more than stage III. In addition to standard echocardiographic parameters we evaluated: 1) inappropriate LV mass, identified as a percent of predicted LV mass &amp;gt;128%, 2) myocardial energetic efficiency as the ratio of stroke volume to heart rate normalized by LV mass (MEEi), and 3) an estimate of arterial stiffness, i.e. the ratio of pulse pressure and stroke index (by allometric normalization by height), as previously reported. The probability of HFpEF was calculated from the HFpEF score, using body mass index, pulmonary systolic pressure, mitral E/E' ratio, age, and history or evidence of atrial fibrillation. Results 188 patients with complete data were analyzed (42% women, age 61±14 years, 9% diabetic). Patients were then divided into 3 groups according to HFpEF probability tertiles and compared by ANOVA and trend analysis (Table 1). Conclusions Probability of HFpEF using HFpEF score and non-standard echocardiographic parameters identify worse CV profile in treated hypertensive patients without dyspnea. Funding Acknowledgement Type of funding source: None

Patent foramen ovale

Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral...

Abstract P406: Atrial Fibrillation (AF) and Stroke Symptoms in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

Background: AF-related thromboembolism increases risk of stroke. Stroke symptoms in the absence of a stroke diagnosis may represent “whispering strokes,” but their association with AF has not been well explored. Objective: To examine cross-sectionally the association between AF and self-reported stroke symptoms in the absence of a stroke diagnosis, and whether associations differ by anticoagulant use. Methods: We examined data from 27,072 REGARDS participants without a history of stroke or transient ischemic attack (TIA) at baseline. The presence, type, and cumulative number of self-reported stroke symptoms were compared between participants with and without self-reported history or ECG evidence of AF. Logistic regression models examined associations between AF and stroke symptoms, adjusting for sociodemographic, socioeconomic, stroke risk factors, and geographic characteristics. To investigate the possibility of stroke symptoms representing embolic stroke, results were stratified by anticoagulant or antiplatelet agent use. Results: The mean age of the sample was 64.4(±9.4), 55.3% were women, and 59.2% were black; 2,124 had evidence of AF. Twenty-nine percent of adults with AF and 17% of those without AF reported at least one stroke symptom. Compared to those without AF, the odds ratio (OR) of any stroke symptom was 2.21 (95% CI 1.88-2.58) among adults with AF not using an anticoagulant or antiplatelet agent and 1.93 (95% CI 1.62-2.30) for those on Aspirin or Plavix only ( Table 1 ). Associations were non-significant for those using Warfarin. Similar patterns were observed by each type and cumulative number of stroke symptoms. Conclusion: The association between AF and stroke symptoms suggests that some stroke symptoms in the absence of a stroke diagnosis may represent sub-clinical or “whispering strokes.” The attenuation of this association with Warfarin use but not antiplatelet agents supports the possibility that stroke symptoms in the absence of a stroke diagnosis represent undiagnosed embolic stroke.

P1954Prognostic value of the CHADS2 score for adverse cardiovascular events in acute myocardial infarction patients without atrial fibrillation: J-MINUET Substudy

Abstract Background The CHADS2score has mainly been used to predict the likelihood of cerebrovascular accidents in patients with atrial fibrillation. However, increasing attention is being paid to this scoring system for risk stratification of patients with coronary artery disease. We investigated the value of the CHADS2 score in predicting cardiovascular events in Japanese acute myocardial infarction (AMI) patients without atrial fibrillation. Methods To elucidate the prognostic value of CHADS2score in AMI patients, we analysed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48-hours of onset from July 2012 to March 2014. We calculated the CHADS2 scores for 3,044 patients without clinical evidence of atrial fibrillation. The presence of heart failure was substituted by Killip classification&gt;2 on admission. Clinical follow-up data was obtained for 3 years. In addition to the in-hospital mortality,we evaluated cardiovascular events, defined as all cause deathor non-fatal MI during 3-year follow up periods. Results In this study, enrolled patients were classified into low- (point 0–1), intermediate- (point 2–3), and high-score (point 4–6) groups by calculating CHADS2 score. Overall patients with low, intermediate and high score were divided into 1,395, 1,393 and 256 patients, respectively. In-hospital mortality among low, intermediate, and high score groups were 2.8%, 7.4% and 14.8%, respectively (P&lt;0.001). The incidence of cardiovascular eventsamong low, intermediate, and high score groups were 7.8%, 16.3%, 29.3%, respectively (P&lt;0.001). Kaplan-Meier analysis showed a significant difference between the groups (Figure). The event rates were significantly higher in both high score and intermediate score group than in low score group (P&lt;0.001). Multivariate Cox hazard analysis identified CHADS2 score (per 1 point) as an independent predictor of cardiovascular events in addition to chronic kidney disease and lower body mass index. (hazard ratio, 1.344; 95% CI, 1.239–1.459; P&lt;0.001). Among the factors constituting CHADS2 score, heart failure and age were identified as independent predictors for in-hospital mortality. With respect to the cardiovascular event during 3 years, heart failure, age, and previous stroke were revealed as significant independent predictors. Conclusion This large cohort study indicated that the CHADS2 score is useful for the prediction of in-hospital mortality and the cardiovascular events during 3-year follow up in Japanese AMI patients without atrial fibrillation.

Sequential approach for the detection of atrial fibrillation in patients with cryptogenic stroke

Introduction and objectivesParoxysmal and asymptomatic episodes of atrial fibrillation (AF) can be the cause of previously diagnosed cryptogenic stroke. Guidelines recommend monitoring in this setting, although the optimum duration and method remains unknown. We aimed to determine the diagnostic yield of a sequential monitoring approach using external and internal loop recorders for detecting AF in patients with cryptogenic stroke after a complete diagnostic evaluation. MethodsA total of 119 patients were enrolled. A 24-h Holter was performed in all patients. An ambulatory external loop recorder was scheduled in patients without evidence of AF on Holter, followed by ambulatory internal loop recorder implantation in cases without evidence of AF at this point. ResultsAF was identified in 43 of 119 patients (36%). The rate of detection was 15.1% at 6 months, 24.3% at 12 months, 35.3% at 24 months, and 36.1% at 36 months. AF was detected in 21/112 patients (18.75%) with the external loop recorder, and in 17/80 (21%) with internal loop recorder. ConclusionsA standardized sequential monitoring strategy in patients in whom an embolic source is suspected detects AF frequently, allowing a reduction in insertable loop recorder implantation as in 60% of cases AF is detected using non-invasive methods.

AURICULAR FIBRILLATION AS THE FIRST SYMPTOM OF A HEPATIC HYDATID CYST

La hidatidosis hepática tiene una forma clínica de presentación muy variada desde una enfermedad asintomática hasta formas muy graves como el shock anafiláctico. Además, el abordaje laparoscópico de la enfermedad hepática está en auge ya que combina los mismos resultados erradicadores de la cirugía abierta con las ventajas de la cirugía mínimamente invasiva. Presentamos el caso de una paciente que debutó con un episodio de fibrilación auricular secundaria a un derrame pericárdico por un quiste hidatídico hepático complicado. Mediante el abordaje laparoscópico, se drenó el absceso subfrénico y se realizó una periquistectomía parcial y una omentoplastia. La paciente fue dada de alta el cuarto día postoperatorio y permanece asintomática 3 años después, sin evidencia de fibrilación auricular o recidiva hidatídica.La fibrilación auricular es una presentación extraordinaria de la hidatidosis hepática. Si bien el abordaje laparoscópico parece seguro y factible en estos pacientes, se necesitan más estudios para demostrar que es una alternativa segura, con menos dolor postoperatorio y menor estancia hospitalaria. hospitalaria.

Prognostic value of global left atrial peak strain in patients with acute ischemic stroke and no evidence of atrial fibrillation.

Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the "Rankin in" Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.

Atrial Cardiopathy and Stroke Prevention.

Many patients with ischemic stroke have a stroke syndrome and neuroimaging findings consistent with embolism, but no evidence of atrial fibrillation. Recent data suggest that the pathological atrial substrate, or atrial cardiopathy, that underlies atrial fibrillation, rather than atrial fibrillation itself, may be an important cause of unexplained strokes. This paper will review the literature on the rationale and data behind the concept of atrial cardiopathy, its pathophysiology, suggested biomarkers of atrial cardiopathy, and therapeutic implications. Several lines of evidence suggest that patients can have strokes associated with disorders of the atrium, even without frank atrial fibrillation. Even in patients with paroxysmal atrial fibrillation, cardiac emboli may occur temporally disassociated from episodes of atrial fibrillation, and the left atrial appendage flow patterns associated with increased thromboembolic risk may occur even when the surface electrocardiogram demonstrates normal sinus rhythm. Biomarkers of left atrial structural and electrophysiological abnormalities have been associated with stroke risk, even in the absence of atrial fibrillation. Atrial cardiopathy, as determined by the presence of biomarkers of left atrial dysfunction, may provide a therapeutic target to reduce the risk of cardioembolic stroke in the absence of atrial fibrillation. Clinical trials are currently ongoing to test this hypothesis.