Identify Atrial Fibrillation Patients Research Articles

Comparative effectiveness and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients with dementia.

Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia. We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC. There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome. Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.

Lipid control and stroke risk in atrial fibrillation patients treated with direct oral anticoagulants and statins.

The risk of ischemic stroke and intracerebral hemorrhage (ICH) with intensive lipid control by statins among patients with atrial fibrillation (AF) who require direct oral anticoagulants (DOAC) is unclear. We aimed to determine the risks of ischemic stroke and ICH in AF patients treated with DOAC and statins. In a population-based retrospective cohort study, we identified AF patients concurrently on DOAC and statins from 2015 to 2021 in Hong Kong. Primary outcome was ischemic stroke. Secondary outcomes were ICH and death. We correlated study outcomes with low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) as time-varying, continuous variables with restricted cubic spline. In secondary analyses, the risks of study outcomes with statin intensity (low, moderate, high) were determined by multivariable time-dependent marginal structural Cox models. We identified 32,752 AF patients co-prescribed with DOAC and statins. Lower LDL-C (p < 0.001) and higher HDL-C (p < 0.001) levels were associated with lower risk of ischemic stroke but not significantly associated with ICH. LDL-C of <1.8 mmol/L (70 mg/dL) was not associated with mortality (19.6% vs 18.4%, difference 1.2% [95% CI -0.35 to 2.13]). High-intensity statin was associated with a lower risk of ischemic stroke compared with low-intensity statin (weighted Cox-specific hazard ratio [95% CI]: 0.82 [0.67-0.99], p = 0.040) independent of LDL-C levels. Similar associations were found in 11,444 AF patients with a history of ischemic stroke. Intensive lipid control by high-intensity statins was associated with a lower risk of ischemic stroke in AF patients who required DOACs and did not appear to increase the risk of ICH.

Data-driven classification of left atrial morphology and its predictive impact on atrial fibrillation catheter ablation.

Various left atrial (LA) anatomical structures are correlated with postablative recurrence for atrial fibrillation (AF) patients. Comprehensively integrating anatomical structures, digitizing them, and implementing in-depth analysis, which may supply new insights, are needed. Thus, we aim to establish an interpretable model to identify AF patients' phenotypes according to LA anatomical morphology, using machine learning techniques. Five hundred and nine AF patients underwent first ablation treatment in three centers were included and were followed-up for postablative recurrent atrial arrhythmias. Data from 369 patients were regarded as training set, while data from another 140 patients, collected from different centers, were used as validation set. We manually measured 57 morphological parameters on enhanced computed tomography with three-dimensional reconstruction technique and implemented unsupervised learning accordingly. Three morphological groups were identified, with distinct prognosis according to Kaplan-Meier estimator (p < .001). Multivariable Cox model revealed that morphological grouping were independent predictors of 1-year recurrence (Group 1: HR = 3.00, 95% CI: 1.51-5.95, p = .002; Group 2: HR = 4.68, 95% CI: 2.40-9.11, p < .001; Group 3 as reference). Furthermore, external validation consistently demonstrated our findings. Our study illustrated the feasibility of employing unsupervised learning for the classification of LA morphology. By utilizing morphological grouping, we can effectively identify individuals at different risks of postablative recurrence and thereby assist in clinical decision-making.

Effects of SGLT2i on reducing risks of cardiovascular events and dementia in atrial fibrillation patients with diabetes mellitus: a nationwide cohort study

Abstract Background/Introduction Patients with atrial fibrillation (AF) are associated with higher risk for cognitive decline and progression to dementia. There are limited data whether sodium-glucose cotransporter-2 inhibitor (SGLT2i) reduces new-onset cognitive dysfunction, especially in Asian patients with AF who also have diabetes mellitus. Purpose This study aimed to investigate whether SGLT2i reduces the risks of cardiovascular events and dementia among AF patients with diabetes. Methods We identified AF patients with diabetes based on the Taiwan's National Health Insurance Research Database (2016). AF patients without prior dementia history and aged 55-85 years were studied: 810 patients were prescribed SGLT2i for at least 180 days and were matched with 1620 patients without SGLT2i using propensity scores (Figure 1). Cardiovascular and dementia events were followed through the end of 2021. Subtypes of dementia were investigated using competing risk models. Results During a follow-up period of 5 years of AF patients with diabetes receiving SGLT2i, as shown in Figure 2, this study provides a detailed insight into the results of survival analyses for clinical outcomes of AF, stroke, total dementia, vascular dementia, all-cause death, and cardiovascular (CV) death. After multivariable adjustment, the risks of AF-related hospitalization (HR: 0.741, 95% CI: 0.563-0.976), stroke (HR: 0.748, 95% CI: 0.599-0.934) and all-cause death (HR: 0.338, 95% CI: 0.245-0.466), were significantly decreased. Both CV death (HR: 0.449, 95% CI: 0.268-0.755) and non-CV death (HR: 0.298, 95% CI: 0.198-0.448) were significantly reduced. SGLT2i use was associated with a significantly decreased risk of total dementia (HR: 0.615, 95% CI: 0.436-0.869) and vascular dementia (HR: 0.419, 95% CI: 0.221-0.793). The reduced risks of Alzheimer’s dementia and other/mixed dementia were not statistically significant. After multivariable adjustment, total dementia and vascular dementia were associated with higher age and stroke events. The beneficial effect on dementia was irrespective of novel oral anticoagulants (NOAC) use, although the SGLT2i benefits were greater in non-warfarin and non-dipeptidyl peptidase 4 (DPP4) users compared to users. Conclusions There were decreased risks of AF-related hospitalization, stroke event, all-cause death, and vascular dementia in the users of SGLT2i in AF patients with diabetes. This was irrespective of NOAC use, although the SGLT2i benefits were greater in non-warfarin users compared to warfarin users.Figure 1:Study flow chart

Safety and healthcare resource utilisation in patients undergoing left-atrial appendage closure - A nationwide analysis

Abstract Background Percutaneous left-atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. Purpose To analyse outcomes of peri-procedural in-hospital safety and healthcare resource utilisation after percutaneous LAAC. Methods The US National Inpatient Sample was utilised to identify AF patients undergoing LAAC from 2016 to 2019. Primary outcomes (safety) were in-hospital stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolisation and mortality. Secondary outcomes (resource utilisation) were adverse discharge disposition, hospital length of stay (LOS) and treatment costs. Logistic and Poisson regression models were used to analye outcomes by adjusting for 10 confounders. Results 11,240 adult patients (with 41.9% being female) with AF undergoing LAAC were included. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (P=0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality remained stable (0.14%). Hospital LOS decreased by 18% (0.78-0.87, P&amp;lt;0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, P=0.005) between 2016 and 2019, while hospital costs did not significantly change (P=0.2). Of note, female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]), while patients with multiple comorbidities had higher risks of major bleeding (P&amp;lt;0.001), mortality (P=0.031), longer hospital LOS (P&amp;lt;0.001) and increased treatment costs (P=0.073). Male patients had the most peculiar decrease in adverse discharge rate between 2016 and 2019: OR 0.45 [95% CI 0.27-0.77]. Significant differences in all outcomes were observed between male and female patients across US regions (Figure). Subgroup analyses confirmed that female patients had a prolonged LOS and higher risk of adverse discharge disposition than male patients. Conclusions LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.

Abstract 18371: Evaluation of the Atrial Fibrillation Better Care Pathway in Patients With Atrial Fibrillation: A Machine Learning Cluster Analysis

Background: Atrial fibrillation Better Care (ABC) pathway is recommended by guidelines on atrial fibrillation (AF) and exerts a protective role against adverse outcomes of AF patients. We hypothesize that cluster analysis, an unsupervised machine learning technique, could comprehensively evaluate multiple clinical characteristics of patients, and define clusters of ABC criteria efficacy in patients with AF. Methods: We used data from an observational cohort that included 2,016 patients with AF. We utilized 46 baseline variables for cluster analysis and got the optimal clusters through the K-prototypes algorithm. We evaluated the management patterns and adverse outcomes of identified phenotypes. We assessed the effectiveness of the ABC criteria in reducing adverse outcomes of these phenotypes. Results: Cluster analysis identified AF patients into three distinct groups with markedly different clinical characteristics and outcomes. The clusters were as followed: Cluster 1, old patients with atherosclerotic-comorbidities (n = 964); Cluster 2, young females with valve-comorbidities (n = 407), and Cluster 3, paroxysmal AF patients with low comorbidities (n = 644). The clusters showed significant differences in MACNE, all-cause death, stroke, cardiovascular death, and hospital readmission for heart failure. All clusters showed that full adherence to the ABC pathway was associated with a significant reduction in the risk of MACNE (all P&lt; 0.05). Adherence to the different ‘A’/’B’/’C’ criteria alone showed differential clinic impact for three clusters. Conclusion: Cluster analysis of the Chinese AF cohort further elucidated the heterogeneity of AF. We proposed suggestions for optimizing risk stratification and integrated management of AF patients.

Thromboembolic and bleeding complications during interruptions and after discontinuation of anticoagulant treatment in patients with atrial fibrillation and active cancer: A daily practice evaluation

Background and aimsCancer provides challenges to the continuity of anticoagulant treatment in patients with atrial fibrillation (AF), e.g. through cancer-related surgery or complications. We aimed to provide data on the incidence and reasons for interrupting and discontinuing anticoagulant treatment in AF patients with cancer and to assess its contribution to the risk of thromboembolism (TE) and major bleeding (MB). MethodsThis retrospective study identified AF patients with cancer in two hospitals between 2012 and 2017. Data on anticoagulant treatment, TE and MB were collected during two-year follow-up. Incidence rates (IR) per 100 patient-years and adjusted hazard ratios (aHR) were obtained for TE and MB occurring during on- and off-anticoagulant treatment, during interruption and after resumption, and after permanent discontinuation. Results1213 AF patients with cancer were identified, of which 140 patients permanently discontinued anticoagulants and 426 patients experienced one or more interruptions. Anticoagulation was most often interrupted or discontinued due to cancer-related treatment (n = 441, 62 %), bleeding (n = 129, 18 %) or end of life (n = 36, 5 %). The risk of TE was highest off-anticoagulation and during interruptions, with IRs of 19 (14–25)) and 105 (64–13), and aHRs of 3.1 (1.9–5.0) and 4.6 (2.4–9.0), respectively. Major bleeding risk were not only increased during an interruption, but also in the first 30 days after resumption, with IRs of 33 (12–72) and 30 (17–48), and aHRs of 3.3 (1.1–9.8) and 2.4 (1.2–4.6), respectively. ConclusionsInterruption of anticoagulation therapy harbors high TE and MB risk in AF patients with cancer. The high incidence rates call for better (periprocedural) anticoagulant management strategies tailored to the cancer setting.

External validation of AF-BLEED for predicting major bleeding and for tailoring NOAC dose in AF patients: A post hoc analysis in the ENGAGE AF-TIMI 48

ObjectiveAF-BLEED, a simple bleeding risk classifier, was found to predict major bleeding (MB) in patients with atrial fibrillation (AF) and identify AF patients at high risk of MB who might potentially benefit from a lower direct oral anticoagulant dose. This post hoc study aimed to externally validate these findings in the ENGAGE AF-TIMI 48 (Effective aNticoaGulation with factor Xa next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction study 48) trial. MethodsThe ENGAGE AF-TIMI 48 trial randomized AF patients to higher-dose edoxaban regimen (HDER 60/30 mg) versus lower-dose edoxaban regimen (LDER 30/15 mg), with prespecified dose reduction criteria. AF-BLEED was calculated in the modified intention-to-treat cohort (n = 21,026 patients) used for primary outcome analysis. Annualized event rates and hazard ratios (HRs) were obtained for the primary composite outcome (PCO) and its single components (MB, ischemic stroke/systemic embolism and death) to compare LDER 30 mg with HDER 60 mg in both AF-BLEED classes. ResultsAF-BLEED classified 2882 patients (13.7 %) as high-risk, characterized by a two- to three-fold higher MB risk than AF-BLEED classified low-risk patients. AF-BLEED classified high-risk patients randomized to LDER 30 mg demonstrated a 3.3 % reduction in MB at the cost of a 0.5 % increase in ischemic stroke/systemic embolism. LDER 30 mg resulted in a 3.1 % reduction of PCO compared to HDER 60 mg (HR of 0.81; 95%CI 0.65–1.01). Additional to existing dose reduction criteria, another 6 % of patients could potentially benefit of this dose adjustment strategy. ConclusionAF-BLEED could identify AF patients to be at high risk of major bleeding. Our findings support the hypothesis that LDER 30 mg might provide a reasonable option in AF patients with legitimate bleeding concerns.

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.

Atrial fibrillation-specific refinement of the STOP-Bang sleep apnoea screening questionnaire: Insights from the Virtual-SAFARI study

Abstract Funding Acknowledgements Type of funding sources: None. Purpose Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients undergoing atrial fibrillation (AF) ablation. Currently, it remains unclear whether all AF patients should be systematically screened for SDB, or whether pre-selection of patients requiring screening can be improved. We aimed 1) to assess the accuracy of the STOP-Bang screening questionnaire as a tool for detecting SDB in patients scheduled for AF ablation; and 2) to develop a refined, AF-specific version of the STOP-Bang to improve pre-selection. Methods Consecutive patients scheduled for AF ablation without a previous history of SDB and/or SDB screening were included. Patients were digitally referred to the previously described Virtual-SAFARI SDB screening and management pathway1 including a home sleep test using polygraphy. An apnoea-hypopnoea-index (AHI) of ≥15 was interpreted as moderate-to-severe SDB. The accuracy of the STOP-Bang questionnaire (Snoring, Tiredness, Observed apneas, blood Pressure, BMI ≥35 kg/m², Age, Neck circumference, and Gender) was evaluated. Logistic regression was used to assess characteristics within and outside the STOP-Bang questionnaire associated with moderate-to-severe SDB. These characteristics were used to refine the STOP-Bang specifically for AF patients. Results Of 206 included patients, 51% was diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (0.573-0.721). AF-specific refinement of the STOP-BANG resulted in the BOSS-GAP score. Therein, tiredness and neck circumference were removed, while body mass index with cut-off point ≥27 kg/m² and previous stroke or transient ischaemic attack were added. The BOSS-GAP questionnaire performed better with an AUROC of 0.738 (0.672-0.805) in the overall population. Conclusion The STOP-Bang questionnaire showed limited value when used as a pre-selection tool for SDB screening. The refined, AF-specific BOSS-GAP questionnaire demonstrated slightly improved, but still limited accuracy in identifying AF patients with SDB. Whether questionnaires bring an advantage in pre-selection for SDB screening compared to structural screening in patients with AF, requires further study.

Analysis of the Amplified P-Wave or Artificial Intelligence-Derived P-wave-Analysis Enable Identification of Patients with Atrial Fibrillation during Sinus Rhythm

Abstract Funding Acknowledgements Type of funding sources: None. Introduction / Aims This study sought to develop and validate diagnostic models to identify individuals with atrial fibrillation (AF) using amplified p-wave analysis or neural-network-trained p-wave-analysis during sinus rhythm (SR). Methods 1492 patients (491 healthy controls, 499 with paroxysmal AF and 502 with persistent AF) underwent digital 12-lead-ECG recording during sinus rhythm. The patient cohort was divided into training and validation set in a 3:2 ratio. P-wave indices including duration of standard p-wave (standard PWD; 10mm/mV, 25mm/sec, see ECG in the left panel), amplified digital p-wave (APWD, 60-100mm/mV, 175mm/sec; see ECG in the middle panel) and advanced inter-atrial block (aIAB) along with the parameters body surface area (BSA) and LA diameter (LAD) were used to develop diagnostic models using logistic regression. Each model was developed from the training set and further tested in both training and validation sets for its diagnostic performance in identifying individuals with AF. A neural-network was trained to identify the p-wave and its features (duration, morphology) to differentiate between individuals with known versus those without AF. Results Compared to standard PWD (Reference model, AUC=0.637 and 0.632, for training and validation set, respectively), APWD (Basic model) importantly improved the accuracy to identify individuals with AF (AUC=0.86 and 0.866). The ECG-based model combining APWD, aIAB and body surface area (BSA) further improved the diagnostic performance for AF (AUC=0.892 and 0.885). The integrated model, which further combined left atrial diameter (LAD) with parameters of the ECG-based model, achieved the highest diagnostic performance (AUC=0.916 and 0.902). Notably, the neural network-based p-wave-analysis identified AF patients with high accuracy during sinus rhythm (AUC: 0.85; sensitivity: 77%; specificity: 78%). Conclusions Both, the analysis of amplified p-wave and a neural-network-based automatic p-wave analysis during sinus rhythm allow identification of individuals with atrial fibrillation. The current diagnostic models provide a new basis for identifying individuals at high risk for AF, who would most benefit from AF screening.

Incidence and Complications of Atrial Fibrillation in a Low Socioeconomic and High Disability United States (US) Population: A Combined Statistical and Machine Learning Approach.

Background Poor socioeconomic status coupled with individual disability is significantly associated with incident atrial fibrillation (AF) and AF-related adverse outcomes, with the information currently lacking for US cohorts. We examined AF incidence/complications and the dynamic nature of associated risk factors in a large socially disadvantaged US population. Methods A large population representing a combined poor socioeconomic status/disability (Medicaid program) was examined from diverse geographical regions across the US continent. The target population was extracted from administrative databases with patients possessing medical/pharmacy benefits. This retrospective cohort study was conducted from Jan 1, 2016, to Sep 30, 2021, and was limited to 18- to 80-year age group drawn from the Medicaid program. Descriptive and inferential statistics (parametric: logistic regression and neural network) were applied to all computations using a combined statistical and machine learning (ML) approach. Results A total of 617413 individuals participated in the study, with mean age of 41.7 years (standard deviation “SD” 15.2) and 65.6% female patients. Seven distinct groups were identified with different combinations of low socioeconomic status and disability constraints. The overall crude AF incidence rate was 0.49 cases/100 person-years (95% confidence limit “CI” 0.40–0.58), with the lowest rate for the younger group (temporary assistance for needy family “TANF”) (0.20, 95%CI 0.18–0.21), the highest rates for the older groups (age, blindness, or disability “ABD” duals—1.51, 95% CI 1.31–1.58; long-term services and support “LTSS” duals—1.45, 95% CI 1.31–1.58), and the remaining four other groups in between the lower and upper rates. Based on independent effects after accounting for confounders in main effect modeling, the point estimates of odds ratios for AF status with various clinical outcomes were as follows: stroke (2.69, 95% CI 2.53–2.85); heart failure (6.18, 95% CI 5.86–6.52); myocardial infarction (3.71, 95% CI 3.49–3.94); major bleeding (2.26, 95% CI 2.14–2.38); and cognitive impairment (1.74, 95% CI 1.59–1.91). A logistic regression-based ML model produced excellent discriminant validity for high-risk AF outcomes (c “concordance” index based on training data 0.91, 95%CI 0.891–0.929), together with similar measures for external validity, calibration, and clinical utility. The performance measures for the ML models predicting associated complications with high-risk AF cases were good to excellent. Conclusions A combination of low socioeconomic status and disability contributes to AF incidence and complications, elevating risks to higher levels relative to the general population. ML algorithms can be used to identify AF patients at high risk of clinical events. While further research is definitely in need on this socially important issue, the reported investigation is unique in which it integrates the general case about the subject due to the different ethnic groups around the world under a unified culture stemming from residing in the US.

Outcomes of left atrial appendage occlusion vs. non-vitamin K antagonist oral anticoagulants in atrial fibrillation

BackgroundThe effects of left atrial appendage (LAA) occlusion compared to non-vitamin K antagonist oral anticoagulant (NOAC) therapy in patients with atrial fibrillation (AF) remain unknown.AimsWe aimed to evaluate the outcomes in patients with AF who received LAA occlusion vs. NOAC therapy.MethodsWe utilised data from TriNetX which is a global federated health research network currently containing data for 88.5 million patients. ICD-10 codes were employed to identify AF patients treated with either LAA occlusion or NOAC between 1st December 2010 and 17th January 2019. Clinical outcomes of interest were analysed up to 2 years.Results108,697 patients were included. Patients who underwent LAA occlusion were younger, more likely to be white Caucasian and male, had a greater incidence of comorbidities, and were less likely to be prescribed other cardiovascular medications. Using propensity score matching, the risk of all-cause mortality was significantly lower among patients who received LAA occlusion compared to NOAC therapy [1.51% vs. 5.60%, RR 0.27 (95% CI 0.14–0.54)], but there were no statistical differences in the composite thrombotic or thromboembolic events [8.17% vs. 7.72%, RR 1.06 (95% CI 0.73–1.53)], ischaemic stroke or TIA [4.69% vs. 5.45%, RR 0.86 (95% CI 0.54–1.38)], venous thromboembolism [1.66% vs. 1.51%, RR 1.10 (95% CI 0.47–2.57)] and intracranial haemorrhage [1.51% vs. 1.51%, RR 1.00 (95% CI 0.42–2.39)].ConclusionOverall, LAA occlusion might be a suitable alternative to NOAC therapy for stroke prevention in patients with AF.Graphical abstract

Abstract 10623: Validation of Embolic and Bleeding Risk Scores in Patients with Atrial Fibrillation and Cancer

Introduction: Atrial fibrillation (AF) is common among cancer patients. Anticoagulation can reduce the risk of stroke and systemic embolism in AF patients. However, anticoagulation in patients with cancer can be difficult given unpredictable changes in thrombosis and bleeding risk. Although CHA 2 DS 2 -VASc and HAS-BLED are useful, their predictive performance in patients with cancer is unknown. Hypothesis: CHA 2 DS 2 -VASc and HAS-BLED scores in AF patients with cancer could lead to misclassification. Methods: Overall, 16,056 AF patients between 2014 and 2018 were followed during a median follow-up of 4.9 years, including 1,137 with cancer history. We used C statistic and Brier score for assessing the performance of both scores. Results: Discrimination, assessed with C statistics (assuming death as a competing risk), was similar between cancer and non-cancer anticoagulated patients. However, in non-anticoagulated patients, c-statistic of CHA 2 DS 2 -VASc was poor and significantly lower in non-cancer patients. The overall precision of the CHA 2 DS 2 -VASc score was good throughout the follow-up (Brier score &lt;0.1), both in patients with and without cancer history. Regarding to HAS-BLED score, calibration and discrimination were poor in cancer patients, although without significant differences in comparison with non-cancer patients. In non-anticoagulated cancer patients and in those with active cancer, the embolic risk of CHA 2 DS 2 -VASc score = 1 was similar to CHA 2 DS 2 -VASc score ≥ 2. Only AF patients with cancer and CHA 2 DS 2 -VASc score = 0 presented a truly low risk of embolic events (negative predictive value 100%). A HAS-BLED score &gt; 3 did not identify AF patients with cancer at higher bleeding risk. Conclusions: In AF patients with cancer, neither the CHA2DS2-VASC score nor the HASBLED score were useful for predicting embolic and hemorrhagic events, respectively. However, a CHA 2 DS 2 -VASc score 0 is useful to identify low embolic risk patients with AF and cancer.

Abstract 12344: Impact of Age on Hospital Outcomes Associated With Percutaneous Left Atrial Appendage Occlusion: Insights From a Nationwide Cohort Sample

Introduction: Percutaneous left atrial appendage occlusion (LAAO) has emerged as a proven alternative for thromboembolism prevention in patients with atrial fibrillation (AF) who cannot tolerate long term anticoagulation. The mean age in clinical trials has been less than 75 years. There are limited data on LAAO safety in older patients. Methods: We used the National Inpatient Sample and ICD-10 codes to identify AF patients who underwent LAAO during the years 2016-2018. Patients were grouped by age &lt;75 and ≥ 75 years. We studied baseline characteristics, length of stay, cost, hospital mortality, and other adverse events, including, hematoma, vascular complications, and perforation/tamponade, and stroke/transient ischemic attack in the two groups. Results: Our search criteria identified a total of 6877 patients, of whom 4160 (60.4%) were ≥ 75 years. LAAO increased similarly among patients in both groups (figure1). The average length of stay after LAAO was 1.5 ± 1.9 days for the entire cohort and did not differ for the two groups (p=0.603). Hospitalization costs were $25635.6 ± 12041.5 among patients ≥ 75 years and $26175.6 ± 11768.0 in those &lt; 75 years (P=0.067). There were 10 deaths in patients ≥75 years and 1 death among patients &lt;75 years (p=0.059). Perforation/tamponade was 1.3% among patients ≥75 years vs 0.6% for those &lt;75 years (p=0.008). This difference persisted on multivariate analysis (OR 1.82; 95% CI 1.04-3.17; p=0.036). There was a trend towards higher combined procedure related adverse events (OR 1.46; 95% CI 0.99-2.15; p= 0.059) among patients ≥75 years. There was no difference in the individual components of hematoma, vascular complication, and stroke/TIA between both groups. Conclusions: Percutaneous LAAO was associated with a higher incidence of perforation and tamponade and a concerning trend towards higher in-hospital mortality among older patients. Further clinical investigations are warranted to explore the risk in this vulnerable group.

Antithrombotic therapy and bleeding complications in patients with atrial fibrillation and active cancer

Abstract Background Little is known about the extent to which an active cancer diagnosis increases bleeding and thromboembolic risks in atrial fibrillation (AF) patients. Data on major bleeding rates per antithrombotic management strategy are lacking in AF patients with active cancer. Purpose To examine the incidence rates of major bleeding per antithrombotic treatment in AF patients with active cancer and to examine whether cancer type impacts major bleeding and thromboembolic risks. Methods We used Danish population-based health care databases to conduct this cohort study. We included all incident AF (including atrial flutter) patients aged ≥50 years between January 1st 1995 and December 31st 2016, out of whom we identified AF patients who subsequently developed cancer. We used International Classification of Diseases 10th Revision codes to identify data on cancer type and outcomes (i.e. major bleeding, arterial and venous thromboembolism). We used Anatomical Therapeutic Chemical codes to provide information on antithrombotic treatment (e.g. no anticoagulant treatment, platelet inhibitors, vitamin K antagonists, direct oral anticoagulants, or a combination of antithrombotic drugs) which was evaluated as a time-dependent variable. The follow-up started from the incident cancer diagnosis until the occurrence of an outcome, death or the end of the two year follow-up. Incidence rates per 100 patient-years and adjusted hazard ratios were computed. Results 22,996 AF patients with a subsequent incident cancer diagnosis were included in the study. These patients had higher major bleeding and thromboembolic risk compared to those without cancer, with adjusted HRs of 2.11 (1.99–2.23) and 1.36 (1.27–1.44), respectively (Figure 1). Highest bleeding risk was observed for intracranial and respiratory cancer, while haematological and respiratory cancer were associated with highest thromboembolic risk. Bleeding risk increased with increasing number of antithrombotic drugs and was higher in AF patients with active cancer compared to those without, across all exposure categories (Figure 2). Conclusions Patients with AF and active cancer are at increased risk of major bleeding and thromboembolisms than those without cancer. Treatment with dual or triple antithrombotic therapy in AF patients with active cancer showed very high bleeding rates. Funding Acknowledgement Type of funding sources: None.

Weighted multi-scale limited penetrable visibility graph for exploring atrial fibrillation rhythm

Atrial fibrillation (AF) is a common cause of serious diseases such as stroke, heart failure and coronary artery disease, and electrocardiogram (ECG) detection is an important means of identifying AF. However, the ECG signal is quite noisy, making it difficult to detect AF through this method. Removing noise interference in ECG signals is a challenging problem. Traditional methods usually adopt various filtering methods to tackle this problem. Inspired by complex network theory, in this paper we present an innovative denoising approach for ECG detection called weighted multi-scale limited penetrable visibility graph (WMS-LPVG), which allows us to detect the rhythms characterizing AF in noisy ECG signals. To our knowledge, this is the first model that represents the AF rhythm series from the perspective of multi-scale complex networks. Furthermore, our WMS-LPVG model characterizes the AF rhythms in more detail, enabling us to identify AF sufferers more accurately. To demonstrate the effectiveness of our WMS-LPVG method, we first propose a new concept, called local efficiency entropy (LEE), which is utilized to identify the dynamic characteristics of time series. We then study the LEE-fluctuation trend under different scale factors. The experimental results show that the proposed LEE criterion can identify four kinds of ECG waveforms at a large scale. We then fuse the extracted LEE features with the original sequential features of ECG signals to build a multi-model complex network and feed the fused features into an XGboost model to identify AF patients. To demonstrate the generality of our WMS-LPVG model, we construct complex networks with WMS-LPVG for periodic and chaotic time series, respectively, and further discuss their degree distributions. The results show that our WMS-LPVG method perfectly retains information about original sequences and offers good anti-noise ability.

Characterization of atrial fibrillation in real-world patients: testing the 4S-AF scheme in the Spanish and French cohorts of the EORP-AF Long-Term General Registry.

The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] has recently been described as a novel approach to in-depth characterization of AF. We aim to determine if the 4S-AF scheme would be useful for AF characterization and provides prognostic information in real-world AF patients. The Spanish and French cohorts of the EORP-AF Long-Term General Registry were included. The baseline 4S-AF scheme was calculated and related to the primary management strategy (rhythm or rate control). Follow-up was performed at 1-year with all-cause mortality and the composite of ischaemic stroke/transient ischaemic attack/systemic embolism, major bleeding, and all-cause death, as primary endpoints. A total of 1479 patients [36.9% females, median age 72 interquartile range (IQR 64-80) years] were included. The median 4S-AF scheme score was 5 (IQR 4-7). The 4S-AF scheme, as continuous and as categorical, was associated with the management strategy decided for the patient (both P < 0.001). The predictive performances of the 4S-AF scheme for the actual management strategy were appropriate in its continuous [c-index 0.77, 95% confidence interval (CI) 0.75-0.80] and categorical (c-index 0.75, 95% CI 0.72-0.78) forms. Cox regression analyses showed that 'red category' classified patients in the 4S-AF scheme had a higher risk of all-cause death (aHR 1.75, 95% CI 1.02-2.99) and composite outcomes (aHR 1.60, 95% CI 1.05-2.44). Characterization of AF by using the 4S-AF scheme may aid in identifying AF patients that would be managed by rhythm or rate control and could also help in identifying high-risk AF patients for worse clinical outcomes in a 'real-world' setting.

Incidence and Predictors of Heart Failure in Patients With Atrial Fibrillation

BackgroundHeart failure (HF) is a frequent cause of hospitalization and death in patients with atrial fibrillation (AF). Identifying AF patients at risk of HF hospitalization could help select individuals for intensive follow-up and treatment. MethodsWe pooled data from 3 randomized trials (ACTIVE-A, RE-LY, AVERROES) of AF patients, for derivation and internal validation of a risk score for first HF hospitalization. Secondary endpoints were cardiovascular death and a composite of HF hospitalizations and cardiovascular death. ResultsIn 23,503 patients, the mean age was 71.3 years, and 62% were male. Over a mean follow-up of 2.0 years, 875 patients (3.7%) experienced their first HF hospitalization, and 1037 patients (4.4%) died from cardiovascular causes. Incidence rates per 100 patient-years were 1.85 for HF hospitalizations, 2.15 for cardiovascular death, and 3.71 for the composite. Independent predictors for HF hospitalizations included the following: increased age, weight, heart rate and serum creatinine level, lower height and systolic blood pressure, diabetes, vascular disease, valvular disease, heart rhythm, left ventricular hypertrophy, and intraventricular conduction delay. The C-statistic (95% confidence intervals by bootstrap simulations) was 0.717 (0.705-0.732). At 2 years of follow-up, the incidence rate of the primary outcome increased across risk-score quintiles: 0.49, 0.87, 1.29, 2.44, and 4.51 per 100 patient-years, respectively. Patients in the highest quintile had an absolute risk of 6.8% for the primary endpoint at 2 years. ConclusionsIn a large AF population, new-onset HF was common. A combination of characteristics can identify high-risk patients for whom strategies to prevent HF should be considered.

Abstract 38: Hemorrhagic Strokes in Patients With Atrial Fibrillation: The Neuro-AFib Study

Background: We aimed to compare the clinical features and short-term outcomes of hemorrhagic stroke (HS) to ischemic stroke (IS) in atrial fibrillation (AF) patients using a large contemporary cohort. Methods: The Neuro-AFib study is a multicenter effort to elucidate the current causes and consequences of IS and HS in AF patients. The retrospective phase of the study is underway, aimed at obtaining detailed clinical, laboratory and multimodal neuro- and cardiac imaging data from ~9,000 patients with AF admitted to 30 academic stroke centers in the US with an IS or HS between 1/2018-12/2019. Preliminary clinical data from 12 sites are presented in this abstract. Results: Of 4764 stroke admissions with AF, 820 (17.2%) had HS and 3944 IS. Patients with HS were younger (74.8 + 12 vs 76.8 + 12), more likely to be male (54% vs 46%) and had lower CHA 2 DS 2 -VASC (3.6 + 1.6 vs 3.9 + 1.6) than IS [all p&lt;0.05]. Patients with HS were more likely to be on AC compared to IS (60% vs 38%, p&lt;0.001). Within the HS cohort, 32% were on direct oral anticoagulant, 28% on warfarin, 16% on antiplatelet, and 24% on no antithrombotic. Patients with HS had worse outcomes than IS in terms of in hospital case fatality (32.4 vs 10.3%, p&lt;0.001) and severe disability (modified Rankin Scale 4-5) at discharge (63.3% vs 53.7%, p=0.002) despite similar rates of severe disability before admission (7% vs 6.2%, p=0.73). All of the reported associations remained significant after adjustment for age, sex and other relevant covariates. Conclusions: Preliminary findings from the Neuro-AFib study show significantly worse outcomes for HS compared to IS in AF patients, with triple case fatality and elevated severe disability risks. These results showcase the importance of identifying AF patients at high HS risk. Detailed imaging markers of HS risk including microbleeds, superficial siderosis, leukoaraiosis within the full cohort will be analyzed and discussed during ISC 2021.