Persistent Forms Research Articles

Abstract 146: Trained Immunity Induced by Dietary Salt Impedes Long-Term Brain Recovery in Experimental Intracerebral Hemorrhage

Introduction: Excessive sodium intake is the top dietary risk factor for mortality and non-communicable diseases such as stroke. However, whether and how a high salt diet (HSD) impacts long-term stroke outcomes - even after salt reduction/withdrawal prior to a stroke is unknown. Methods: Intracerebral hemorrhage (ICH) was modeled by blood or collagenase injections in mice. Bone marrow (BM) progenitor and immune cell compositions as well as monocyte-derived macrophage (MDM) and microglial phenotypes were profiled using flow cytometry. BM chimeras were created to test innate immune memory. Glycolysis and OXPHOS were measured by Seahorse assays. Macrophage phagocytosis was evaluated using in vivo and in vitro erythrophagocytosis assays. RNA-seq was used to analyze the progenitor transcriptome. Hematoma, neuron loss, and astrogliosis were assessed with immunofluorescence. LysM Cre/+ : NR4a1 fl/fl ; Nr4a2 fl/fl ; NR4a3 -/- mice, LysM Cre/+ : NR4a1 fl/fl mice, and celastrol treatment were used to elucidate the mechanism underlying HSD-induced trained immunity. Results: HSD impaired long-term ICH recovery despite prior salt withdrawal. HSD triggered innate immune training in BM progenitor cells by downregulating the NR4a family and OXPHOS. This training selectively compromised MDM reparative polarization without altering their initial inflammatory response in the ICH brain. Healthy mice transplanted with BM from HSD-fed mice retained training signatures, confirming a persistent form of trained immunity that originates in the BM. Lack of NR4a1 in MDMs recapitulated HSD-induced negative impacts on ICH outcomes. Notably, transplantation of healthy BM and gain of NR4a1 function enabled stroke recovery in the HSD animals. Conclusions: These findings provide the first evidence that links HSD-induced trained immunity to the acquisition of persistent dysregulated inflammatory responses and unveil NR4a1 as a potential therapeutic target.

Understudied and underaddressed: Femicide, an extreme form of violence against women and girls.

Little is known about the prevalence and dynamics of femicide, a persistent form of violence against women and girls, due to challenges associated with its documentation. Research by Abrahams and colleagues comparing rates of femicide in South Africa over 18 years, however, suggests that femicide is preventable.

The role of laboratory markers in predicting the effectiveness of catheter treatment for atrial fibrillation: a literature review

Atrial fibrillation (AF) is the most common cardiac arrhythmia among the adult population. There are many possible causes of AF: structural heart disease, inflammatory and autoimmune diseases, obesity, alcohol abuse, diabetes mellitus, obstructive sleep apnea and old age. The ectopic activity of pulmonary vein couplings lies in the pathogenesis of paroxysmal and persistent forms of AF. The role of AF itself in triggering the inflammatory process in the atrium myocardium has also been proven. Despite the large amount of existing data, the search for the causes of AF continues. Previously, AF was considered the outcome of prolonged hemodynamic stress, arterial hypertension and valvular heart disease. Recently, views on the pathogenesis of AF have changed, since patients with metabolic diseases, without hypertrophy and dilatation of the left ventricle, but with disturbances in the structure and function of the atria, most often the left atrium, are increasingly encountered. There is an active search for laboratory markers to identify groups of patients most susceptible to developing AF. Determining the cause of atrial fibrillation and pathogenesis in each patient is important for selecting therapy and determining treatment tactics. Currently, a search is underway for laboratory markers that may be associated with the manifestation of atrial fibrillation, with atriopathy, and the effectiveness/ineffectiveness of catheter treatment for atrial fibrillation. An analysis of clinical studies was carried out based on articles indexed in the Scopus, VAK, Russian Science Citation Index, PubMed, and Web of Science databases.

Pathophysiology of Atrial Fibrillation and Approach to Therapy in Subjects Less than 60 Years Old.

Atrial fibrillation (AF) is an arrhythmia that affects the left atrium, cardiac function, and the patients' survival rate. Due to empowered diagnostics, it has become increasingly recognized among young individuals as well, in whom it is influenced by a complex interplay of autoimmune, inflammatory, and electrophysiological mechanisms. Deepening our understanding of these mechanisms could contribute to improving AF management and treatment. Inflammation is a complexly regulated process, with interactions among various immune cell types, signaling molecules, and complement components. Addressing circulating antibodies and designing specific autoantibodies are promising therapeutic options. In cardiomyopathies or channelopathies, the first manifestation could be paroxysmal AF; persistent forms tend not to respond to antiarrhythmic drugs in these conditions. Further research, both in vitro and in vivo, on the use of genomic biotechnology could lead to new therapeutic approaches. Additional triggers that can be encountered in AF patients below 60 years of age are systemic hypertension, overweight, diabetes, and alcohol abuse. The aims of this review are to briefly report evidence from basic science and results of clinical studies that might explain the juvenile burden of the most encountered sustained supraventricular tachyarrhythmias in the general population.

Tolerability of Current Treatments for Dry Eye Disease: A Review of Approved and Investigational Therapies.

Dry eye disease (DED) is a common, multifactorial ocular disease impacting 5% to 20% of people in Western countries and 45% to 70% in Asian countries. Despite the prevalence of DED and the number of treatment approaches available, signs and symptoms of the disease continue to limit the quality of life for many patients. Standard over-the-counter treatment approaches and behavior/environmental modifications may help some cases but more persistent forms often require pharmacological interventions. Approved and investigational pharmaceutical approaches attempt to treat the signs and symptoms of DED in different ways and tend to have varying tolerability among patients. While several pharmacological approaches are the standard for persistent and severe disease, mechanical options provide alternate treatment modalities that attempt to balance efficacy and comfort. Newer approaches target the causes of DED, utilizing novel delivery methods to minimize irritation and adverse events. Here, we review approved and investigational approaches to treating DED and compare patient tolerability.

Establishing a Zebrafish Model for Borrelia burgdorferi Infection Using Immersion and Microinjection Methods.

Borrelia burgdorferi is the spirochetal bacterium that causes Lyme disease. Even though antimicrobial sensitivity of B. burgdorferi has been widely studied, there is still a need to develop an affordable, practical, high-throughput in vivo model which can be used to find effective antibiotic therapies, especially for the recently discovered persister and biofilm forms. Here, we describe the immersion and microinjection methods to introduce B. burgdorferi spirochetes into zebrafish larvae. The B. burgdorferi-zebrafish model can be produced by immersing 5-day post-fertilization (dpf) zebrafish in a B. burgdorferi culture, or by injecting B. burgdorferi into the hindbrain of zebrafish at 28h post-fertilization (hpf). To demonstrate that B. burgdorferi indeed infect the fish, nested polymerase chain reaction (PCR), reverse transcription PCR (RT-PCR), live fluorescence imaging, histological staining, and wholemount immunohistochemical (IHC) methods can be used on B. burgdorferi-infected zebrafish.

Pathogenesis and pathological anatomy of chlamydial infections

The review presents modern view on the global problem of chlamydial infections. Current nomenclature of chlamydiae was adduced. Epidemiology, etiology, clinical features, pathogenesis, diagnosis and treatment of chlamydiosis received full coverage. The potential involvement of chlamydiae in the progression of various infectious and somatic diseases was revealed. Special attention was paid to pathomorphological alterations in human tissues, which develop during primary infection with chlamydia as well as during chronic infection. Key problems were demonstrated: underestimation of prevalence of chlamydiae among humans in worldwide clinical practice, the difficulty of detection of extragenital chlamydiosis, the lack of effective methods for diagnosis and treatment of persistent forms, the paucity of descriptions of pathomorphological picture of human chlamydiosis, the absence of specific prevention of infection.

Эффективность и безопасность приёма оральных антикоагулянтов у пациентов с фибрилляцией предсердий

The coagulation and platelet parameters of the hemostasis system in patients with paroxysmal and persistent forms of atrial fibrillation against the background of taking direct oral anticoagulants used for the prevention of ischemic stroke and other systemic thromboembolic events in this group of patients were analyzed. Self-cancellation and irregular intake of anticoagulant therapy is the cause of thrombosis risk in the studied patients.

Problems of cattle health improvement and protection of population against viral diarrhoea under current conditions of animal husbandry

The article presents the dynamics of the prevalence of bovine viral diarrhoea virus (BVDV) in livestock enterprises of the Ural region in the period 2018-2023. Retrospective and operational analysis of monitoring data showed that the epizootic situation was consistently tense. The share of unfavourable livestock enterprises ranged from 18.2% to 33.3%. The cumulative infection rate in different age groups of cattle ranged from 2.3% to 23.3%. Clinical symptoms of acute course of BVDV-infection in examined cattle were registered in 10.9% of cases; persistent form of BVDV-infection - in 16.5% of cases; subclinical course of BVDV-infection and latent form - in 73.6% of cases. Phylogenetic analysis of BVDV isolates obtained from animal biosamples showed that 81.8% of isolates belong to the Cp-biotype of BVDV, 18.2% of isolates - to the Ncpbiotype of BVDV. It has been established that the intensity of pathogen eradication decreases in livestock enterprises when the regulations of specific prophylaxis are violated, as evidenced by the increase in the number of animals carrying BVDV by 4%; calves with diseases caused by BVDV infection - by 2.5%; cows and heifers with reproductive losses - by 5.7%.

Rape and Sexual Abuse Against Women in the Holocaust — Deprived Credibility and Refused Recognition as a Form of Harm

Sexual violence research is often not limited to the direct perpetration of violence, but also focusses on the (inter-)personal processing of the violence experienced. This article presents the various ways in which female survivors of sexual violence in German concentration camps were denied recognition of their suffering, both by the representatives of the Nazi regime in the camps, as well as by their fellow prisoners and finally by the German authorities after the war. In order to understand these complex forms of victimisation, I examine various reasons why women’s experiences were often misrepresented and not taken seriously, thereby silencing the victims and making them almost invisible (deprivation of credibility). Against this background, I show why the deprivation of credibility, long after the physical assaults, should be understood as a persistent form of harm.

Persistent form of bovine viral diarrhea

The review provides an analysis of literature data on the persistent form of Bovine Viral diarrhea/Mucosal disease (BVD) and is focused on virus and host factors, including those related to immune response, that contribute the persistence of the virus. BVD is a cattle disease widespread throughout the world that causes significant economic damage to dairy and beef cattle. The disease is characterized by a variety of clinical signs, including damage to the digestive and respiratory organs, abortions, stillbirths and other failures of reproductive functions.

Thermally Induced Persistent Covalent-Organic Frameworks Radicals.

Persistent covalent-organic framework (COF) radicals hold important applications in magnetics and spintronics; however, their facile synthesis remains a daunting challenge. Here, three p-phenylenediacetonitrile-based COFs (named CityU-4, CityU-5, and CityU-6) were synthesized. Upon heat treatment (250 °C for CityU-4 and CityU-5 or 220 °C for CityU-6), these frameworks were brought into their persistent radical forms (no obvious changes after at least one year), together with several observable factors, including color changes, red-shifted absorption, the appearance of electron spin resonance (ESR) signals, and detectable magnetic susceptibility. The theoretical simulation suggests that after heat treatment, lower total energy and nonzero spin density are two main factors to guarantee persistent COFs radicals and polarized spin distributions. This work provides an efficient method for the preparation of persistent COF radicals with promising potentials.

Assessing left atrial intramyocardial fat infiltration from computerized tomography angiography in patients with atrial fibrillation.

Epicardial adipose tissue might promote atrial fibrillation (AF) in several ways, including infiltrating the underlying atrial myocardium. However, the role of this potential mechanism has been poorly investigated. The aim of this study is to evaluate the presence of left atrial (LA) infiltrated adipose tissue (inFAT) by analysing multi-detector computer tomography (MDCT)-derived three-dimensional (3D) fat infiltration maps and to compare the extent of LA inFAT between patients without AF history, with paroxysmal, and with persistent AF. Sixty consecutive patients with AF diagnosis (30 persistent and 30 paroxysmal) were enrolled and compared with 20 age-matched control; MDCT-derived images were post-processed to obtain 3D LA inFAT maps for all patients. Volume (mL) and mean signal intensities [(Hounsfield Units (HU)] of inFAT (HU -194; -5), dense inFAT (HU -194; -50), and fat-myocardial admixture (HU -50; -5) were automatically computed by the software. inFAT volume was significantly different across the three groups (P = 0.009), with post-hoc pairwise comparisons showing a significant increase in inFAT volume in persistent AF compared to controls (P = 0.006). Dense inFAT retained a significant difference also after correcting for body mass index (P = 0.028). In addition, more negative inFAT radiodensity values were found in AF patients. Regional distribution analysis showed a significantly higher regional distribution of LA inFAT at left and right superior pulmonary vein antra in AF patients. Persistent forms of AF are associated with greater degree of LA intramyocardial adipose infiltration, independently of body mass index. Compared to controls, AF patients present higher LA inFAT volume at left and right superior pulmonary vein antra.

Trained immunity induced by high-salt diet impedes stroke recovery.

A high-salt diet (HSD) elicits sustained sterile inflammation and worsens tissue injury. However, how this occurs after stroke, a leading cause of morbidity and mortality, remains unknown. Here, we report that HSD impairs long-term brain recovery after intracerebral hemorrhage, a severe form of stroke, despite salt withdrawal prior to the injury. Mechanistically, HSD induces innate immune priming and training in hematopoietic stem and progenitor cells (HSPCs) by downregulation of NR4a family and mitochondrial oxidative phosphorylation. This training compromises alternative activation of monocyte-derived macrophages (MDMs) without altering the initial inflammatory responses of the stroke brain. Healthy mice transplanted with bone marrow from HSD-fed mice retain signatures of reduced MDM reparative functions, further confirming a persistent form of innate immune memory that originates in the bone marrow. Loss of NR4a1 in macrophages recapitulates HSD-induced negative impacts on stroke outcomes while gain of NR4a1 enables stroke recovery in HSD animals. Together, we provide the first evidence that links HSD-induced innate immune memory to the acquisition of persistent dysregulated inflammatory responses and unveils NR4a1 as a potential therapeutic target.

Duration of left and right atrial activation wavefront assessed non-invasively is significantly higher in patients with atrial fibrillation than in controls

Abstract Introduction Ablation strategies in atrial fibrillation (AF) are currently a "one-size- fits- all" type of approach. Pulmonary vein isolation as the standard of care is not perfect, especially in the persistent forms, but none of the alternatives has shown better results. The dichotomic paroxysmal versus persistent AF classification in no longer acceptable. Characterization of the atrial substrate before ablation is needed. Electrocardiographic imaging (ECGI) is capable of non-invasively assess atrial activation in a single beat and in a panoramic fashion. The aim of this study was to evaluate the feasibility and accuracy of ECGI to assess the activation speed and identify possible targets for ablation. Methods We studied 18 consecutive patients, 9 referred for ablation of paroxysmal AF and 9 without AF, referred for ablation of premature ventricular contractions (PVCs), that had an ECGI performed before ablation. No patient had structural heart disease and all patients had normal electrocardiographic evaluation in sinus rhythm (SR). The ECGI was performed in SR with the AMYCARD 01 system, based on body surface electrocardiograms of a maximum of 224 electrodes and computed tomography imaging data. Total duration of atrial activation, left atrial (LA), and right atrial (RA) activation duration, and presence of lines of conduction block (LOB) defined as the presence of a jump in the local activation time of 50 ms or more between contiguous points, were assessed. The results were compared in patients with and without AF. Results The results are depicted in the Table. Patients with AF were older. Total atrial activation duration, LA, and RA activation duration were longer in patients with AF and there was a trend towards a higher prevalence of LOB in the LA in patients with AF (Figure). Discussion & Conclusion Total atrial activation duration as well as LA and RA activation duration assessed with the ECGI were significantly prolonged in patients with AF. Presence of LOB in the LA showed a trend towards a higher prevalence in AF patients. These pilot study has proved that this technology is accurate in identifying a pathological substrate in AF patients. We intend to use ECGI in a subsequent study that will include patients with AF both in paroxysmal and persistent forms, in order to identify markers of disease as well as possible targets to perform a customized AF ablation.Comparison between AF and control groupsECGI showing local activation times

Preliminary results of studying the prevalence of atrial fibrillation and the adequacy of prevention of thromboembolic complications

Abstract Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia that complicates the course of various cardiovascular diseases, and is also accompanied by the frequent development of thromboembolic complications (TEC), primarily ischemic stroke. In this regard, AF represents a huge socio-economic problem for the health system and society as a whole. Purpose study the real situation in terms of the incidence of various forms of AF and the adequacy of the prevention of TEC among the population of family clinic (FC) №5 in Tashkent. Materials and methods To achieve this goal, out of 12 districts of Tashkent, a (FP) №5 of M. Ulugbek district of Tashkent was selected with a total population of 21,606 people. After exclusion from the study of persons under 18 years of age (n=3546), the total number of adults was 18060 people. Random selection (n=1407) was performed using computer programs with the function of a random number generator in Microsoft Excel. The risk of TEC and bleeding in patients with various forms of AF was assessed using the CHA2DS2-VASc and HAS-BLED score. The study of the situation regarding the compliance of the use of anticoagulants with the current recommendations of the ESC (2020) was carried out by analyzing the structure of the pharmacological prevention of feasibility studies at the time of the survey. Research results: A total of 1407 (725 (51.53%) men) of the population were examined, registered with FC№5 in the M. Ulugbek district of Tashkent. It was found that 406 (28.86%) of the examined patients were diagnosed with coronary heart disease and/or hypertension, 5 (0.36%) of the population were diagnosed with chronic rheumatic heart disease and 369 (26.23%) people with a disease of other organs and systems. In 627 (44.56%) examined patients, non-organic pathologies were found. In general, it was found that 16 (1.13%) out of the total number of examined patients had various clinical forms of AF of both valvular (18.75%) and non-valvular etiology (81.25%). In general, among the identified clinical forms of AF, the permanent form of AF prevailed, amounting to 56.25%, and persistent ones, including long-term persistent and paroxysmal AF were detected in 4 (25%) and 2 (18.75%) patients, respectively. An analysis of the characteristics of the pharmacological prevention of thromboembolic complications showed that at the time of the survey, only 50% of patients were taking the oral anticoagulant therapy recommended in the standards (12.5% warfarin, without proper control of INR and 37.5% of novel oral anticoagulants). Conclusions 1) It was found that the prevalence of various forms of AF was 16 (1.13%) of the total number of patients examined: of these, 56.25% had a permanent form, 25% had a persistent form, and 18.75% had a paroxysmal form. 2) According to the ESC 2020 recommendations, the prevention thromboembolic complications in patients with AF is assessed as unsatisfactory.

Low voltage and low wave speed are rarely present outside the left atrium-pulmonary veins junction in paroxysmal atrial fibrillation but frequently present in persistent forms

Abstract Background and aim Multielectrode high-density catheters have enabled acquisition of comprehensive and dense maps of electrogram’s amplitude and timing. However, automated activation and voltage mapping are flawed by catheter orientation in relation to the wavefront activation. Omnipolar mapping technology (OT) uses both unipolar and bipolar signals to obtain OT signals and increases the accuracy of automatic point acquisition allowing for a high- density map in a quick and efficient way. The aim of this study was to automatically assess with OT, the left atrium (LA) voltage and wave speed propagation map in sinus rhythm (SR) according to the type of atrial fibrillation (AF). Methods We studied 14 consecutive patients referred for ablation of AF, either paroxysmal (PAF) (n=6) or persistent (Pers-AF) (n=8) using catheters with OT. Patients with Pers-AF were cardioverted, and a SR map was obtained before ablation in all patients and voltage and propagation wave speed maps were obtained. The cut-off for low voltage areas (LVAs) was less than 0.1 mV and for low wave speed (LWS) was less than 0.4 mm/ms. Results were compared according to the type of AF. Results The results are depicted in the Table. The median duration of AF in Pers-AF was 18 (5-24) months. Patients with Pers-AF had larger LA volumes and displayed presence of LVAs and LWS areas in 100% of cases in comparison with 17% and 33% of cases respectively for PAF patients (p=0.003 and p=0.015). Also, the total LVAs and LWS areas in cm2 were significantly higher, (p=0.001 and p=0.005)). The LVAs and the LWS areas were more frequently located outside the PV-LA junction in Pers-AF than in PAF, respectively 75% vs 0% and 88% vs 0%, p=0.010 and p=0.005 (Figure). Conclusions Patients with PAF never presented LVAs or LWS outside the PV-LA junction. On the contrary, patients with Pers-AF had frequently anatomical and electrophysiological abnormalities in the LA body. These findings may suggest the need for a wider ablation strategy in Pers-AF.Normal voltage in purple ; LWS in white

The assessment of left atrial and left atrial appendage mechanics in patients with different stages of atrial fibrillation

Abstract Background Atrial fibrillation (AF) is associated with left atrial (LA) mechanical dysfunction, which predisposes to stasis of blood within the LA and thus increases the risk of stroke. However, limited is known about the mechanical functional alterations of left atrial appendage (LAA) in relation to stages of AF. Here, we sought to analyse LA and LAA mechanics during different stages of AF in detail. Methods A total of 92 patients with AF referring for radiofrequency ablation were consecutively enrolled. Patients were categorized according to rhythm and stages of AF:sustained AF(SAF) (n=31), paroxysmal AF with sinus rhythm(PAF-SR)(n=30) andAF rhythm(PAF-AF)(n=31)at the time of echocardiography. Twenty-seven patients without a history of AF were included as controls. Using speckle-tracking echocardiography, LA and LAA global peak positive longitudinal strain (GLS) and mechanical dispersion (MD) were measured in all patients. Mechanical dispersion was defined as the standard deviation of the time to peak of the regional strain corrected by R-R interval. Results Patients with PAF-AF and SAF displayed prominently impaired LA and LAA mechanics(all P < 0.01 vs. PAF-SR and no AF). In the presence of SR, only LAA mechanical function were lower in PAF patients than patients without AF(LAA GLS 20.5±5.7%(no AF) vs 15.9±5.4%(PAF-SR); LAA MD 6.9±3.8%(no AF) vs 9.4±3.9(PAF-SR),both P<0.01). AF stages were independent determinants of LA and LAA mechanics after adjusting for age and comobidities. Conclusions AF affected mechanical function of LA and LAA on their own, and more so if stage of AF has advanced to more persistent forms. In addition, LAA mechanical dysfunction occurred earlier than that of LA.fig 1fig 2

Zero x-ray pulmonary vein isolation with heliostar radiofrequency balloon: efficacy and safety

Abstract Introduction Single shot pulmonary vein isolation techniques are currently an attractive and effective alternative to point-by-point ablation. The Heliostar® radiofrequency balloon is capable of producing single shot isolation with reduced procedure times and high efficacy and safety. A particular feature of this new balloon is its ability to be visualized on the Carto 3® navigation system, which makes it possible to reduce or even eliminate the use of X-rays (XR) in this type of procedure. Objectives Our objective was to demonstrate the efficacy and safety of pulmonary vein isolation with Heliostar® radiofrequency balloon without the use of XR. Methods Twenty-five patients with paroxysmal (68%) or persistent (32%) atrial fibrillation were prospectively included in our centre and underwent pulmonary vein isolation with radiofrequency balloon. Ten cases were performed without XR (40%), and the remaining 15 (60%) using fluoroscopy. All cases were performed under general anaesthesia and using the Carto 3® navigation system. Electroanatomical mapping was performed pre and post ablation in all cases. Mapping was performed in sinus rhythm. In cases without XR, intracardiac echocardiography was used to guide the transseptal puncture and the rest of the procedure. Technical and clinical data were collected. Cases with and without XR were compared. Results There were no complications in either group. All veins were successfully isolated, with 56% first pass isolation in the non-XR group versus 68% in the XR group (non-significant difference). The vein with the highest percentage of first pass isolations was the left inferior vein in both groups. Procedure times were similar (median left atrial dwell time of 34 minutes in the non-XR group and 36 minutes in the XR group, non-significant difference). There was also no difference in the median time to isolation from the start of radiofrequency application in each vein (10 seconds in both groups). Left atrial size was normal in most patients, and ventricular function was preserved, with no differences between the two groups. The non-XR group had a higher number of patients with left main trunk, but the XR group had a higher percentage of patients with persistent forms of atrial fibrillation. Conclusion Zero-XR pulmonary vein isolation with Heliostar® balloon is possible and safe, with similar efficacy and first pass isolation rate, similar procedure time and no relevant complications in our series.

Breaking habits: safety and efficacy of elective electrocardioversion of atrial fibrillation and atrial flutter in the setting of day hospital

<p><strong>Aim <br /></strong>To examine safety and efficiency of electrocardioversion (EC) in elective treatment of atrial fibrillation and atrial flutter in<br />the setting of Day Hospital by determining success rate, frequency of adverse events and possible cost benefit compared to admitting a patient into hospital.<br /><strong>Methods </strong><br />This prospective observational cohort study was performed in Day Hospital and in Intensive Care Department of Internal<br />Medicine Clinic, University Clinical Centre Tuzla from January 2019 to December 2022 and included 98 patients with a persistent form of atrial fibrillation (AF) or atrial flutter. The patients who were divided in two groups, 56 hospitalized and 42 patients accessed in Day Hospital. In all patients, medical history, physical examination, electrocardiogram (ECG) and transthoracic echocardiogram (TTE) evaluation was performed in addition to laboratory findings. Electrocardioversion was performed with a monophasic General Electric defibrillator in anterolateral electrode position with up to three repetitive shocks.<br /><strong>Results</strong> <br />In hospital setting group overall succes rate of electrocardioversion was 85%, with average 2.1 EC attemps, there was with one fatal outcome due to stroke, one case of ventricular fibrillation (VF) due to human error, and 6 minor adverse events; with average cost of was 1408.70 KM (720.23 €) per patient. In Day Hospital setting succes rate was 88%, with average 2 EC attempts, no major adverse events, 8 minor adverse events; and average cost was of 127.23 KM (65.05 €) per patient.<br /><strong>Conclusion</strong> <br />Performing elective electrocardioversion in Day Hospital setting is as safe as admitting patients into hospital but substantially more cost effective.</p>