Higher Risk Of Atrial Fibrillation Research Articles

Impact of Atrial Fibrillation on Inpatient Outcomes Among Hospitalized Patients With Multiple Myeloma.

BackgroundThough multiple myeloma (MM) patients have been reported to have the highest risk of atrial fibrillation compared to other cancer patients, studies are lacking on the impact of atrial fibrillation on health outcomes in this population. In this study, we examined the impact of atrial fibrillation on inpatient outcomes among hospitalized patients with MM.MethodologyRetrospective cohort analyses were conducted using National Inpatient Sample data from 2016 to 2018. Descriptive analyses were performed to explore the prevalence of atrial fibrillation among MM patients. Multivariable logistic and linear regression models were used to examine the association between atrial fibrillation and inpatient all-cause mortality, length of stay, and total hospital charges among hospitalized patients with MM.ResultsOverall, 13.1% of the patients reported having atrial fibrillation. MM patients with atrial fibrillation had 1.2 times (adjusted odds ratio (AOR) = 1.16; 95% confidence interval (CI) = 1.05-1.29) higher odds of inpatient all-cause mortality when compared to those without atrial fibrillation. They were also 1.3 times (AOR = 1.29; 95% CI = 1.23-1.35) more likely to have a length of stay of more than five days relative to five days or less. Additionally, MM patients with atrial fibrillation had $8,020 (95% CI = $5,495.2-$10,546.3) higher hospital costs when compared to their counterparts without atrial fibrillation. Stratified results by the use of anticoagulation further showed that MM patients who were not using anticoagulation had bad health outcomes, reporting higher odds of inpatient all-cause mortality (AOR = 1.40; 95% CI = 1.25-1.57), a longer length of hospital stay of more than five days (AOR = 1.44; 95% CI = 1.36-1.53), and total hospital charges (β = $14,772.5; 95% CI = $11,467.8-$18,077.3).ConclusionsOur findings stress the need for monitoring and possible screening to detect atrial fibrillation in MM patients as anticoagulation helps improve mortality in these patients. Medication reconciliation remains a key component of hospital admissions/discharges and may help in decreasing the length of stay and healthcare costs.

Myeloperoxidase as prognostic factor for atrial fibrillation development in patients with ST-segment elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background Arrhythmia is among the most common and severe myocardial infarction complications. Myeloperoxidase as an important immune factor can be linked to atrial fibrillation (AF) development. Previous studies indicated myeloperoxidase (MPO) as a significant mortality predictor in ST-segment elevation myocardial infarction (STEMI). The MPO role in prognosis for adverse clinical outcomes, as atrial fibrillations in STEMI patients remains not fully understood. The purpose of the investigation was to examine the MPO in prognosis of adverse outcomes presented by atrial fibrillations in patients with STEMI. Methods The study included 233 STEMI patients, 112 males, 121 females, and average age 67.87±7.11 years. Follow-up period was 14 days. Adverse outcome was observed and included atrial fibrillations. Plasma MPO levels were determined by ELISA, MPO was collected on admission. Results Patients with indicated adverse effects showed significantly increased MPO levels compared to those without ones, 169.91 IQR [89.45; 201.98] ng/ml vs 81.4 [33.91;181.29] ng/ml; p < 0.001. A ROC analysis determined a MPO cut-off value for arrhythmia (AF) development of 176.53 ng/ml with a sensitivity of 71.1% and specificity of 77.6%, AUC 0.732; 95 % CI 0.677-0.782; p <0.001. Elevated MPO concentration was a significant predictor for AF (OR 1.115; 95% CI: 1.007-1.841; p<0.001). Even adjusted for age and sex MPO remained significantly predictive for arrhythmia development. Conclusions The study suggests that increased levels of MPO are associated with the higher risk of atrial fibrillation. MPO could be a possible significant factor for therapy optimization in high-risk STEMI patients.

Atrial fibrillation and stroke risk of patients with hypertrophic cardiomyopathy in denmark from 2005-2018: a nationwide cohort study

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Internal funding: Herlev-Gentofte Cardiovascular Research Department. Background Hypertrophic cardiomyopathy (HCM) can be associated with serious complications such as heart failure, atrial fibrillation (AF) and sudden cardiac death. The treatment of AF in HCM patients can be challenging since AF often aggravates symptoms. Previous studies have suggested that HCM patients with AF have an elevated risk of thromboembolism and stroke compared to AF patients without HCM regardless of their CHA2DS2VASc score. Purpose To determine the risk of AF and stroke in HCM patients. Methods Through the Danish National Registers all patients aged 16 or older diagnosed with HCM between the 1st of January 2005, and the 31st of December 2018 were included in the analysis. The association between HCM, AF, and stroke was investigated using multivariable Cox proportional-hazard analysis adjusted for gender, age, atrial fibrillation, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease and hypertension. Cumulative incidence of AF and stroke was calculated using the Aalen-Johansen estimator, taking death as a competing risk into account. Results A total of 3856 patients were included, 2060 (53,4%) were male and median age of 67,8 (IQR 56 and 77,8) years. During the study period, 384 (10%) patients were diagnosed with AF. The risk of AF was significantly lower in males (HR 0,72 (0,59–0,90), p-value = 0.003) and for patients below 60 years (HR 0,18 (0,12–0,27), p-value = <0.001). (Figure 1) 157 (4,1%) of the HCM patients developed stroke. The risk of developing stroke was significantly decreased for patients aged under 60 (HR 0,32 (0,2–0,52), p-value = <0.001). There was no increased risk of stroke comparing genders. Stroke risk was further analyzed in patients with known AF at time of inclusion, 656 (17%) in total. Compared to patients without AF and adjusted for age, gender and co-morbidities, there was no significant difference in stroke risk between these groups (HR 1.2 (0,81-1,76), p-value = 0.36). (Figure 2) Conclusion AF and stroke are common complications in HCM. Women are more susceptible to developing AF than men, and age over 60 at the time of diagnosis was associated with significantly higher risk of AF and stroke. HCM patients with previously known AF did not have a significantly elevated risk of stroke. More research will be needed to further explore these connections.

Real world outcomes of minimally invasive epicardial surgical left atrial appendage exclusion in atrial fibrillation patients with high risk of stroke and bleeding

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): AtriCure, Inc Introduction The left atrial appendage (LAA) is the site of thrombus formation in patients with atrial fibrillation (AF) and first line therapy for reducing the risk of stroke is oral anticoagulation (OACs). A subset of patients with AF carry a very high risk of stroke and bleeding and are ineligible for OAC and percutaneous LAA occlusion; these patients may be suitable for minimally invasive thoracoscopic epicardial surgical LAA exclusion (LAAE) which can be used with a wide variety of LAA morphologies with a ~98% rate of complete exclusion. While use of LAAE is well studied as a concomitant procedure, there are relatively few data on its use as a stand-alone procedure. Purpose To compare real-world outcomes of LAAE versus no-LAAE in AF patients at high risk of stroke and bleeding who are not on OACs. Methods We performed an analysis of Medicare beneficiaries with AF who were not on OACs and received LAAE (ICD10-PCS code 02L74CK, Oct 2015 – Dec 31, 2017) in the absence of a concomitant surgical or catheter AF ablation procedure. Patients were propensity-matched (1:4) to otherwise similar patients who did not receive LAAE (control), using age, gender, race, region, AF type, CHA2DS2-VASc, HAS-BLED, and co-morbidities. The primary endpoint was hospital readmission for a thromboembolic event (ischemic stroke, systemic embolism, or transient ischemic attack). Kaplan Meier event rates were calculated and 95% CI were generated via bootstrapping. Results A total of 243 patients who underwent LAAE and 1.7M control patients met study criteria. In the matched cohort, the mean age was 75 years, 61% were men, 77% had non-paroxysmal AF, and the mean CHADS2-VASC and HAS-BLED scores were 5.5 and 4.2, respectively. The 1-year rate of thromboembolism in the LAAE and control arms were 7.3% (95% CI 4.3% -10.9%) and 13.6 (95% CI 11.0% -16.4%) (Figure), respectively, with an absolute and relative risk reduction of 6.2% (95% CI 2.0-10.3, p-value=0.001, NNT 17) and 0.54 (95% CI 0.29-0.68, p=0.001). Conclusion Among high-risk AF patients who were not on OAC, LAAE was associated with a clinically meaningful and significantly lower risk of TE. Additional studies are needed to confirm these finding.

24-hour ambulatory blood pressure telemonitoring in patients at risk of atrial fibrillation: results from the TEMPLAR project.

Hypertension is the most common risk factor for atrial fibrillation (AF). The ability to screen for potential AF during blood pressure (BP) measurement may be a valuable tool for early AF detection. This study evaluated the frequency of irregular pulse rates suggestive of AF in subjects undergoing ambulatory BP monitoring (ABPM) and compared the characteristics of patients at low risk of presumed AF vs. those at high risk. ABPM recordings were obtained in 4419 subjects aged ≥65 years visiting 304 community pharmacies, with clinically validated automated monitors equipped with an algorithm for detecting possible AF episodes during BP measurement. Subjects with <30% of the readings suggestive of AF were categorized as having a low risk of AF, and those with ≥30% of readings were classified as high risk. A total of 531 subjects (12.0%) were categorized as having a high risk of AF, with the risk increasing with advancing age. Subjects at high risk of AF had lower average systolic BP, higher average diastolic BP and pulse rate (PR), increased BP and PR variabilities, and blunted sleep-associated reductions in BP and PR. In repeated recordings, the reliability of the AF detection algorithm per se was good (kappa 0.476, p = 0.0001; intraclass correlation coefficient 0.56, p = 0.0001). Simultaneous BP measurement and screening for potential AF by ABPM in elderly people in clinical practice may help improve BP control and the detection of subjects at high risk of AF. However, a finding of presumed AF must always be confirmed by an electrocardiogram (ECG).

Effects of Acute Triiodothyronine Treatment in Patients with Anterior Myocardial Infarction Undergoing Primary Angioplasty: Evidence from a Pilot Randomized Clinical Trial (ThyRepair Study).

Background: Thyroid hormone has a differential action on healthy and ischemic heart. Triiodothyronine (T3) administration improved postischemic cardiac function while it limited apoptosis in experimentally induced ischemia. Thus, the present study investigated the potential effects of acute liothyronine (LT3) treatment in patients with anterior myocardial infarction. Methods: This study is a pilot, randomized, double-blind, placebo-controlled trial (ThyRepair study). We randomized 52 patients and analyzed data from 37 patients (n = 16 placebo and n = 21 LT3), per prespecified per protocol analysis. We excluded three patients who had died of cardiovascular causes (one in placebo and two in LT3 arm), four with small infarct size below a pre-specified threshold (in the placebo arm), and the rest, who lacked follow-up data. LT3 treatment started after stenting as an intravenous (i.v.) bolus injection of 0.8 μg/kg of LT3 followed by a constant infusion of 0.113 μg/kg/h i.v. for 48 hours. All patients had cardiac magnetic resonance (CMR) at hospital discharge and 6 months follow-up. The primary end point was CMR left ventricular (LV) ejection fraction (LVEF) and secondary endpoints were LV volumes, infarct volume (IV), and safety. Results: The CMR LVEF% at 6 months was 53.6 ± 9.5 for the LT3-treated group and 48.6 ± 11 for placebo, p = 0.15. Acute LT3 treatment resulted in a significantly lower LV end-diastolic volume index (92.2 ± 16.8 mL/m2 vs. 107.5 ± 22.2, p = 0.022) and LV systolic volume index (47.5 ± 13.9 mL/m2 vs. 61.3 ± 21.7, p = 0.024) at hospital discharge, but not at 6 months. There was no statistically significant difference in CMR IV at hospital discharge between the groups (p = 0.24). CMR IV tended to be lower in the LT3-treated group at 6 months (18.7 ± 9.5 vs. 25.9 ± 11.7, in placebo, p = 0.05). Serious, life-threatening events related to LT3 treatment were not observed. A tendency for an increased incidence of atrial fibrillation (AF) was found in the LT3 group during the first 48 hours (19% for T3 group vs. 5% for placebo, p = 0.13). Conclusion: This pilot randomized, placebo-controlled trial study suggests potential favorable effects (acute cardiac dilatation and 6-month IV) as well as potential concerns regarding a higher risk of AF after LT3 administration early after myocardial infarction, which should be tested in a larger scale study.

Emergency catheter ablation: A feasible option for acute treatments of patients with unstable pre-excited atrial fibrillation.

Pre-excited atrial fibrillation (AF) is associated with increased risk of life-threatening events. However, at times, patients with pre-excited AF still repetitively suffer from hemodynamic disturbance, with resistance to acute treatments of antiarrhythmic therapy and cardioversion. To evaluate the feasibility in correcting hemodynamic disturbance, patients with pre-excited AF who underwent catheter ablation of accessory pathway as an emergency procedure, were retrospectively collected from two centers of China. The medical records of patients were analyzed and summarized in this case series. Five patients with pre-excited AF who received emergency catheter ablation of accessory pathway, were collected from two contributor centers and reported in this case series. All collected patients still repetitively suffered from hemodynamic disturbance induced by rapid anterograde conduction of AF via pathway, even guideline recommended acute interventions of intravenous antiarrhythmic therapy and cardioversion had been performed. Finally, as an emergency procedure, catheter ablation of accessory pathway was performed in collected patients. Correspondingly, the hemodynamic unstable status was greatly relieved. Meanwhile, all collected patients with high risk of pre-excited AF were combined with left-sided accessory pathway, with shortest RR interval of widened pre-excited QRS complex less than 250 ms. Thus, combination with left-sided pathway is proposed as an indicator for the increased risk of life-threatening events in patients with high risk of pre-excited AF. Emergency catheter ablation of accessory pathway is an effective option for the acute managements of patients with high risk of pre-excited AF in unstable hemodynamics, which is resistant to antiarrhythmic therapy and cardioversion.

Usability of a smartwatch for atrial fibrillation detection in older adults after stroke

BackgroundSmartwatches can be used for atrial fibrillation (AF) detection, but little is known about how older adults at risk for AF perceive their usability.MethodsWe employed a mixed-methods study design using data from the ongoing Pulsewatch study, a randomized clinical trial (NCT03761394) examining the accuracy of a smartwatch-smartphone app dyad (Samsung/Android) compared to usual care with a patch monitor (Cardea SOLO™ ECG System) for detection of AF among older stroke survivors. To be eligible to participate in Pulsewatch, participants needed to be at least 50 years of age, have had an ischemic stroke, and have no major contraindications to anticoagulation therapy should AF be detected. After 14 days of use, usability was measured by the System Usability Scale (SUS) and investigator-generated questions. Qualitative interviews were conducted, transcribed, and coded via thematic analysis.ResultsNinety participants in the Pulsewatch trial were randomized to use a smartwatch-smartphone app dyad for 14 days (average age: 65 years, 41% female, 87% White), and 46% found it to be highly usable (SUS ≥68). In quantitative surveys, participants who used an assistive device (eg, wheelchair) and those with history of anxiety or depression were more likely to report anxiety associated with watch use. In qualitative interviews, study participants reported wanting a streamlined system that was more focused on rhythm monitoring and a smartwatch with a longer battery life. In-person training and support greatly improved their experience, and participants overwhelmingly preferred use of a smartwatch over traditional cardiac monitoring owing to its comfort, appearance, and convenience.ConclusionOlder adults at high risk for AF who were randomized to use a smartwatch-app dyad for AF monitoring over 14 days found it to be usable for AF detection and preferred their use to the use of a patch monitor. However, participants reported that a simpler device interface and longer smartwatch battery life would increase the system’s usability.

First- versus second-generation Bruton tyrosine kinase inhibitors in Waldenström's Macroglobulinemia: A systematic review and meta-analysis.

Bruton tyrosine kinase inhibitors (BTKi) are important treatment options in Waldenström's macroglobulinemia (WM). Whether second-generation BTKi are associated with improved outcomes and/or better safety profile remains unclear. We did a systematic review and meta-analysis of clinical trials that reported data on the outcomes of patients with WM who received either first- or second-generation BTKi in the period between January 2010 and August 2021. Studies with twenty or fewer patients were excluded. The primary outcomes were efficacy measured by response and survival data. Eleven studies met the eligibility criteria and were included in the final analysis (n= 730 patients). A total of 298 patients received 1st-generation BTKi and 432 received a 2nd-generation BTKi. Pooled overall response rate (ORR) and major response rate (MRR) for both generations were similar (94.2% and 78.5% in 1st vs. 88.9% and 75.1% in 2nd, respectively). MRR for both generations was higher in MYD88 Mut/CXCR4 WT patients compared to MYD88 Mut/CXCR4 Mut patients (odds ratio [OR]: 3.9, 95% CI: 2.2 to 5.5). Pooled 18-mo progression-free survival (PFS) was similar for both generations (88.5% vs. 87.3%). Grade 3/4 atrial fibrillation was higher in 1st-generation BTKi (3.1% vs. 0.4%); however, grade-3/-4 infections and neutropenia were more frequent in 2nd-generarion BTKi (20.9% vs. 13.2%, 17.7% vs. 12%, respectively). The efficacy of 1st- and 2nd-generation BTKis is comparable. The 1st-generation BTKi were associated with a higher risk of atrial fibrillation, whereas infections and neutropenia occurred more frequently in 2nd-generation BTKi.

Cost-effectiveness Of Insertable Cardiac Monitors For Detection Of Undiagnosed Atrial Fibrillation In High-risk Patients With Heart Failure

<h3>Introduction</h3> Atrial fibrillation (AF) is a major risk factor for stroke, the risk of which is mitigated through AF detection and subsequent treatment with oral anticoagulation. The REVEAL AF study demonstrated that ICMs detect a high rate of AF in high-risk patients, and a resulting cost-effectiveness analysis found ICM use to be cost-effective in preventing strokes. Given the known deleterious relationship between AF and heart failure (HF), this analysis sought to examine the cost effectiveness of ICMs in the sub-population of the REVEAL AF study with HF. <h3>Methods</h3> A lifetime Markov model assessed the cost-effectiveness of ICM vs. SoC from a US payer perspective. Patient characteristics, health utilities, and AF detection rates for the ICM group were based on the heart failure subgroup within the REVEAL-AF study (N=81). Standard of care AF detection rates were based on a subsequent simulation of the REVEAL-AF study. The observed two-year AF diagnostic yields of 38.4% with ICM and 1.4% in SoC were extrapolated to the 3-year device lifespan using logarithmic extrapolation (ICM = 43.8%; SOC=1.7%). AF detection was assumed to prompt switching from aspirin to direct oral anticoagulation (DOAC), unless precluded by prior bleeds. Subsequent risks of ischemic strokes and bleeding events were modeled based on published literature. U.S. payer-perspective costs, extracted from Medicare and commercial payer administrative datasets, and drug effects were discounted at 3% annually. <h3>Results</h3> ICM in REVEAL-AF sub-population with HF was associated with a 0.19 quality-adjusted life year (QALY) gain compared to SoC (7.11 vs. 6.92) and $5,895 higher per-patient costs, resulting in an incremental cost-effectiveness ratio (ICER) of $31,452 per QALY gained. In sensitivity analyses, where we assumed no further AF was detected after 2 years (38.4% diagnostic yield at year 3), the ICER increased to $35,358, whereas a linear extrapolation (48% diagnostic yield at year 3) reduced the ICER to $29,026. The ICER was also sensitive to use of warfarin (ICER=$49,525) rather than DOAC anticoagulation in the base case analysis, and device and insertion procedure cost (+/- 30%: ICER=$42,724; $20,179, respectively). Further, increasing the device longevity to 4.5 years yielded an ICER of $29,146. <h3>Conclusions</h3> ICMs are a cost-effective diagnostic tool for the prevention of ischemic strokes in patients with heart failure and at high risk for atrial fibrillation. Improvements in ICM battery life could further enhance their clinical and economic value.

Identification of undiagnosed atrial fibrillation using a machine learning risk-prediction algorithm and diagnostic testing (PULsE-AI) in primary care: a multi-centre randomized controlled trial in England.

The aim of the PULsE-AI trial was to assess the effectiveness of a machine learning risk-prediction algorithm in conjunction with diagnostic testing for identifying undiagnosed atrial fibrillation (AF) in primary care in England. Eligible participants (aged ≥30 years without AF diagnosis; n = 23 745) from six general practices in England were randomized into intervention and control arms. Intervention arm participants, identified by the algorithm as high risk of undiagnosed AF (n = 944), were invited for diagnostic testing (n = 256 consented); those who did not accept the invitation, and all control arm participants, were managed routinely. The primary endpoint was the proportion of AF, atrial flutter, and fast atrial tachycardia diagnoses during the trial (June 2019-February 2021) in high-risk participants. Atrial fibrillation and related arrhythmias were diagnosed in 5.63% and 4.93% of high-risk participants in intervention and control arms, respectively {odds ratio (OR) [95% confidence interval (CI)]: 1.15 (0.77-1.73), P = 0.486}. Among intervention arm participants who underwent diagnostic testing (28.1%), 9.41% received AF and related arrhythmia diagnoses [vs. 4.93% (control); OR (95% CI): 2.24 (1.31-3.73), P = 0.003]. The AF risk-prediction algorithm accurately identified high-risk participants in both arms. While the proportions of AF and related arrhythmia diagnoses were not significantly different between high-risk arms, intervention arm participants who underwent diagnostic testing were twice as likely to receive arrhythmia diagnoses compared with routine care. The algorithm could be a valuable tool to select primary care groups at high risk of undiagnosed AF who may benefit from diagnostic testing.

Echocardiographic Parameters to Predict Atrial Fibrillation in Clinical Routine—The EAHsy-AF Risk Score

BackgroundEchocardiographic parameters representing impaired left atrial (LA) function and remodeling are of high value to predict atrial fibrillation (AF). This study aimed to develop a prediction model for AF easily to apply in clinical routine containing echocardiographic parameters associated with LA remodeling and—function.Methods and ResultsThis monocentric, semi-blinded, controlled analysis included 235 patients to derive a prediction model. This prediction model was tested in a validation cohort encompassing 290 cardiovascular inpatients. The derivation and validation cohort included 54 (23%) and 66 (23%) patients with AF, respectively. Transthoracic echocardiography, comprising parameters indicating left atrial remodeling [septal/lateral total atrial conduction time (s/l PA-TDI)] and left atrial volume indexed to a' (LAVI/a') was performed in each patient. Based on multivariable regressions analysis, four variables were enclosed into the EAHsy (Echocardiography, Age, Hypertension)-AF risk score for AF prediction: Hypertension, Age, LAVI/a‘ and septal PA-TDI. In the validation cohort discrimination was strong (C-statistic 0.987, 95%CI 0.974–0.991) with an adequately performed calibration. The EAHsy-AF risk score was associated with a more precise prediction of AF in comparison to commonly used AF-scores (CHADS2-, ATLAS-, ARIC-, CHARGE-AF score).ConclusionThe EAHsy-AF-Score containing age, hypertension and echocardiographic parameters of atrial dysfunction and remodeling precisely predicts the incidence of AF in a general population of patients with cardiovascular disease. The EAHsy-AF risk score may enable more selective rhythm monitoring in specific patients at high risk for AF.

La concentración plasmática de microARN-1-3p se asocia con fibrilación auricular subclínica en los pacientes con ictus criptogénico

Introduction and objectivesIdentifying biomarkers of subclinical atrial fibrillation (AF) is of most interest in patients with cryptogenic stroke (CrS). We sought to evaluate the circulating microRNA (miRNA) profile of patients with CrS and AF compared with those in persistent sinus rhythm. MethodsAmong 64 consecutive patients with CrS under continuous monitoring by a predischarge insertable monitor, 18 patients (9 with AF and 9 in persistent sinus rhythm) were selected for high-throughput determination of 754 miRNAs. Nine patients with concomitant stroke and AF were also screened to improve the yield of miRNA selection. Differentially expressed miRNAs were replicated in an independent cohort (n=46). Biological markers were stratified by the median and included in logistic regression analyses to evaluate their association with AF at 6 and 12 months. ResultsEight miRNAs were differentially expressed between patients with and without AF. In the replication cohort, miR-1-3p, a gene regulator involved in cardiac arrhythmogenesis, was the only miRNA to remain significantly higher in patients with CrS and AF vs those in sinus rhythm and showed a modest association with AF burden. High (= above the median) miR-1-3p plasma values, together with a low left atrial ejection fraction, were independently associated with the presence of AF at 6 and 12 months. ConclusionsIn this cohort, plasma levels of miR-1-3p were elevated in CrS patients with subsequent AF. Our results preliminarily suggest that miR-1-3p could be a novel biomarker that, together with clinical parameters, could help identify patients with CrS and a high risk of occult AF.

Association between lung function and the risk of atrial fibrillation in a nationwide population cohort study

We investigated the association between lung function and atrial fibrillation (AF) in 21,349 adults without AF aged ≥ 40 years who underwent spirometry. The study participants were enrolled from the Korean National Health and Nutritional Examination Survey between 2008 and 2016. The primary outcome was new-onset non-valvular AF identified from the National Health Insurance Service database. During the median follow-up of 6.5 years, 2.15% of participants developed new-onset AF. The incidence rate of AF per 1000 person-years was inversely related to the forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC quartile. After adjustment for multiple variables, the AF risk in the lowest FEV1 quartile was 1.64-fold higher than that in the highest quartile (hazard ratio (HR) 1.64 (95% confidence interval (CI) 1.26–2.12) for lowest FEV1 quartile). The lowest quartile of FVC had 1.56-fold higher AF risk than the highest quartile (HR 1.56 (95% CI 1.18–2.08) for lowest FVC quartile). Although the lowest FEV1/FVC quartile was associated with an increased risk of AF in the unadjusted model, this increased risk was not statistically significant in the multivariable analysis. Compared to those with normal lung function, participants with restrictive or obstructive lung function had 1.49 and 1.42-fold higher AF risks, respectively. In this large nationwide cohort study, both obstructive and restrictive patterns of reduced lung function were significantly associated with increased AF risk.

Sedentary Behavior and Atrial Fibrillation in Older Women: The OPACH Study.

BackgroundSedentary behavior is associated with cardiovascular disease, but its association with incident atrial fibrillation is not well studied. Our aim was to measure the association between objectively measured sedentary behavior and incident atrial fibrillation.Methods and ResultsSedentary behavior was measured by a triaxial accelerometer worn on a belt for 1 week. Incident atrial fibrillation was ascertained from Medicare claims. The associations between total sedentary time (or patterns of sedentary behavior) and incident atrial fibrillation were assessed using Cox proportional hazards models adjusted for demographic and clinical covariates. Among 2675 participants (mean age, 78.2 years), there were 268 (10.0%) cases of incident atrial fibrillation at a rate of 31 cases per 1000 person‐years. Greater total sedentary time was associated with a higher risk of incident atrial fibrillation after adjustment for age, race and ethnicity, body mass index, education, smoking history, hypertension, diabetes, stroke, heart disease, and other chronic conditions (quartile 4 versus quartile 1: hazard ratio, 1.20, [95% CI, 0.81–1.78]; P for trend=0.05). After adjusting for physical function and self‐rated health, this was no longer statistically significant. Both longer mean sedentary bout duration and more continuous sedentary periods (versus frequent breaks in sedentary time) were also associated with higher risks of incident atrial fibrillation, but these associations were also attenuated with serial adjustment.ConclusionsTotal sedentary time and prolonged patterns of sedentary accumulation were associated with a higher risk of atrial fibrillation in this prospective study of community‐dwelling older women, but these associations were attenuated by adjustment for physical function and self‐reported health. This suggests that associations between sedentary behavior and atrial fibrillation may be attributable to global measures of overall function and health.

Abstract P107: Trends In Oral Anticoagulation Therapy In Non-valvular Atrial Fibrillation Patients At High-risk Of Stroke After The 2019 AHA/ACC/HRS Update For The Management Of Patients With Atrial Fibrillation Guidelines

Background: Oral anticoagulation (OAC) reduces the risk of ischemic stroke in patients with atrial fibrillation (AF) but is underutilized in high-risk patients. We aimed to assess the impact of the 2019 guideline-recommended use of non-vitamin K OAC (NOACs) as first line therapy over warfarin for high-risk patients with non-valvular AF. Methods: Adult patients at Essentia Health with AF or atrial flutter on their problem list, seen in an ambulatory clinic between 7/1/2020-7/12/2021, were included in the baseline cohort. Patients were excluded if they had moderate to severe rheumatic mitral stenosis or mechanical heart valves, or were deceased or missing 1-year follow-up data. High-risk AF was defined as males with a CHA2DS2-VASc score ≥2 and females with a score ≥3. ATRIA bleed score was calculated using electronic health record data and divided into 3 groups: low-risk (0-3), intermediate (4) or high-risk (5-10). Patients were separated into three groups: warfarin, NOAC, or no OAC therapy. Results: Of the 12,014 patients in the baseline non-valvular AF registry, 8,032 were high-risk (mean age 75.9 ± 9.8 years, 57.5% male). Over half (57.1%, n=4619) were age ≥ 75 years and 63.4% (n=5095) were rural dwelling. Compared to baseline, at 1-year follow up, high-risk AF patients had similar use of any OAC (75.6%; n=6069 at baseline vs. 75.7%; n=6083 at 1-year follow-up). The use of warfarin decreased 2.3% [from 39.3% (n=3160) to 37.0% (n=2973), p &lt;0.001] while NOAC use increased 2.4% [from 36.2% (n=2909) to 38.7% (n=3110; p &lt;0.001]. Eliquis was the most prevalent NOAC prescribed (57.9%; n=1802). At 1-year follow-up, patients with high-risk AF and low-risk ATRIA bleed score, the use of any OAC therapy increased by 0.9% while those at high-risk AF and high-risk ATRIA bleed score, the use of any OAC therapy decreased 1%. In the multivariate logistical model, age, male sex, CHA2DS2-VASc score 4-6, hypertension, stroke/transient ischemic attack/thromboembolism, and cardiology visit within the last 3 years showed an increased association with prescription of any OAC (p&lt;0.05). Vascular disease, high risk ATRIA bleed score, severe renal risk, prior hemorrhage, and left atrial appendage occlusion device (WATCHMAN) had a decreased odds of any OAC use (p&lt;0.05). Conclusion: Implementation of the 2019 ACC/AHA/HRS guidelines that established NOACs as first line therapy over warfarin for non-valvular AF resulted in a slight increase in NOAC use and decrease in warfarin use in a large high-risk non-valvular AF population. Approximately one in four high risk patients with AF are not on any OAC therapy and may benefit from treatment to reduce thromboembolic risk.

Association of Sleep Duration, Midday Napping with Atrial Fibrillation in Patients with Hypertension

ObjectiveThis study aimed to assess the associations of sleep duration, midday napping and the risk of atrial fibrillation (AF) in patients with hypertension.MethodsWe conducted a cross-sectional study enrolling 11,524 hypertensive participates from the Chinese Hypertension Registry Study. Information on sleep duration and midday napping were obtained by a self-administered questionnaire. Multivariate logistic regression analyses were performed to estimate odds ratio (OR) and 95% confidence intervals (CIs) for the risk of AF.ResultsCompared with sleeping 6 to ≤8 hours/night, those reporting shorter sleep duration (≤5 hours/night) had a greater risk of AF (OR 1.95; 95% CI 1.28–2.95) in the fully adjusted model, while longer sleep (≥9 hours/night) was not significantly associated with the risk of AF. Compared with nonhabitual nappers, nappers had a higher risk of AF (OR 1.28; 95% CI 1.03–1.60) in the fully adjusted model. Moreover, we observed significant joint effects of sleeping ≤5 hours/night and nap (OR 2.13; 95% CI 1.09–4.14) on the risk of AF after adjusting for confounding factors.ConclusionShort sleep duration and midday napping were independently and jointly associated with higher risks of AF in patients with hypertension.

Budget impact analysis of a machine learning algorithm to predict high risk of atrial fibrillation among primary care patients.

We investigated whether the use of an atrial fibrillation (AF) risk prediction algorithm could improve AF detection compared with opportunistic screening in primary care and assessed the associated budget impact. Eligible patients were registered with a general practice in UK, aged 65 years or older in 2018/19, and had complete data for weight, height, body mass index, and systolic and diastolic blood pressure recorded within 1 year. Three screening scenarios were assessed: (i) opportunistic screening and diagnosis (standard care); (ii) standard care replaced by the use of the algorithm; and (iii) combined use of standard care and the algorithm. The analysis considered a 3-year time horizon, and the budget impact for the National Health Service (NHS) costs alone or with personal social services (PSS) costs. Scenario 1 would identify 79 410 new AF cases (detection gap reduced by 22%). Scenario 2 would identify 70 916 (gap reduced by 19%) and Scenario 3 would identify 99 267 new cases (gap reduction 27%). These rates translate into 2639 strokes being prevented in Scenario 1, 2357 in Scenario 2, and 3299 in Scenario 3. The 3-year NHS budget impact of Scenario 1 would be £45.3 million, £3.6 million (difference ‒92.0%) with Scenario 2, and £46.3 million (difference 2.2%) in Scenario 3, but for NHS plus PSS would be ‒£48.8 million, ‒£80.4 million (64.8%), and ‒£71.3 million (46.1%), respectively. Implementation of an AF risk prediction algorithm alongside standard opportunistic screening could close the AF detection gap and prevent strokes while substantially reducing NHS and PSS combined care costs.

Obstructive sleep apnea and atrial fibrillation: insights from a bidirectional Mendelian randomization study

BackgroundObservational studies have suggested that obstructive sleep apnea (OSA) is in relation to atrial fibrillation (AF); however, these studies might be confounded and whether the relationship is causal remains unclear. We conducted a bidirectional Mendelian randomization (MR) study to clarify the causal inference between OSA and AF.MethodsGenetic instruments for OSA and AF were obtained from genome-wide association studies. The fixed-effects inverse-variance weighted (IVW) method was used as the main method, supplemented by several sensitivity analyses. For replication, another AF dataset was used to validate the causal effect of OSA on AF. Furthermore, multivariable MR analyses were performed to obtain direct estimates adjusting for potential confounders.ResultsGenetic liability to OSA was found to be significantly associated with a higher AF risk in the fixed-effects IVW method [odds ratio (OR) 1.210; 95% CI 1.119–1.307; P = 1.51 × 10–6]. The results were consistent in MR sensitivity analyses as well as in replication analyses, and the significance remained after adjusting for potential confounders. In the reverse MR analyses, there was no causal effect of AF on OSA.ConclusionsOur study strengthened the causal evidence of genetically predicted OSA with a higher AF risk. Early screening and appropriate management of OSA might show anti-arrhythmic benefits.

Edoxaban-based long-term antithrombotic therapy in patients with atrial fibrillation and stable coronary disease: Rationale and design of the randomized EPIC-CAD trial

BackgroundAnticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD. DesignThe EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA2DS2-VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization. ResultsAs of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023. ConclusionsEPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD.