First-detected Atrial Fibrillation Research Articles

Right and left atrial echocardiographic parameters and outcome in patients with atrial fibrillation

Abstract Background Atrial remodeling in atrial fibrillation (AF) can be evaluated by measuring atrial dimensions, volumes, or function, in the left atrium (LA) but right atrial (RA) changes are often neglected. Purpose The aim of the analysis was to evaluate the power of LA and RA parameters in predicting a composite endpoint (CEP) of all-cause death, any thromboembolism, any acute coronary syndrome, and hospitalization for new or worsening heart failure. Methods From March 2016 to December 2021, patients with ECG-documented AF within 1 year were prospectively enrolled. We retrieved echo data by reviewing clips and collected clinical and laboratory data. Patients were followed up after 1 month and every 6 months thereafter unless clinically relevant events occurred. We considered left and right atrial antero-posterior diameter (iLAAPD, iRAAPD), left and right atrial volume (LAVI, RAVI), left and right atrial sphericity index (LASI, RASI), right and left atrial emptying fraction (RAEF, LAEF). Volumes and diameters were indexed by body surface area. Echo parameters were collected according to the 2015 recommendations of the American Society of Echocardiography. Results We enrolled 489 patients, 300 males (61.3%), median age 75 (IQR 66-80) years, median CHA2DS2VASc 3 (2-5), median HAS-BLED 1 (1-2). Four-hundred fifty-one (92.2%) patients were anticoagulated. Eighty-seven patients (17.8%) had a paroxysmal AF, 141 (28.8%) a persistent AF, 198 (40.5%) a permanent AF, and 63 (12.9%) a first-detected AF. After a median follow-up of 1114 (392-1384) days, 129 (26.3%) achieved the CEP. LAEF < 28% and iRAAPD ≥ 44 mm/m2 showed better sensitivity (respectively 72% and 73%) while iLAAPD and LAVI showed better negative predictive values (both 81%). At multivariable Cox regression analysis (adjusted for CHA2DS2VASc, AF type, and pattern of anticoagulation), building one model for every echocardiographic parameter, LA dimension, volume and function were associated with a higher risk of worse outcome (LAAPD > 22 mm/m2 HR 1.78; 95%CI 1.24-2.57; LAVI ≥ 42 ml/m2 HR 1.50 95%CI 1.03-2.19; LAEF < 28% HR 1.74 95%CI 1.21-2.48) while RASI, LASI, and RA parameters (except for iRAAPD ≥ 44 mm/m2: HR 1.65; 95%CI 1.10-2.47) were not. Comparing those models with a null one (i.e. variables used for adjustments) using the likelihood ratio test, the above-mentioned models demonstrated a significant improvement in predicting the risk of CEP (iLAAPD p=0.0018; LAVI p=0.0347; LAEF p=0.0028; iRAAPD p=0.0148). Visual analysis of multivariable restricted cubic splines regression graphs confirmed iLAAPD and LAVI as the only atrial parameters that refined risk prediction, with their lower limits of CI exceeding the 1 HR line at reference points (Figure). Conclusions In patients with AF, LAVI and iLAAPD allow better discrimination and risk prediction for the composite outcome, while sphericity indexes and most of the RA parameters do not provide adequate predictionFigure

Factors Associated with Progression of Atrial Fibrillation and Impact on All-Cause Mortality in a Cohort of European Patients.

Paroxysmal atrial fibrillation (AF) may often progress towards more sustained forms of the arrhythmia, but further research is needed on the factors associated with this clinical course. We analyzed patients enrolled in a prospective cohort study of AF patients. Patients with paroxysmal AF at baseline or first-detected AF (with successful cardioversion) were included. According to rhythm status at 1 year, patients were stratified into: (i) No AF progression and (ii) AF progression. All-cause death was the primary outcome. A total of 2688 patients were included (median age 67 years, interquartile range 60-75, females 44.7%). At 1-year of follow-up, 2094 (77.9%) patients showed no AF progression, while 594 (22.1%) developed persistent or permanent AF. On multivariable logistic regression analysis, no physical activity (odds ratio [OR] 1.35, 95% CI 1.02-1.78), valvular heart disease (OR 1.63, 95% CI 1.23-2.15), left atrial diameter (OR 1.03, 95% CI 1.01-1.05), or left ventricular ejection fraction (OR 0.98, 95% CI 0.97-1.00) were independently associated with AF progression at 1 year. After the assessment at 1 year, the patients were followed for an extended follow-up of 371 days, and those with AF progression were independently associated with a higher risk for all-cause death (adjusted hazard ratio 1.77, 95% CI 1.09-2.89) compared to no-AF-progression patients. In a contemporary cohort of AF patients, a substantial proportion of patients presenting with paroxysmal or first-detected AF showed progression of the AF pattern within 1 year, and clinical factors related to cardiac remodeling were associated with progression. AF progression was associated with an increased risk of all-cause mortality.

Patterns of care for first-detected atrial fibrillation: Insights from the Get With The Guidelines® - Atrial Fibrillation registry.

Despite multiple trials comparing rate with rhythm control, there is no consensus on the optimal management of first-detected atrial fibrillation (AF). We analyzed current patterns of care for first-detected AF in the nationwide Get With The Guidelines® - Atrial Fibrillation registry. Patients hospitalized with first-detected AF from 2013 to 2019 were included, and a descriptive analysis was performed comparing planned rate with rhythm control. Multivariable logistic regression analysis was performed to identify predictors for choosing rhythm over rate control. Of the 86,759 patients with AF, 17.8% (15,473) had first-detected AF; 11,685 patients were included from 126 sites. Overall, 51.3% (5999) of patients were treated with rate control and 48.7% (5686) with rhythm control at admission. Patients with planned rhythm control had a shorter length of stay and were more likely to be discharged home than a facility. A higher percentage of patients with planned rhythm control were discharged on anticoagulation than those with planned rate control (75.6% vs 70.9%) despite a higher underlying stroke risk in the rate control group (higher median CHA2DS2-VASc score 4; Q1-Q3 2-5 for rate control vs 3; Q1-Q3 2-4 for rhyhtm control; P < .001). While Hispanic ethnicity, Medicaid insurance, age >70 years, and liver disease decreased the likelihood of rhythm control, factors such as heart failure, stroke, or prior bleeding diathesis had no association with the chosen treatment strategy. Less than half of the patients with first-detected AF receive rhythm control at admission. Given recent trial results, further studies should assess the long-term impact of rhythm control on patients' symptoms and quality of life, cardiovascular morbidity, and mortality.

Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EORP atrial fibrillation general long-term registry

BackgroundCardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear. AimTo assess the factors associated with cTn testing in routine practice and evaluate the association with outcomes. MethodsPatients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into 3 groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism /any acute coronary syndrome/cardiovascular (CV) death, defined as Major Adverse Cardiovascular Events (MACE) and all-cause death were the main endpoints. ResultsAmong 10 445 AF patients (median age 71 years, 40.3% females) cTn were tested in 2834 (27.1%). cTn was elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients. Female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease, and atypical AF symptoms were independently associated with cTn testing. Elevated cTn were independently associated with a higher risk for MACE (Model 1, hazard ratio [HR] 1.74, 95% confidence interval [CI] 1.40–2.16, Model 2, HR 1.62, 95% CI 1.28–2.05; Model 3 HR 1.76, 95% CI 1.37–2.26) and all-cause death (Model 1, HR 1.45, 95% CI 1.21–1.74; Model 2, HR 1.36, 95% CI 1.12–1.66; Model 3, HR 1.38, 95% CI 1.12–1.71). ConclusionsElevated cTn levels were associated with an increased risk of all-cause mortality and adverse CV events. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

684 Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: a report from the ESC-EHRA EORP atrial fibrillation general long-term registry

Abstract Aims Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear. To assess the factors associated with cTn testing in routine clinical practice and to evaluate the association of elevated levels of cTn with adverse outcomes in a large contemporary cohort of European AF patients. Methods and results Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into three groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), and (iii) cTn elevated (&amp;gt;99th percentile). The composite outcome of any thromboembolism/any acute coronary syndrome (ACS)/cardiovascular (CV) death, defined as major adverse cardiovascular events (MACE) and all-cause death were the main endpoints. 10 445 (94.1%) AF patients were included in this analysis [median age 71 years, interquartile range (IQR): 63–77; males 59.7%]. cTn were tested in 2834 (27.1%). Overall, cTn was elevated in 904 (8.7%) and in-range in 1930 (18.5%) patients. Patients in whom cTn was tested tended to be younger (P &amp;lt; 0.001) and more frequently presenting with first detected AF and atypical AF-related symptoms (i.e. chest pain, dyspnoea, or syncope) (P &amp;lt; 0.001). On multivariable logistic regression analysis, female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease (CAD), and atypical AF symptoms were independently associated with cTn testing. After a median follow-up of 730 days (IQR: 692–749), 957 (9.7%) composite endpoints occurred while all-cause death was 9.5%. Kaplan–Meier analysis showed a higher cumulative risk for both outcomes in patients with elevated cTn levels (Figure) (Log Rank tests, P &amp;lt; 0.001). On adjusted Cox regression analysis, elevated levels of cTn were independently associated with a higher risk for MACE [hazard ratio (HR): 1.74, 95% confidence interval (CI): 1.40–2.16] and all-cause death (HR 1.45, 95% CI: 1.21–1.74). Elevated levels of cTn were independently associated with a higher occurrence of MACE, all-cause death, any ACS, CV death and hospital readmission even after the exclusion of patients with history of CAD, diagnosis of ACS at discharge, those who underwent coronary revascularization during the admission and/or who were treated with oral anticoagulants plus antiplatelet therapy. Conclusions Elevated cTn levels were independently associated with an increased risk of all-cause mortality and adverse CV events, even after exclusion of CAD patients. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

Changes to oral anticoagulant therapy and risk of death over a 3-year follow-up of a contemporary cohort of European patients with atrial fibrillation final report of the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) pilot general registry

BackgroundContemporary European data regarding patients with atrial fibrillation (AF) allow us to assess the use of oral anticoagulants (OACs) and long-term outcomes. MethodsPatients with AF presenting to cardiologists in 9 European Society of Cardiology participating countries were enrolled and followed-up for 3-years. ResultsAmong the 2119 patients (40.4% female; mean age 69 ± 11 years) the prevalent types of AF at baseline were first-detected (30.5%) and paroxysmal AF (27.0%).The composite of stroke/TIA/peripheral embolism/all-cause death at 3-years occurred in 18.2%, with first detected AF and permanent AF reporting the highest event rates (22.5% and 27.3%, respectively; p < 0.0001). Age, diabetes mellitus, heart failure, restrictive cardiomyopathy, chronic kidney disease and no physical activity were significant predictors of all-cause death. Paroxysmal and persistent AF patients were more likely to be hospitalised than other types of AF (34.1% and 37.9%, p < 0.0001).At follow-up, OAC drugs were used in 80.1% of patients, with non-vitamin K antagonists (NOACs) accounting for 24.3% of patients. OAC treatment at follow-up visits changed throughout time, with a shift from VKA to NOACs reported in 5.4% of the cases, while the reverse shift (from NOACs to VKA) occurred in 8.6%. Discontinuation of OAC was recorded in while in 9.5% of visits. ConclusionsPatients outcomes at 3-years follow-up differ according to type of AF at baseline, with worse outcomes in patients presenting with first-detected or permanent AF. Changes in the type of OAC use with shifts from NOACs to VKA and vice-versa are not uncommon, as were interruptions of OAC.

Stroke as the Initial Manifestation of Atrial Fibrillation: The Framingham Heart Study.

To prevent strokes that may occur as the first manifestation of atrial fibrillation (AF), screening programs have been proposed to identify patients with undiagnosed AF who may be eligible for treatment with anticoagulation. However, the frequency with which patients with AF present with stroke as the initial manifestation of the arrhythmia is unknown. We estimated the frequency with which AF may present as a stroke in 1809 community-based Framingham Heart Study participants with first-detected AF and without previous strokes, by tabulating the frequencies of strokes occurring on the same day, within 30 days before, 90 days before, and 365 days before first-detected AF. Using previously reported AF incidence rates, we estimated the incidence of strokes that may represent the initial manifestation of AF. We observed 87 strokes that occurred ≤1 year before AF detection, corresponding to 1.7% on the same day, 3.4% within 30 days before, 3.7% within 90 days before, and 4.8% ≤1 year before AF detection. We estimated that strokes may present as the initial manifestation of AF at a rate of 2 to 5 per 10 000 person-years, in both men and women. We observed that stroke is an uncommon but measureable presenting feature of AF. Our data imply that emphasizing cost-effectiveness of population-wide AF-screening efforts will be important given the relative infrequency with which stroke represents the initial manifestation of AF.

'Real-world' management and outcomes of patients with paroxysmal vs. non-paroxysmal atrial fibrillation in Europe: the EURObservational Research Programme-Atrial Fibrillation (EORP-AF) General Pilot Registry.

Atrial fibrillation (AF) has different presentations (first detected, paroxysmal, persistent, permanent), with uncertain impact on outcome. The aim of this study was to investigate clinical presentation, management, and outcome of paroxysmal and non-paroxysmal AFs within the EURObservational Research Programme-Atrial Fibrillation General Pilot Registry. Overall 2589 patients with available 1-year follow-up data were evaluated according to AF type. Patients with paroxysmal AF (26.8%) were younger, had lower prevalence of heart disease (particularly valvular), and major co-morbidities, as well as lower CHADS2, CHA2DS2-VASc, and HAS-BLED scores. Patients with first-detected AF (29.9%) had characteristics similar to persistent AF patients (25.9%), but lower use of oral anticoagulants. Patients with permanent AF represented 17.4% of the cohort. At 1 year, the rate of stroke/transient ischaemic attack and thromboembolism was low (0.6-1.0%) and did not differ between paroxysmal and non-paroxysmal AFs. All-cause mortality was higher in non-paroxysmal vs. paroxysmal AF (log rank test, P = 0.0018). Using a multivariable Cox model, non-paroxysmal AF was not an independent predictor of death during follow-up. Independent predictors of death were age, chronic heart failure, chronic kidney disease, diabetes, restrictive cardiomyopathy, and physical activity. In this 'real-world' contemporary observational registry, patients with non-paroxysmal AF had a worse outcome, in terms of all-cause mortality, which was related to a more severe clinical profile. The risk of stroke at 1 year was relatively low, perhaps reflecting the high rates of anticoagulation use in this cohort.

Long-term outcomes of secondary atrial fibrillation in the community: the Framingham Heart Study.

Guidelines have proposed that atrial fibrillation (AF) can occur as an isolated event, particularly when precipitated by a secondary, or reversible, condition. However, knowledge of long-term AF outcomes after diagnosis during a secondary precipitant is limited. In 1409 Framingham Heart Study participants with new-onset AF, we examined associations between first-detected AF episodes occurring with and without a secondary precipitant and both long-term AF recurrence and morbidity. We selected secondary precipitants based on guidelines (surgery, infection, acute myocardial infarction, thyrotoxicosis, acute alcohol consumption, acute pericardial disease, pulmonary embolism, or other acute pulmonary disease). Among 439 patients (31%) with AF diagnosed during a secondary precipitant, cardiothoracic surgery (n=131 [30%]), infection (n=102 [23%]), noncardiothoracic surgery (n=87 [20%]), and acute myocardial infarction (n=78 [18%]) were most common. AF recurred in 544 of 846 eligible individuals without permanent AF (5-, 10-, and 15-year recurrences of 42%, 56%, and 62% with versus 59%, 69%, and 71% without secondary precipitants; multivariable-adjusted hazard ratio, 0.65 [95% confidence interval, 0.54-0.78]). Stroke risk (n=209/1262 at risk; hazard ratio, 1.13 [95% confidence interval, 0.82-1.57]) and mortality (n=1098/1409 at risk; hazard ratio, 1.00 [95% confidence interval, 0.87-1.15]) were similar between those with and without secondary precipitants, although heart failure risk was reduced (n=294/1107 at risk; hazard ratio, 0.74 [95% confidence interval, 0.56-0.97]). AF recurs in most individuals, including those diagnosed with secondary precipitants. Long-term AF-related stroke and mortality risks were similar between individuals with and without secondary AF precipitants. Future studies may determine whether increased arrhythmia surveillance or adherence to general AF management principles in patients with reversible AF precipitants will reduce morbidity.

Antiarrhythmic strategies in patients with atrial fibrillation managed by cardiologists and internists: Antithrombotic Agents in Atrial Fibrillation (ATA-AF) survey.

To provide insights on the antiarrhythmic management of atrial fibrillation among patients enrolled in the Antithrombotic Agents in Atrial Fibrillation (ATA-AF) study, and to assess the adherence of the Italian cardiologists and internists to guidelines recommendations. The ATA-AF study is a multicenter, observational study with prospective data collection on the management and treatment of patients with atrial fibrillation. From March to July 2010, 6910 patients with atrial fibrillation were recruited in 164 Italian Cardiology (Card) and 196 Internal Medicine (IMed) centers. Permanent atrial fibrillation was diagnosed in 50.8%, persistent atrial fibrillation in 24.4%, paroxysmal in 15.5%, and first-detected atrial fibrillation in 9.3% of the patients. Rhythm control (rhyC) strategy was pursued in 27.5% (39.6% Card vs. 12.9% IMed; P < 0.0001) and rate control (raC) in 51.4% (43.7% Card vs. 60.7% IMed; P < 0.0001); in 21.1% the antiarrhythmic strategy was not defined. Patients assigned to rhyC were younger and with less comorbidities than those assigned to raC. Adjusted multivariable analysis showed that atrial fibrillation type, setting of management, age and site of patient discharge were the most important independent predictors of rhyC assignment. The severity of atrial fibrillation-related symptoms was not associated with rhyC assignment. At discharge, beta-blockers, amiodarone and class 1c antiarrhythmic drugs were the drugs mainly used in the Card centers; and beta-blockers, digitalis, amiodarone and diltiazem/verapamil were used in the IMed centers. Amiodarone was overused in both Card and IMed centers. In the present study, rhyC was the strategy mainly pursued by cardiologists and raC by internists; treatment strategy assignment and antiarrhythmic therapy often do not agree with the guideline recommendations.

Decreased serum endogenous secretory receptor for advanced glycation endproducts and increased cleaved receptor for advanced glycation endproducts levels in patients with atrial fibrillation

This clinical protocol was approved by the institutional Medical Ethics Committee and conducted according to the ethical guidelines outlined in the Declaration of Helsinki. A total of 72 consecutive atrial fibrillation (AF) patients who understood this experiment and agreed to participate in this study were enrolled. Another 30 age- and sex-matched healthy people who understood this experiment and agreed to participate in this study were considered as control group. Detailed medical history, physical examination, routine biochemical testing, and 12-lead electrocardiograms were performed both in AF patients and control group. Valvular functions, left ventricular size (left ventricular end-diastolic dimension, LVEDD) and functions (left ventricular ejection fraction, LVEF), and left atrial diameter (LAD) were evaluated by echocardiography. The diameter of the left atrium was measured in parasternal long axis view. AF duration was determined by the patient's description of a well-defined and abrupt onset palpitation with subsequent electrocardiogram evidence of AF at the time of presentation. Exclusion criteria were as follows: structural heart disease, coronary artery disease, left ventricular ejection fraction less than 45%, other types arrhythmias, surgery or stroke within 6 months, a history of infection, chronic inflammatory, hepatic or malign disease, chronic renal failure, autoimmune diseases, abnormal thyroid function, imbalance of electrolytes, use of anti-inflammatory drugs such as corticoids, and nonsteroidal anti-inflammatory drugs excluding aspirin. AF lasting less than or equal to 7 days is defined as new onset. After two or more episodes, AF is considered recurrent. If the arrhythmia terminates spontaneously, recurrent AF is designated paroxysmal; when sustained beyond 7 days, it is termed persistent which may include permanent AF. First-detected AF may be either paroxysmal or persistent. Lone AF was defined as AF occurring in the absence of structural heart disease and hypertension [ [1] Fuster V. Ryden L.E. Cannom D.S. et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: e257-e354 Crossref PubMed Scopus (2003) Google Scholar ].

Distribution of First-Detected Atrial Fibrillation Patients Without Structural Heart Diseases in Symptom Classifications

The characteristics and prognosis of patients with first-detected atrial fibrillation (AF) in Japan remain unclear. First-detected AF patients without structural heart disease (n=289) were reviewed with regard to 2 symptom classifications (CCS-SAF and EHRA). In both classifications, asymptomatic patients comprised ≈40% of the patients, and patients in the most symptomatic class (≈6%) had peculiar characteristics and poor prognosis. In other symptomatic classes, symptoms affected the treatment strategy without a significant difference in the patients' backgrounds and prognosis. This is the first report to describe the distribution, characteristics and outcomes of first-detected AF patients according to symptom classifications.

Abstract 8688: Incident Stroke and Mortality Associated with First-detected Atrial Fibrillation in Patients Hospitalized with Severe Sepsis

Allan J Walkey, 2011 Finalist and Presenting Author

Predictors of costs related to cardiovascular disease among patients with atrial fibrillation in five European countries

To estimate predictors of direct costs and costs of hospitalization related to cardiovascular disease (CVD) in patients with atrial fibrillation (AF) recruited to the Euro Heart Survey on AF (EHS-AF) in Greece, Italy, Poland, Spain, and the Netherlands. Annual direct costs were modelled by country using ordinary least squares (OLS) regression. For costs of hospitalization related to CVD, logistic regressions followed by conditional OLS regression were employed. In each case, effects of the following potential explanatory variables were tested: age, sex, body mass index, type of AF, diabetes, hypertension, myocardial infarction (MI), angina pectoris (AP), valvular heart disease (VHD), congestive heart failure (CHF), stroke, and/or other underlying heart disease at the time of enrolment in the EHS-AF. Estimated direct annual costs for the reference EHS-AF patient (female aged <65 years with first-detected AF and no co-morbidities at baseline) were €933 in Greece, €1383 in Italy, €698 in Poland, €1316 in Spain, and €1544 in the Netherlands. The co-morbidities identified as predictors of direct costs were VHD in Greece, Italy, and Spain, AP in Italy and Spain, diabetes and stroke in Poland, CHF in Italy, MI in Spain and other underlying heart disease in Poland and the Netherlands. For costs of CVD-related hospitalization, the most important co-morbidity identified as a predictor was VHD. The results reported in this study increase the understanding of the cost structure of CVD in AF patients and may therefore inform the targeting of intervention therapy in selected groups of at-risk patients.