Hospitalization For Atrial Fibrillation Research Articles

Abstract 12441: Ambient Fine Particulate Matter Air Pollution but Not Ozone is Associated With Elevated Risk of All-Cause Hospitalization in Patients With a Prior Diagnosis of Atrial Fibrillation

Introduction: Short-term increases (days to weeks) in fine particulate matter (PM 2.5 ) air pollution are associated with atrial fibrillation (AF) episodes. We previously reported that PM 2.5 was not associated with severe AF measured as emergency or inpatient hospitalization for the primary diagnosis of AF. Mild AF, though, may influence all-cause hospitalizations. This study evaluated if short-term increases in PM 2.5 and ozone were associated with all-cause hospitalization at 11 Intermountain Health hospitals in patients with AF, and if this differed between wildfire (June-Oct.) and winter inversion (Nov.-March) seasons. Methods: Patients carrying an AF diagnosis (N=347,157) were evaluated for all-cause hospitalization and, secondarily, AF hospitalization (N=25,601) and first AF diagnosis (N=77,893). PM 2.5 levels were measured from January 1, 1999 to March 31, 2022 (ozone: 2006-2022) in subjects residing on Utah’s Wasatch Front. Using the case-crossover design that matched individual-level characteristics, Poisson regression also adjusted for weather variables. Results: Mean age was 72±15 years and 51.0% were female. Overall, PM 2.5 increases at a lag of 0 days, 1 day, 3-day moving average (mAvg) (days 0-2), and 7-day mAvg (days 0-6) were associated with all-cause hospitalization [respectively: odds ratio (OR)=1.010, 1.008, 1.011, 1.009 per +10 μg/m 3 ; p=0.0004, 0.006, 0.0004, 0.028]. Associations differed by seasons (Figure). Regressions entering both ozone and PM 2.5 mildly increased PM 2.5 ORs for all-cause hospitalization. PM 2.5 was not associated with first AF diagnosis. Increases in ozone were not associated with higher risk of any outcome. Conclusions: Short-term increases in PM 2.5 air pollution were associated with all-cause hospitalization in patients with a prior AF diagnosis. Lag structure varied for wildfire and inversion seasons, with greater effect sizes in wildfire season. Increases in ozone did not associate with elevated risk.

Abstract 12823: As Anticoagulation Use Increases, Embolic Events Downtrend in Atrial Fibrillation Hospitalizations

Background: Direct oral anticoagulants and Left atrial appendage closure (LAAC) were approved for use in 2010 and 2015, respectively. Data on temporal changes in stroke prevention strategies and rates of embolic complications in atrial fibrillation (AF) in the 2010s decade are limited. Aims: Describe trends in long-term anticoagulation (AC), LAAC use, and in-hospital AF associated ischemic stroke (IS), transient ischemic attacks (TIA), and systemic embolic events (SEE) between 2010 and 2019. Methods: The national inpatient database was used to identify patients with AF from 2010 to 2019. Data were divided into 2 eras: 2010-2014 and 2015-2019. Results: A total of 40,787,136 inpatients with AF were identified: prevalence increased from 18,594,372 in 2010 to 2014 (46%; mean [SD] age 75.5 [12.0] years; 50.3% male) to 22,192,764 in 2015 to 2019 (54%; mean [SD] age 75.1 [11.8] years; 52.5% male). There was a marked increase in long-term AC use (27.2% to 40.2%; P=0.001) and rates of percutaneous LAAC procedures (0.01% to 0.6%; P <0.001) from 2015 to 2019. IS rates among patients with AF increased from 2010 to 2014 (3.5% to 3.8%; P=0.04), with no significant temporal change from 2015 to 2019 (P=0.84). TIA rates declined from 2010 to 2014 (1.2% to 1.0%; P=0.017) and continued a downtrend from 2015 to 2019 (0.9% to 0.7%; P=0.002). There was no temporal change in SEE or the composite outcome of all embolic events from 2010 to 2014, followed by a decline from 2015 to 2019 in SEE (0.5% to 0.4%; P 0.012) and all embolic events (5.1% to 4.8%; P 0.026) ( Figure 1 ). Mean rates of major bleeding events increased from 5.7% in 2010-2014 to 9.1% in 2015-2019 (P <0.001). Conclusion: In an inpatient AF population, the composite outcome of all embolic events and specifically SEE downtrend from 2015 to 2019, likely due to increased AC use. Further data assessing the risk-benefit ratio of available therapies for stroke prevention in inpatients with AF - AC and LAAC - are needed to optimize personalized strategies.

Abstract 17940: Effects of Continuous Accelerated Pacing on Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction: Three Year Follow Up of the myPACE Randomized Clinical Trial

Background: Heart failure with a preserved ejection fraction (HFpEF) is prevalent and has few evidence-based therapies. In a trial of HFpEF patients with specialized pacemakers, an accelerated personalized pacing rate averaging 75 bpm (myPACE) improved quality of life, NT-proBNP, physical activity, and atrial fibrillation burden compared with the standard lower rate setting of 60bpm (usual care). The one-year myPACE trial was not powered for clinical outcomes, but most patients elected to remain on their assigned treatment. Methods: The myPACE study was a single-center, blinded, randomized controlled trial that enrolled patients from June 2019 to November 2020. In this per-protocol analysis of clinical events over a 3-year follow-up, we included trial participants who remained on their assigned heart rate after study completion. The outcome of this analysis is a composite of the first clinical event (urgent visit or hospitalization for heart failure or atrial fibrillation, unstable angina or myocardial infarction, stroke, and death). Events were obtained by chart review and adjudicated by two blinded investigators. A Kaplan-Meier event-free survival plot and a log-rank test evaluated differences between the two treatment arms. Results: Of the 100 myPACE trial participants, most (40/48 myPACE and 48/52 usual care) remained on their assigned heart rate over a median (IQR) of 3.3 (2.6, 3.7) years after enrollment. The median (IQR) age was 75(69-80), and 45% were female. Accelerated personalized pacing was associated with reduced adverse clinical outcomes by about 60 percent. The Kaplan-Meier event-free survival plot for the composite of clinical events is shown in the Figure. Conclusions: In a per-protocol clinical event analysis of the extended myPACE study, those who continued the myPACE accelerated pacing protocol had fewer adverse clinical events than those with a lower rate setting of 60 bpm.

Abstract 12614: Procedural Volume and Outcomes With Atrial Fibrillation Ablation: A Report From the NCDR AFib Registry

Introduction: Operator and hospital procedure volumes are associated with outcomes in many cardiac procedures. Objective: To determine the association between hospital/physician procedural volume and safety/success for atrial fibrillation (AF) ablation in the current era. Methods: Procedures reported to the NCDR AFib Registry between 7/2019 to 6/2022 were analyzed. Physician and hospital procedural volumes were annualized and stratified into quartiles (Q) to compare procedural success and major adverse events (MAE). Three level hierarchical (patient, hospital and physician) generalized linear models were used to assess the adjusted relationship between procedural volume and likelihood of acute outcomes. Results: A total of 70,296 first time AF ablation patients' at 186 US hospitals were studied. Mean age was 66.1 ± 10.3 years. 36% were women; mean CHA2DS2-VASc score was 2.7±1.6, and 57.4% were of paroxysmal AF. The median annual procedural volumes for hospitals and physicians were 230 and 66 respectively. Acute procedural success was 98.5% and the MAE rate was 1.0%. With Q4 (highest) hospital procedural volume as a reference, the adjusted likelihood of procedural success was significantly less among Q1 (OR: 0.44, CI: 0.3-0.7), Q2 (OR:0.50, CI:0.3-0.8) and Q3 (OR:0.60,CI:0.4-0.9). Similarly, for physician volume, the adjusted likelihood of success was less among Q1 (OR: 0.38,CI: 0.3-0.5), Q2 (OR: 0.51,CI: 0.4-0.7) and Q3 (OR:0.55,CI:0.4-0.7). With regards to MAE, compared to Q4, there was an inverse relationship to procedural volume for hospitals in Q1 (OR: 1.78, CI:1.3-2.5) but not in Q2 (OR: 1.06, CI 0.8-1.5) or Q3 (OR: 1.19, CI: 0.9-1.6) and for physicians in Q1 (OR: 1.93, CI 1.4-2.6) and Q2 (OR:1.49, CI: 1.1-2.0) but not in Q3 (OR: 1.22, CI: 0.9-1.6)(figure). Conclusions: In this national cohort of first time AF ablations, hospital and physician procedural volume were directly related to acute procedural success and inversely related to the rate of MAE.

Abstract 15327: Clinical Outcomes of Methamphetamine-Associated Cardiomyopathy Compared to Ischemic Cardiomyopathy: A Single Institution Retrospective Longitudinal Study

Background: Methamphetamine-associated cardiomyopathy (MAC) leads to significant morbidity and mortality. The benefit of implantable cardioverter-defibrillator (ICD) in this population is poorly characterized. Aims: To evaluate ICD use and outcomes in patients with MAC compared to ischemic cardiomyopathy (ICM). Methods: Electronic health record (EHR) was queried for all heart failure hospitalizations using ICD-9 codes between 2011 and 2019. Patients with an EF ≤ 35% were included. The MAC cohort was derived from this population and defined by ICD-9 code or positive urine toxicology and compared to ICM cohort. Baseline characteristics and outcomes were extracted from the EHR. MACE was defined as death, ventricular tachycardia, cardiac arrest, rehospitalization, atrial fibrillation (AF) or stroke. Results: The study included 294 patients in the MAC group and 373 patients in the ICM group. MAC patients were younger (56 vs 61 years, p<0.001) compared to ICM (table 1). Readmission rates for heart failure at one year were similar (13% vs 11.2%, p=ns). Significantly fewer patients with MAC had ICD for primary prevention (15.0% vs 27.9%, p<0.001). Mortality and AF were lower in MAC compared to ICM, however VT (2.38% vs 5.09%, p=0.072) and cardiac arrest (6.1% vs 7.8%, p=0.408) were similar between the two groups. MACE outcomes were worse in the ICM cohort (38.3% vs 21.1%, p=0.012) than MAC. In the MAC cohort, ICD presence was associated with 56.82% incidence of MACE compared to 40.00% without ICD (OR = 1.97, CI 1.032-3.77, p = 0.040) mainly due to higher AF hospitalization (22% vs 8%, p=0.01). Conclusion: ICM patients had higher mortality and atrial fibrillation compared to MAC. ICD implantation for primary prevention was not associated with reduced mortality, however this cohort had higher AF hospitalization. We need further studies to assess the benefit of ICD in MAC.

Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients With Atrial Fibrillation in the United States.

Among patients hospitalized for atrial fibrillation, the frequency of off-label direct oral anticoagulant (DOAC) dosing, associated factors, hospital-level variation, and temporal trends in contemporary practice are unknown. Using the Get With The Guidelines-Atrial Fibrillation registry, patients admitted from January 1, 2014, to March 31, 2020, and discharged on DOACs were stratified according to receipt of underdosing, overdosing, or recommended dosing. Factors associated with off-label dosing (defined as underdosing or overdosing) were identified using logistic regression. Median odds ratio (OR) and time-series analyses were used to assess hospital-level variation and temporal trends, respectively. Of 22 470 patients (70.1±12.1 years, 48.1% female, 82.5% White) prescribed a DOAC at discharge from hospitalization for atrial fibrillation (66% apixaban, 29% rivaroxaban, and 5% dabigatran), underdosing occurred among 2006 (8.9%), overdosing among 511 (2.3%), and recommended dosing among 19 953 (88.8%). The overall rate of off-label dosing was 11.2%. Patient-related factors associated with off-label dose included age (underdosing: OR, 1.06 per 1-year increase [95% CI, 1.06-1.07]; overdosing: OR, 1.07 per 1-year increase [95% CI, 1.06-1.09]), dialysis dependence (underdosing: OR, 5.50 [95% CI, 3.76-8.05]; overdosing: OR, 5.47 [95% CI, 2.74-10.88]), female sex (overdosing: OR, 0.79 [95% CI, 0.63-0.99]), and weight (overdosing: OR, 0.96 per 1-kg increase [95% CI, 0.95-1.00]). Across hospitals, the adjusted median OR for off-label DOAC dose was 1.45 (95% CI, 1.34-1.65; underdosing: OR, 1.52 [95% CI, 1.39-1.76]; overdosing: OR, 1.32 [95% CI, 1.20-1.84]), indicating significant hospital-level variation. Over the study period, recommended dosing significantly increased over time (81.9%-90.9%; P<0.0001 for trend) with a corresponding decline in underdosing (14.4%-6.6%; P<0.0001 for trend) and overdosing (3.8%-2.5%; P=0.001 for trend). Over 1 in 10 patients hospitalized for atrial fibrillation are discharged on an off-label DOAC dose with significant variation across hospitals. While the proportion of patients receiving recommended dosing has significantly improved over time, opportunities to improve DOAC dosing persist.

Relationship of health-related social needs and hospital readmissions in patients following a hospitalization for atrial fibrillation

Atrial fibrillation (AF) has a high economic burden on the healthcare system with rehospitalizations as the most significant contributing factor necessitating an understanding of aspects related to hospitalizations to minimize economic costs and improve patient outcomes. Our study aims to assess whether all-cause 30-day hospital readmission following AF-specific hospitalization is associated with health-related social needs (HRSN) using the Nationwide Readmissions Database (NRD). All hospitalization data were abstracted from the 2015–2019 NRD, including hospitalizations for patients at least 18 years of age with a primary discharge diagnosis of AF. For each hospitalization, we identified secondary diagnoses for five HRSN domains including employment, family, housing, psychosocial, and socioeconomic status. Primary outcomes included all-cause 30-day readmission rates. Secondary outcomes included all-cause 90-day readmissions and diagnosis on readmissions. An estimated 1,807,460 index hospitalizations in the United States included a primary discharge diagnosis of AF. Of these, 97.3 % included a diagnosis in only one HRSN domain with the most frequently diagnosed HRSN domain being housing (54.5 %) followed by socioeconomic (29.4 %), family (10.0 %), employment (6.1 %), and psychosocial (2.8 %). Index hospitalizations that included any HRSN diagnosis had 2.2-times greater unadjusted odds of all-cause 30-day readmission (95 % CI: 2.1 to 2.3-times greater, p < .001). Index hospitalizations that included an HRSN diagnosis were associated with higher rates of 90-day readmission due to conduction disorder and COPD. In conclusion, there is a significant association between HRSN and hospital readmissions in patients with AF. Further research is required to explain the true nature of this relationship with a specific emphasis on housing insecurity.

Trends in Atrial Fibrillation Management—Results from a National Multi-Center Urgent Care Network Registry

Background: Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). Objectives: We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. Methods: This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. Results: In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43–2.45), p &lt; 0.001), evening or night shifts (OR 1.31 (95% CI 1.11–1.55), p &lt; 0.001; OR 1.68 (95% CI 1.32–2.15), p &lt; 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26–0.37), p &lt; 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46–0.67), p &lt; 0.001), beta blockers (OR 0.63 (95% CI 0.52–0.76), p &lt; 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48–0.69), p &lt; 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. Conclusions: The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.

Colchicine for the Prevention of Recurrent Arrhythmia After Catheter Ablation of Atrial Fibrillation: Results of a Single-Center, Retrospective Study.

There is evidence to suggest that colchicine reduces the risk of recurrent atrial fibrillation (AF) after catheter ablation; however, the tolerability and safety of colchicine in routine practice is unknown. Patients undergoing catheter ablation for AF who received colchicine after ablation were matched 1:1 to patients who did not by age, sex, and renal function. Recurrent AF was compared between groups categorically at 12months and via propensity weighted Cox proportional hazards models with and without a 3-month blanking period. Overall, 180 patients (n=90 colchicine and n=90 matched controls) were followed for a median (Q1, Q3) of 10.3 (7.0, 12.0) months. Mean age was 65.3 ± 9.1 years, 33.9% were women, mean CHA2DS2-VASc score was 2.9 ± 1.5, and 51.1% had persistent AF. Most patients (70%) received colchicine 0.6mg daily for a median of 30days. In the colchicine group, 55 patients (61.1%) were receiving at least one known interacting medication with colchicine. After ablation, one patient required colchicine dose reduction and four patients required discontinuation. After adjusting for covariate imbalance using propensity weighting, no significant association between colchicine use and AF recurrence was identified (adjusted hazard ratio 0.94, 95% confidence interval [CI] 0.48-1.85; p=0.853). No significant association was found between colchicine use and all-cause hospitalizations (adjusted odds ratio 0.74, 95% CI 0.28-1.96; p=0.548). Despite the frequent presence of drug-drug interactions, a 30-day course of colchicine is well-tolerated after AF ablation; however, we did not observe any association between colchicine and lower rates of AF recurrence or hospitalization.

Cardiovascular Hospitalizations and Resource Use Following Atrial Fibrillation Ablation.

Background Over the next few years, atrial fibrillation (AF)-related morbidity and costs will increase significantly. Thus, it is prudent to examine the impact of AF treatment on health care resource use. This study examined the impact of AF ablation on hospitalization, length of stay, and resource use for patients undergoing AF ablation in a multihospital system. Methods and Results In an observational analysis, outcomes of total, cardiovascular, and AF hospitalizations, emergency department visits, and length of stay were compared for 3417 patients between 12 months before and 24 months following AF ablation. Use of electrical cardioversions and antiarrhythmic use were also compared 1 year before to 2 years after AF ablation. There were fewer total (0.7±1.3 versus 0.3±0.7; P<0.001), cardiovascular (0.7±1.2 versus 0.2±0.6; P<0.001), and AF (0.6±1.1 versus 0.1±0.3; P<0.001) hospitalizations and emergency department visits (0.8±2.1 versus 0.4±0.9; P<0.001) per patient-year for the 2 years following AF ablation compared with 1 year before. Average length of stay per patient-year (1.4±7.9 versus 3.6±5.3 days; P<0.0001), the percentage of patients on antiarrhythmic therapy (21.2% versus 58.5%; P<0.0001), and those undergoing electrical cardioversions (16.1% versus 28.1%; P<0.0001) were lower 2 years following AF ablation versus 1 year before. Conclusions We noted a decrease in total, cardiovascular, and AF hospitalizations and health care resource use during the 2-year period after index AF ablation, compared with the 1 year before. AF ablation may portend a decline in patient morbidity and health care costs.

The Impact of Age on the Epidemiology and Cost of Atrial Fibrillation Hospitalizations

Atrial fibrillation (AF) is the most common arrhythmia and increases with age. This rising prevalence of AF is contributing to an increasing public health and economic burden. The 2018 Healthcare Cost and Utilization Project National Inpatient Sample dataset was used. All patients ≥15years with a principal discharge diagnosis of AF were included. The patient population was divided into an "older" cohort (aged ≥65years) and a "younger" (aged <65years). Desired outcomes included hospital length of stay, discharge disposition, hospital charges, and in-hospital mortality. A generalized linear mixed model was used to calculate hospitalization rates for the "younger" and "older" groups. We identified 896,328 AF hospitalizations. Younger patients (18.1%) were more likely to be male (65.5% vs 49.9%), to smoke (21.6% vs 6.1%), and to use alcohol (9.7% vs 2.1%). Older patients were more likely to have heart failure (49.6% vs 43.9%) and hypertension (84.6% vs 76.1%). Hospitalization rates increased with increasing age groups. Older patients had higher in-hospital mortality (4.6% vs 2.9%) and were more likely to be discharged to another facility (31.6% vs 13.2%). AF hospitalization rates vary between hospitals across the United States. Hospital divisions with greater than expected admissions for AF, when compared with the national mean, were driven by higher "older" patient hospitalizations. In conclusion, older patients account for most AF hospitalizations. Older patients have higher AF morbidity and mortality. Hospitalization rates for AF increase with increasing increments of age.

Protein-Energy Malnutrition Is Associated with Worse Outcomes in Patients with Atrial Fibrillation: A Nationwide Analysis.

Protein-energy malnutrition (PEM), which leads to a reduced ability of tissues to regenerate and repair themselves, may exacerbate many chronic diseases, including atrial fibrillation (AF), which occurs as a response of the heart to chronic inflammation. However, population-based studies examining the association between PEM and the prevalence and health care burden of AF are lacking. The aim of this retrospective cohort study was to estimate the impact of PEM on the prevalence and clinical outcomes of hospitalization for AF. The National Inpatient Sample (NIS) 2016 and 2017 datasets were searched for data on hospitalized adult patients with AF as a principal diagnosis; we subsequently identified AF patients with and without PEM as a secondary diagnosis using International Classification of Diseases, Tenth Revision (ICD-10), codes. The primary outcome of our study was inpatient mortality, while the secondary outcomes were hospital length of stay (LOS), total hospital cost (THC), cardiogenic shock, pacemaker insertion, successful ablation, and restoration of cardiac rhythm. Propensity score-weighted analysis was used accordingly to adjust for confounders. Out of 821,630 AF hospitalizations, 21,385 (3%) had PEM. Hospitalization for AF with PEM led to a statistically significant increase in mortality (adjusted odds ratio [aOR], 2.30; 95% confidence interval [CI], 1.93-2.75; P < .001) with an adjusted increase in the THC of $15,113 (95% CI, 11,246-18,980; P < .001), a 2-day increase in the LOS (95% CI, 1.92-2.41; P < .001), increased odds of cardiogenic shock (aOR, 1.36; 95% CI, 1.01-1.85; P = .04), and decreased odds of undergoing successful ablation (aOR, .71; 95% CI,.56-.88; P = .002) and achieving the restoration of cardiac rhythm (aOR, 0.56; 95% CI, 0.49-0.0.63; P ≤ .001) compared to those without PEM. These results indicate that PEM is associated with worse in-hospital outcomes in patients with AF. This potential association suggests that nutritional rehabilitation may be essential for improving hospitalization outcomes in AF patients.

Implementation of an Atrial Fibrillation Decision Aid Care Pathway in the Emergency Department Reduces Atrial Fibrillation Hospitalizations.

A straightforward decision aid to guide disposition of atrial fibrillation (AF) patients in the emergency department (ED) was developed for use by ED providers. The implementation of this decision aid in the ED has not been studied. A pragmatic stepped-wedge cluster approach for analysis of retrospectively collected electronic health record data was used in which 5 hospitals were selected to commence the intervention at periodic intervals following an initial 1-year baseline assessment with 5 additional hospitals included in the comparison group (all in North Carolina). The primary end point of analysis was hospitalization rate. Hierarchical multivariable logistic regression analyses for admission as a function of the intervention while controlling for prespecified patient and hospital predictors were performed with clustering done at the hospital level. Between October 2017 and May 2020, a total of 11 458 patients (mean age, 71.4; 50.5% female) presented to 1 of the 10 hospitals with a primary diagnosis of AF. Absolute admission rate was reduced from 60.5% to 48.3% following the intervention (odds ratio, 0.83 [95% CI, 0.71-0.97]; P=0.016). After adjusting for covariates, the intervention was associated with a small increased rate of return to the ED for AF within 30 days of the initial presentation (1.6% to 2.7%; hazard ratio, 1.70 [95% CI, 1.26-2.31]; P<0.001). We demonstrate that implementation of a novel decision aid to guide disposition of patients primary diagnosis of AF presenting to the ED was associated with a reduced admission rate independent of patient and hospital factors. Use of the protocol was associated with a small but significant increase in rate of repeat presentations for AF at 30-day follow-up. Use of a decision aid such as the one described here represents an important tool to reduce unnecessary AF hospitalizations.

Effect of sodium glucose cotransporter 2 inhibitors on atrial tachy-arrhythmia burden in patients with cardiac implantable electronic devices.

Use of sodium glucose cotransporter 2 inhibitors (SGLT2i) was associated with a reduction in atrial fibrillation hospitalizations. Therefore, we aim to evaluate the effects of SGLT2i on atrial tachy-arrhythmias (ATA) in patients with cardiac implantable electronic devices (CIEDs). All 13 888 consecutive patients implanted with a CIED in two tertiary medical centers were enrolled. Treatment with SGLT2i was assessed as a time dependent variable. The primary endpoint was the total number of ATA. Secondary endpoints included total number of ventricular tachy-arrhythmias (VTA), ATA and VTA, and death. All events were independently adjudicated blinded to the treatment. Multivariable propensity score modeling was performed. During a total follow-up of 24 442 patient years there were 62 725 ATA and 10 324 VTA events. Use of SGLT2i (N = 696) was independently associated with a significant 22% reduction in the risk of ATA (hazard ratio [HR] = 0.78 [95% confidence interval {CI} = 0.70-0.87]; p < .001); 22% reduction in the risk of ATA/VTA (HR = 0.78 [95% CI = 0.71-0.85]; p < .001); and with a 35% reduction in the risk of all-cause mortality (HR = 0.65 [95% CI = 0.45-0.92]; p = .015), but was not significantly associated with VTA risk (HR = 0.92 [95% CI = 0.80-1.06]; p = .26). SGLT2i were associated with a lower ATA burden in heart failure (HF) patients but not among diabetes patients (HF: HR = 0.68, 95% CI = 0.58-0.80, p < .001 vs. Diabetes: HR = 0.95, 95% CI = 0.86-1.05, p = .29; p < .001 for interaction between SGLT2i indication and ATA burden). Our real world findings suggest that in CIED HF patients, those with SGLT2i had a pronounced reduction in ATA burden and all-cause mortality when compared with those not on SGLT2i.

Direct-Acting Antivirals and the Risk of Arrhythmias and Conduction Disorders in Patients with Chronic Hepatitis C: A French Nationwide Cohort Study.

To quantify the risk of arrhythmias and conduction disorders (ACD) in patients receiving direct-acting antiviral (DAA) therapy for hepatitis C. All individuals aged 18 to 85 years old treated with DAAs between 01 January 2014 and 31 December 2021 were selected from the French national healthcare database (SNDS). Individuals with a history of ACD were excluded. The primary outcome was the incidence of hospitalization or medical procedure for ACD. Marginal structural models were used to adjust for age, sex, medical comorbidities, and concomitant medications. After analyzing 87,589 individuals (median age, 52 years; 60% male) from 01 January 2014 to 31 December 2021, 2131 hospitalizations or medical procedures for ACD were observed over 672,572 person-years (PY) of follow-up. The incidence of ACD was 245/100,000 PY [95% confidence interval (CI), 228-263/100,000 PY] before DAA and 375/100,000 PY (95% CI 355-395/100,000 PY) after DAA exposure (rate ratio 1.53; 95% CI 1.40-1.68; P < 0.001). The risk of ACD was increased after DAA exposure, compared with the pre-DAA period (adjusted hazard ratio,1.66; 95% CI 1.43-1.93; P < 0.001). The increase in ACD risk was similar among individuals treated with sofosbuvir-based and sofosbuvir-free regimens. Of the 1398 ACD detected after DAA exposure, 30% were hospitalizations for atrial fibrillation, 25% were medical procedures for ACD, and 15% were hospitalizations for atrioventricular blocks. A significant increase in the risk of ACD was observed in the population-level cohort of individuals treated with DAAs, regardless of the regimen. Further research is needed to identify patients at risk of ACD, determine cardiac monitoring strategies, and evaluate the need for Holter monitoring after DAA therapy.

Weekend atrial fibrillation hospitalizations are associated with higher short-term mortality

Background Previous investigations have analysed the relationship between weekend (WE) admission and early death in patients with atrial fibrillation (AF) patients without reaching univocal results. We systematically reviewed the available literature and performed a meta-analysis of data from cohort studies to estimate the association between WE admission and short-term mortality in AF patients. Methods This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. We searched relevant publications using MEDLINE and Scopus from inception until 15 November 2022. Studies reporting the mortality risk as an adjusted odds ratio (OR), with relative 95% confidence interval (CI) comparing early (in‐hospital or 30‐day) mortality between patients admitted during the WE (Friday to Sunday) versus weekdays (WD) and having confirmed AF were included into the analysis. Data were pooled using a random-effects models with OR and related 95% CI. Results Overall, 5.164.986 AF patients (mean age 69.7 years old, 47.6% males) enrolled in five retrospective investigations were considered for the analysis. A random-effect model evidenced that AF patients admitted during the WE had a higher risk of 30-day or in-hospital death (adjusted OR: 1.57; 95% CI, 1.05–1.27, p = .003, I2 = 64.7%). Sensitivity analysis confirmed yielded results. A meta-regression analysis showed a relationship between mortality and the mean age of the studies included (p = .001) while no associations were identified using sex as moderating variables (p = .15). Conclusions Patients admitted during WE for AF are characterised by an approximately 58% excess in the risk of early death.

Care Fragmentation Following Hospitalization for Atrial Fibrillation in the United States

BackgroundDespite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied. ObjectivesThe present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined. MethodsAll adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization. ResultsOf an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs. ConclusionsCF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.

CAROTID PLAQUE OFFSETS THE SEX DIFFERENCE IN CARDIOVASCULAR RISK IN YOUNG TO MIDDLE AGE HYPERTENSIVE PATIENTS: THE CAMPANIA SALUTE NETWORK

Objective: The aim of the present study is to assess whether presence of carotid artery plaque (CP) has a similar impact on the sex difference in risk for future cardiovascular events. Design and method: we studied 5209 women and men &lt;65 years old with hypertension and free from prevalent cardiovascular disease enrolled in the prospective Campania Salute Network registry were followed over a mean of 5.9 years. Subjects were grouped according to the absence or the presence of CP identified by Doppler ultrasound (intima-media thickness&gt;15mm). Main outcome was major cardiovascular events (MACE; combined acute coronary syndromes, stroke, hospitalization for heart failure and incident atrial fibrillation). Results: Among patients without CP (n = 3139), women were older, with higher systolic BP, cholesterol level and prevalent LVH but lower triglycerides and eGFR, compared to men (all p&lt;0.001). Among patients with CP (n = 2070), women were older, taking higher number of antihypertensive drug, with higher cholesterol level and prevalent LVH but lower triglycerides and eGFR compared to men (all p&lt;0.001). In Cox regression analysis adjusting for cardiovascular risk factors, LVH and antihypertensive treatment during follow up women without CP had lower hazard rate (HR = 0.41) for MACE (n = 107) than men (95% confidence interval [CI] 0.39–0.89, p = 0.01). In contrast, among patients with CP, women had similar HR for MACE (n = 132) as men (HR 0.79 [95% CI 0.54–1.14], p = 0.203). Conclusions: This study demonstrates that presence of carotid organ damage in hypertension contributes to offset the female sex-protection in cardiovascular risk. Thus, expanding previous finding, young to middle-age women and men with hypertension and carotid organ damage have comparable cardiovascular risk.

Left Atrial Volume Quantified by MSCT Predicts Emergency Hospitalizations for AF and Arrhythmia Recurrence after Catheter Ablation

Abstract Introduction This study aimed to investigate the correlation between multislice computed tomography (MSCT)-derived parameters characterizing atrial enlargement and the frequency of emergency hospitalizations after catheter ablation for atrial fibrillation (AF). Methods The study included 52 patients with paroxysmal or persistent AF, who presented criteria for interventional rhythm control strategies and underwent MSCT evaluation prior to ablation. Results The majority of emergency hospital admissions were due to heart failure caused by high-frequency arrhythmia (90.33%), or by cardioembolic complications, causing acute stroke (9.67%). The number of emergency referrals was significantly increased in cases of moderately enlarged left atrial volume (69.23%), and re-admission was necessary for over three quarters of the patients with highly enlarged left atrial volume (76.92%, p = 0.02). The average recurrence rate of AF following ablation therapy was 28.84% during the one-year follow-up, being 0% for volumes &lt;71.33 mL, 32% for volumes between 71.33 mL and 109.5 mL, and 53.84% for volumes &gt;109.5 mL (p = 0.01). Conclusion A large volume of the left atrium, determined by MSCT, is associated with a higher risk of emergency rehospitalizations following catheter ablation of AF.

Prophylactic rivaroxaban in the early post-discharge period reduces the rates of hospitalization for atrial fibrillation and incidence of sudden cardiac death during long-term follow-up in hospitalized COVID-19 survivors.

Introduction: While acute Coronavirus disease 2019 (COVID-19) affects the cardiovascular (CV) system according to recent data, an increased CV risk has been reported also during long-term follow-up (FU). In addition to other CV pathologies in COVID-19 survivors, an enhanced risk for arrhythmic events and sudden cardiac death (SCD) has been observed. While recommendations on post-discharge thromboprophylaxis are conflicting in this population, prophylactic short-term rivaroxaban therapy after hospital discharge showed promising results. However, the impact of this regimen on the incidence of cardiac arrhythmias has not been evaluated to date. Methods: To investigate the efficacy of this therapy, we conducted a single center, retrospective analysis of 1804 consecutive, hospitalized COVID-19 survivors between April and December 2020. Patients received either a 30-day post-discharge thromboprophylaxis treatment regimen using rivaroxaban 10mg every day (QD) (Rivaroxaban group (Riva); n = 996) or no thromboprophylaxis (Control group (Ctrl); n = 808). Hospitalization for new atrial fibrillation (AF), new higher-degree Atrioventricular-block (AVB) as well as incidence of SCD were investigated in 12-month FU [FU: 347 (310/449) days]. Results: No differences in baseline characteristics (Ctrl vs Riva: age: 59.0 (48.9/66.8) vs 57 (46.5/64.9) years, p = n.s.; male: 41.5% vs 43.7%, p = n.s.) and in the history of relevant CV-disease were observed between the two groups. While hospitalizations for AVB were not reported in either group, relevant rates of hospitalizations for new AF (0.99%, n = 8/808) as well as a high rate of SCD events (2.35%, n = 19/808) were seen in the Ctrl. These cardiac events were attenuated by early post-discharge prophylactic rivaroxaban therapy (AF: n = 2/996, 0.20%, p = 0.026 and SCD: n = 3/996, 0.30%, p < 0.001) which was also observed after applying a logistic regression model for propensity score matching (AF: χ 2-statistics = 6.45, p = 0.013 and SCD: χ 2-statistics = 9.33, p = 0.002). Of note, no major bleeding complications were observed in either group. Conclusion: Atrial arrhythmic and SCD events are present during the first 12months after hospitalization for COVID-19. Extended prophylactic Rivaroxaban therapy after hospital discharge could reduce new onset of AF and SCD in hospitalized COVID-19 survivors.