Incidence Of New Atrial Fibrillation Research Articles

Pulmonary vein dose and risk of atrial fibrillation in patients with non-small cell lung cancer following definitive radiotherapy: An NI-HEART analysis

Background and purposeSymptomatic arrhythmia is common following radiotherapy for non-small cell lung cancer (NSCLC), frequently resulting in morbidity and hospitalization. Modern treatment planning technology theoretically allows sparing of cardiac substructures. Atrial fibrillation (AF) comprises the majority of post-radiotherapy arrhythmias, but efforts to prevent this cardiotoxicity have been limited as the causative cardiac substructure is not known. In this study we investigated if incidental radiation dose to the pulmonary veins (PVs) is associated with AF. Material and methodsA single-centre study of patients completing contemporary (chemo)radiation for NSCLC, with modern planning techniques. Oncology, cardiology and death records were examined, and AF events were verified by a cardiologist. Cardiac substructures were contoured on planning scans for retrospective dose analysis. ResultsIn 420 eligible patients with NSCLC treated with intensity-modulated (70%) or 3D-conformal (30%) radiotherapy with a median OS of 21.8 months (IQR 10.8–35.1), there were 26 cases of new AF (6%). All cases were grade 3 except two cases of grade 4. Dose metrics for both the left (V55) and right (V10) PVs were associated with the incidence of new AF. Metrics remained statistically significant after accounting for the competing risk of death and cardiovascular covariables for both the left (HR 1.02, 95%CI 1.00–1.03, p = 0.005) and right (HR 1.01 (95%CI 1.00–1.02, p = 0.033) PVs. ConclusionRadiation dose to the PVs during treatment of NSCLC was associated with the onset of AF. Actively sparing the PVs during treatment planning could reduce the incidence of AF during follow-up, and screening for AF may be warranted for select cases.

PP47 Experience And Its Implication For Reassessment Of The Transcatheter Aortic Valve Implantation Using Real World Data

IntroductionSouth Korea has introduced conditionality to coverage decisions for certain difficult or high-risk procedures. The transcatheter aortic valve implantation (TAVI) was included in the coverage with evidence development (CED) in 2014. This study reviewed the results of reassessment for the TAVI using real world data (RWD) and suggested its implications.MethodsHealthcare providers authorized to use the promising technologies are required to collect the RWD for suitability evaluation, safety monitoring, and cost-effectiveness, differing from the general reassessment process. In 2021, 45 healthcare providers collected clinical information for TAVI patients. Their registries were linked with the national health insurance claims, which provided data on 19 items to assess safety and effectiveness such as overall mortality, reoperation rates, hospital readmission rates, and degree of functional improvement.ResultsAccording to the Society of Thoracic Surgeons’ predicted risk of mortality (STS), 988 TAVI patients were classified into three groups; high (STS >8 percent, n=347), intermediate (STS 4-8 percent, n=272), and low (STS <4 percent, n=369); We compared main outcomes and estimated survival probabilities between subgroups. Within 30 days, the overall mortality rates were 4.9 percent (high), 2.6 percent (intermediate), and 1.4 percent (low); major bleeding rates were 7.6 percent (high), 6.2 percent (intermediate),and 1.4 percent (low); incidence of new atrial fibrillation were 6.8 percent (high), 4.2 percent (intermediate), and 3.2 percent (low). Based on the quantitative results using RWD and systematic review for the safety and effectiveness, TAVI is reported to have essential benefits for high-risk group and elderly patients (>80 years). Whereas, intermediate and low-risk groups have out-of-pocket payment rates of 50 percent and 80 percent, respectively.ConclusionsThe reassessment system through RWD accumulation enabled the evidence-based evaluation for the TAVI. Based on the transition to CED for essential benefits, a systematic framework such as RWD collection from treatment commencement should be introduced to broaden RWD use for benefit management of medical technologies with uncertain levels of evidence. Therefore, this ensures overall quality of care and effective coverage in health.

10-year trends in oral anticoagulation therapies and ischemic stroke among 157,583 patients with non-valvular atrial fibrillation

Abstract Purpose Initiation of oral anticoagulation therapy (OAC) for stroke prevention in patients with atrial fibrillation (AF) is often suboptimal in clinical practice. We aimed to describe trends in OAC uptake and incidence of ischemic stroke over the past decade. Methods We retrospectively analyzed consecutive patients with non-valvular (NV) AF between January 2012 and July 2022 from 16 public hospitals. Annual incidence of AF was the number of new AF cases as proportion of adult population reported by Census and Statistics Department. Prescription of OAC (vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC)) were recorded. OAC uptake was defined as initiation of OAC within 12 months from AF diagnosis. Incidence of ischemic stroke was calculated for both incident and prevalent AF cohorts over time. Logistic regression was conducted to identify predictors of OAC uptake. Results 157,583 NVAF patients (mean age 76.6±12.5 and female 49.6%) with mean CHA2DS2VASC 2.6±1.3 were identified. Between 2012 and 2022, incidence of new AF was steady across the years with mean of 0.19%±0.03% (range 0.16% to 0.24%) per year. OAC prescription increased from 15.3% to 46.0% and the incidence of ischemic stroke decreased significantly from 4.0% to 0.6% over the last decade (both p for trend <0.01). DOAC use increased steadily from 6.2% to 41.0% whereas VKA decreased from 9.1% to 3.5% (Figure). Mean time from AF diagnosis to OAC prescription was 0.6±1.6 months. Of all patients prescribed OAC, 40.8% initiated OAC within 1 month after AF diagnosis. CHA2DS2VASC scores ≥4 was associated with higher likelihood of OAC uptake (OR=1.74 (95%CI: 1.69-1.78). Conclusion Our real-world data demonstrated steady incidence of new NVAF diagnosis with increasing trend in OAC prescription, predominantly DOAC and decreasing incidence ischemic stroke over the last decade. However, overall utilization of OAC for stroke prevention remains suboptimal.

Abstract 17859: Real World Cardiovascular Events With Next Generation Bruton's Tyrosine Kinase Inhibitors - An Updated Analysis

Introduction: Acalabrutinib and zanubrutinib are next generation Bruton’s tyrosine kinase inhibitors (BTKIs) associated with dramatic efficacy against B cell malignancies. In early trials, these BTKIs show less cardiac activity than ibrutinib. Yet, whether this is seen in longer term follow up is unknown. Methods: Leveraging the US Food and Drug Administration’s Adverse Events Reporting System (FAERS), we identified the relative incidence and predictive factors for atrial fibrillation (AF) after BTKI initiation from 2015-2022. Secondary outcomes were the reporting odds ratios (ROR) of major adverse cardiovascular adverse events (AEs), defined as AF, non-AF atrial arrhythmias, heart failure, conduction blocks, and ventricular arrythymias. In addition, using a registry cohort of 838 hematologic malignancy patients treated with ibrutinib or acalabrutinib from 2012-2020, we assessed the comparative incidence of new AF. Observed incident AF rates were compared with Framingham heart predicted rates, and absolute excess risks of AF were estimated. Multivariable logistic-regression models were used to identify factors associated with AF, other cardiac AEs, and mortality. Results: Among 21,435 events reported to FAERS during BTKI use, 3,453 were cardiovascular AEs. AF was the most reported AE (ROR 8.8, 95% CI, 8.3-9.4; Figure A ). The likelihood (ROR) of cardiac AE reporting in next generation BTKI treated patients was >3.0 ( P <0.05; Figure A ) for AF events. Furthermore, in acalabrutinib treated registry patients, 9.7% developed incident AF over a median follow up of 42 months. In those without prior ibrutinib use, the weighted average incidence was 281 per 10,000 person years compared to the Framingham predicted rate of 103 per 10,000 person years (RR 2.73, P <0.001; AER 178; Figure B ). Conclusions: These data suggest residual AF risk with next generation BTKIs.

Higher incidence of new atrial fibrillation in hospitalised COVID-19 patients compared to lower respiratory tract infection, however, less patients anticoagulated at discharge

Higher incidence of new atrial fibrillation in hospitalised COVID-19 patients compared to lower respiratory tract infection, however, less patients anticoagulated at discharge

Higher incidence of new atrial fibrillation in hospitalised COVID-19 patients compared to lower respiratory tract infection, however, less patients prescribed anticoagulants at discharge

Infection contributes to developing cardiac arrhythmias, such as atrial fibrillation (AF), which causes over 25% of ischaemic stroke. We analysed a hospital coding database of patients hospitalised with Coronavirus 2019 (COVID-19) ± AF or a lower respiratory tract infection (LRTI) ± AF, to compare the incidence of first-diagnosed or 'new' AF (nAF) between COVID-19 and LRTI, as well as risk factors associated with developing nAF during COVID-19. In total, 2,243 patients with LRTI and 488 patients with COVID-19 were included. nAF was diagnosed in significantly more patients with COVID-19 compared with those with LRTI (7.0% vs 3.6%, p=0.003); however, significantly fewer patients with COVID-19 were discharged on anticoagulation medication (26.3% vs 56.4%, p=0.02). Patients who developed nAF during COVID-19 were older (p<0.001), had congestive cardiac failure (p=0.004), ischaemic heart disease (IHD) or peripheral vascular disease (PVD) (p<0.001) and a higher CHA2DS2-VASc score (p=0.02), compared with patients with COVID-19 patients who did not develop nAF. Older age (Odds ratio (OR) 1.03, p=0.007) and IHD/PVD (OR 2.87, p=0.01) increased the odds of developing nAF with COVID-19.

Anxiety, patient activation, and quality of life among stroke survivors prescribed smartwatches for atrial fibrillation monitoring

The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined. To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health. We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes. A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch. The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

Abstract 9757: Frequency of Atrial Fibrillation in a Contemporary Elderly Primary Care Population: A Vital-af Trial Study

Introduction: Reliable estimates of atrial fibrillation (AF) frequency can inform our understanding of population disease burden and shape interventions to reduce AF-related morbidity. Methods: We quantified the prevalence and incidence of AF in VITAL-AF (NCT035115057), a cluster-randomized trial of AF screening using single-lead handheld electrocardiograms within 16 primary care practices affiliated with Massachusetts General Hospital. Potential AF events were identified using the electronic health record. AF events satisfying a high specificity electronic algorithm for prevalent AF (positive predictive value 98.4%) were classified as prevalent AF, while all other potential AF events (including all incident AF events) were manually adjudicated. We calculated AF prevalence and incidence overall and within clinical strata, among individuals who were not screened. Results: Of 18,812 individuals enrolled but not screened between 7/31/2018-10/8/2019 (mean age 74.6±7.2 years, 56.3% women), 2,503 (13.3%) had prevalent AF. AF prevalence was particularly high among individuals aged ≥85 years (29.1%) and individuals with heart failure (43.4%). The AF incidence rate among 16,309 individuals without prevalent AF was 20.1 per 1,000 person-years (95% CI 20.9-26.4). AF incidence also increased markedly with age (e.g., 13.6 at ages 65-69 to 37.1 at ages ≥85 years, p&lt;0.01), was greater in men versus women (26.9 vs. 15.0, p&lt;0.01), and was particularly high among individuals with heart failure (30.7, 95% CI 43.8-69.0). Detailed estimates of AF prevalence and incidence across clinical strata are shown in the Table . Conclusions: Using rigorous methodology within a contemporary, elderly primary care population, we observed the highest reported prevalence of diagnosed AF, including nearly a third of individuals aged 85 years and older. The incidence of new AF is also substantial. Preventive efforts are warranted to reduce the risk of AF and associated complications.

Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study.

Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22–25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.

Detection of Atrial Fibrillation After Central Retinal Artery Occlusion.

Central retinal artery occlusion (CRAO) causes sudden, irreversible blindness and is a form of acute ischemic stroke. In this study, we sought to determine the proportion of patients in whom atrial fibrillation (AF) is detected by extended cardiac monitoring after CRAO. We performed a retrospective, observational cohort study using data from the Optum deidentified electronic health record of 30.8 million people cross-referenced with the Medtronic CareLink database of 2.7 million people with cardiac monitoring devices in situ. We enrolled patients in 3 groups: (1) CRAO, (2) cerebral ischemic stroke, and (3) age-, sex-, and comorbidity-matched controls. The primary end point was the detection of new AF (defined as ≥2 minutes of AF detected on a cardiac monitoring device). We reviewed 884 431 patient records in common between the two databases to identify 100 patients with CRAO, 6559 with ischemic stroke, and 1000 matched controls. After CRAO, the cumulative incidence of new AF at 2 years was 49.6% (95% CI, 37.4%–61.7%). Patients with CRAO had a higher rate of AF than controls (hazard ratio, 1.64 [95% CI, 1.17–2.31]) and a comparable rate to patients with stroke (hazard ratio, 1.01 [95% CI, 0.75–1.36]). CRAO was associated with a higher incidence of new stroke compared with matched controls (hazard ratio, 2.85 [95% CI, 1.29–6.29]). The rate of AF detection after CRAO is higher than that seen in age-, sex-, and comorbidity-matched controls and comparable to that seen after ischemic cerebral stroke. Paroxysmal AF should be considered as part of the differential etiology of CRAO, and those patients may benefit from long-term cardiac monitoring.

Racial differences in the incidence of atrial fibrillation after cryptogenic stroke

The incidence of atrial fibrillation (AF) is lower in nonwhites than in whites despite a higher burden of AF risk factors. However, the incidence of new AF after cryptogenic stroke in minorities is unknown. The purpose of this study was to determine the incidence of AF after cryptogenic stroke in different racial/ethnic groups. We retrospectively analyzed 416 consecutive patients undergoing insertable cardiac monitor implantation at our hospital from 2014 through 2019. Incidence of AF was identified through the review of device monitoring, including adjudication of AF episodes for accuracy, and compared by race. The mean follow-up time was 1.5 ± 1.1 years. The predominantly nonwhite cohort included 244 (59%) blacks and 109 (26%) Hispanics, and 45% (n=189) were male. The mean age was 62 ± 12 years; Blacks and Hispanics had more hypertension, diabetes, and chronic kidney disease and higher body mass index than did whites. In blacks and Hispanics, the cumulative incidences of AF at 1, 2, and 3 years were 14.1%, 19.9%, and 24% and 12.9%, 18.3%, and 20.9%, respectively. By comparison, the incidence in whites was significantly higher: 20.8%, 34.3%, and 40.3%. In a Cox proportional hazards model adjusting for common AF risk factors, blacks (hazard ratio 0.49; confidence interval 0.26-0.82; P= .03) and Hispanics (hazard ratio 0.39; confidence interval 0.18-0.83; P = .01) were less likely to have incident AF than whites. In patients with an insertable cardiac monitor after cryptogenic stroke, the incidence of newly detected AF is approximately double in whites compared with both blacks and Hispanics. This has important implications for the investigation and treatment of nonwhites with cryptogenic stroke.

Risk markers of incident atrial fibrillation in patients with coronary heart disease

In patients with coronary heart disease (CHD), atrial fibrillation (AF) is associated with increased morbidity and mortality. We investigated the associations between clinical risk factors and biomarkers with incident AF in patients with CHD. Around 13,153 patients with optimally treated CHD included in the STabilization of Atherosclerotic plaque By Initiation of darapLadIb TherapY (STABILITY) trial with plasma samples obtained at randomization. Mean follow-up time was 3.5 years. The association between clinical risk factors and biomarkers with incident AF was estimated with Cox-regression models. Validation was performed in 1,894 patients with non-ST-elevation acute coronary syndrome included in the FRISC-II trial. The median (min-max) age was 64 years (range 26-92) and 2,514 (19.1%) were women. A total of 541 patients, annual incidence rate of 1.2%, developed AF during follow-up. In multivariable models, older age, higher levels of NT-proBNP, higher body mass index (BMI), male sex, geographic regions, low physical activity, and heart failure were independently associated with increased risk of incident AF with hazard ratios ranging from 1.04 to 1.79 (P ≤ .05). NT-proBNP improved the C-index from 0.70 to 0.71. In the validation cohort, age, BMI, and NT-proBNP were associated with increased risk of incident AF with similar hazard ratios. In patients with optimally treated CHD, the incidence of new AF was 1.2% per year. Age, NT-proBNP as a marker of impaired cardiac function, and BMI were the strongest factors, independently and consistently associated with incident AF. Male sex and low physical activity may also contribute to the risk of AF in patients with CHD.

Device closure for patent foramen ovale in patients with cryptogenic stroke: which patients should get it?

Patent foramen ovale (PFO) and cryptogenic stroke (CS) both have a high prevalence. The optimal treatment to reduce stroke recurrence after CS remains controversial. Results from clinical trials, meta-analyses, and position papers, support percutaneous PFO device closure and medical therapy compared to medical therapy alone. However, the procedure may be associated with cardiac complications including an increased incidence of new atrial fibrillation. The benefit/risk balance should be determined on a case-by-case basis with the greatest benefit of PFO closure in patients with atrial septal aneurysm and PFO with large shunts. Future studies should address unsolved questions such as the choice of medical therapy in patients not undergoing closure, the duration of antiplatelet therapy, and the role of PFO closure in patients over 60 years old.

Abstract 16415: Racial Differences in Incidence of Atrial Fibrillation After Cryptogenic Stroke

Introduction: The incidence of atrial fibrillation (AF) is lower among non-whites compared to whites, despite a higher burden of AF risk factors. Current knowledge of first detection of AF after cryptogenic stroke (CS) by an implantable cardiac monitor (ICM) is based on a predominantly white cohort. The incidence of new AF after CS among minorities is unknown. We hypothesized that the incidence of AF after CS would be lower in non-whites. Methods: We reviewed charts of all patients without a history of AF undergoing implantation of an ICM after CS at our hospital from July 2014 to December 2019. Incidence of AF was identified through review of ICM monitoring for each patient, including adjudication of AF episodes for accuracy. Kaplan Meier survival analysis was performed, and cumulative incidence of AF using adjusted Cox proportional hazards regression was compared by race. Results: We identified 417 patients who underwent ICM implant after CS during the study period, with a mean follow-up time of 1.5 ± 1.1 years. Mean age was 62 ± 12 years, and 46% (n=190) were male. The majority of patients were non-white (white, 15%, n=63; black, 59%, n=244; Hispanic, 26%, n=110). At baseline, blacks, Hispanics, and whites were of similar age (mean 62.2, 62.1, and 61.5 years, respectively), and blacks and Hispanics had more AF risk factors, including heart failure, hypertension, diabetes, chronic kidney disease, and higher BMI, than whites. Hispanics had more coronary artery disease than whites and blacks (25.5%, 17.5%, 9.1% respectively, p &lt; 0.001). Among blacks, the cumulative incidence of newly detected AF at one, two, and three years was 13.0%, 18.9%, and 23%, which was similar to Hispanics (12.9%, 18.2%, and 20.9%). By comparison, the incidence in whites was significantly higher (20.8%, 34.3%, 40.3%; blacks p=0.02; Hispanics p=0.01) Conclusion: In patients undergoing ICM after CS, the incidence of newly detected AF is approximately double in whites compared to both blacks and Hispanics.

Abstract 23: Detection of Atrial Fibrillation by Implantable Cardiac Monitoring After Acute Central Retinal Artery Occlusion

Introduction: Central retinal artery occlusion (CRAO) is a form of ischemic stroke and necessitates a comprehensive workup, including for cardioembolic sources such as atrial fibrillation (AF). However, the incidence of new AF diagnosed after CRAO is unknown. We aimed to examine the incidence of new, cardiac device-detected AF after CRAO in a large population-based cohort. Methods: Using patient-level data from the Optum® de-identified EHR dataset (2007-2017) linked with Medtronic implantable cardiac device data, we identified patients that had a diagnosis-code corresponding to CRAO and no known history of AF, and who also had either a device in-situ at the time of CRAO or implanted ≤1 year post-CRAO with continuous AF monitoring data available. AF incidence was defined as ≥2 minutes of device-detected AF in a day. Results: Of 467,167 patients screened, 246/433 (56.8%) with CRAO had no history of AF, of whom 39 had an eligible implantable cardiac device (mean age 66.7±14.8, 41.0% female). Prevalence of vascular risk factors was high (hypertension, 71.8%; hyperlipidemia, 61.5%; coronary artery disease, 46.2%). Within 3 months, 7.7% of these patients (n=3) had device-detected AF. At 36 months, 33.3% of patients (n=13). The maximum daily AF burden post CRAO ranged from 2 minutes to 24 hours with a mean of 390±530 minutes. Of the patients with device-detected AF, 9 were found by an implantable cardiac monitor and 4 by pacemaker or defibrillator. Discussion: The rate of long-term AF detection after CRAO was high in patients with implanted cardiac devices, and appears comparable with rates seen after cryptogenic ischemic stroke and in other high-risk populations. Our findings warrant future prospective studies not limited by selection bias.

Postoperative Atrial Fibrillation Following Noncardiac Surgery Increases Risk of Stroke

BackgroundNew-onset postoperative atrial fibrillation is well recognized to be an adverse prognostic marker in patients undergoing noncardiac surgery. Whether postoperative atrial fibrillation confers an increased risk of stroke remains unclear. MethodsA systematic review and meta-analysis was performed to assess the risk of stroke after postoperative atrial fibrillation in noncardiac surgery. MEDLINE, Cochrane, and EMBASE databases were searched for articles published up to May 2019 for studies of patients undergoing noncardiac surgery that reported incidence of new atrial fibrillation and stroke. Event rates from individual studies were pooled and risk ratios (RR) were pooled using a random-effects model. ResultsFourteen studies of 3,536,291 patients undergoing noncardiac surgery were included in the quantitative analysis (mean follow-up 1.4 ± 1 year). New atrial fibrillation occurred in 26,046 (0.74%), patients with a higher incidence following thoracic surgery. Stroke occurred in 279 (1.5%) and 6199 (0.4%) patients with and without postoperative atrial fibrillation, respectively. On pooled analysis, postoperative atrial fibrillation was associated with a significantly increased risk of stroke (RR 2.51; 95% confidence interval, 1.76-3.59), with moderate heterogeneity. The stroke risk was significantly higher with atrial fibrillation following nonthoracic, compared with thoracic, surgery (RR 3.09 vs RR 1.95; P = .01). ConclusionNew postoperative atrial fibrillation following noncardiac surgery was associated with a 2.5-fold increase in the risk of stroke. This risk was highest among patients undergoing nonthoracic noncardiac surgery. Given the documented efficacy of newer anticoagulants, randomized controlled trials are warranted to assess whether they can reduce the risk of stroke in these patients.

Patent Foramen Ovale Closure Versus Medical Therapy for Cryptogenic Stroke: Meta-Analysis of Randomised Trials

Patent foramen ovale (PFO) is a common anatomic variant associated with cryptogenic stroke. Percutaneous PFO closure in these patients to prevent recurrent neurological events has been controversial for decades, and mixed results have been reported from past and recent observational and randomised studies. This meta-analysis of randomised trials aims to compare the efficacy and safety of PFO closure with medical therapy for cryptogenic stroke patients. Medline, PubMed, EMBASE, Scopus and Cochrane were searched from January 1980 to September 2017 by two authors independently to include original randomised trials comparing PFO closure with medical therapy for secondary stroke prevention. Relevant study and baseline characteristics and outcomes were extracted and pooled using random-effects models. Amongst 619 articles searched giving 10 full-texts assessed, six studies reporting five randomised trials and totalling 1,829 PFO closure and 1,611 medical therapy patients were included. Pooled hazards ratios (95% confidence interval, p-value) ischaemic stroke, transient ischaemic attack (TIA) and composite neurovascular or mortality events were 0.41 (0.19-0.90, p=0.03), 0.77 (0.51-1.14, p=0.19) and 0.60 (0.44-0.81, p<0.001) for PFO closure compared to medical therapy. Any adverse events, major bleeding and all-cause mortality were similar between modalities (p=0.37-0.95), however PFO closure had higher rates of new onset atrial fibrillation at 4.6 times (p<0.001). Our meta-analysis found that, in patients with cryptogenic stroke, percutaneous PFO closure is beneficial at reducing ischaemic stroke and composite neurovascular or mortality events, with a higher incidence of new atrial fibrillation, compared to medical therapy.

Automatic Blood Pressure Monitor Accurately Detects AF

Automatic blood pressure screening with a blood pressure monitor can accurately detect new cases of atrial fibrillation (AF) among older populations, according to a recent U.S. study. Long-term residents of skilled nursing facilities frequently have multiple risk factors for strokes due to AF, and studies have shown that screening for AF may allow residents the opportunity to begin treatment that lowers their risk for stroke. The American Heart Association and the British National Institute for Health and Care Excellence (NICE) both recommend AF screening for residents 65 years and older in primary care clinics. NICE specifically recommends the Microlife WatchBP Home A (BPM-AF), an automatic blood pressure monitor that can detect AF when set to a triple-reading mode. Results from past studies have shown that the monitor has a sensitivity of 95% and specificity of 90% for detecting AF. In 2016 Joseph Wiesel, MD, and Thomas J. Salomone, DrNP, FNP, conducted a pilot program to assess the efficacy of the BPM-AF monitor for AF screening among long-term residents at an SNF in the northeastern United States. Their results, published in the American Journal of Cardiology [July 24, 2017; doi: 10.1016/j.amjcard.2017.07.016], showed that the BPM-AF identified 9 residents with possible AF out of 101 residents screened. In five of those residents the AF was confirmed by a 12-lead electrocardiogram (ECG), and in two of the remaining four it was confirmed using an immediate 30-second single-lead ECG. Overall, 113 residents of extended care units who were 65 and older were eligible to participate, and a total of 101 residents were screened. The average age of the screened residents was 77.7 years, and men made up 52% of the cohort. Residents with dementia, using a ventilator, or housed in short-term rehabilitation were excluded, as were residents with previously diagnosed AF, those who had a pacemaker or a defibrillator, and those who were unavailable or uncooperative. The investigators used the BPM-AF in the automatic three-sequential-reading mode, as recommended for AF screening and maximum blood pressure accuracy. If the BPM-AF detected possible AF, the nurse on the unit would request a standard 12-lead ECG as per routine practice. All 12-lead ECGs in the study were interpreted by a board-certified cardiologist who provided routine ECG readings for the facility. When the investigators could not perform a 12-lead ECGs until several days after an abnormal BPM-AF reading, they immediately collected a backup with a 30-second single-lead ECG handheld device. In the cases where the resident’s delayed 12-lead ECG did not show AF, a board-certified cardiologist interpreted the 30-second single-lead ECG result. The residents with AF confirmed by either the 12-lead ECG or the immediate single-lead ECG were considered to have AF. With one screening BMP-AF reading and a routine confirmatory 12-lead ECG, the incidence of new AF was 4.9%. Including the residents whose AF was confirmed by an immediate 30-second single-channel ECG, the incidence rate increased to 6.9%. The false-positive rate was 2%. The investigators noted that their AF detection rates were significantly higher than the 1.61% rate obtained via systematic screening using one ECG in participants 65 and older from a general outpatient medical population (BMJ 2007;335:383–388) and the 1.2% incidence rate recorded for ECG screening among 75-year-old community residents (Circulation 2013;127:930–937). “Residents of skilled nursing facilities may be at particularly high risk of undiagnosed AF and would benefit from routine screening for AF,” wrote Drs. Wiesel and Salomone. They also noted that “given the high prevalence of previously undiagnosed AF found in this study, expanding the criteria for AF screening to include younger skilled nursing facility residents may be appropriate.” Braxton Poe is a freelance writer in the Philadelphia area. We certainly have the technology to do widespread screening for asymptomatic atrial fibrillation in our nursing home residents. Considering the prevalence of risk factors for stroke that would make them good candidates for anticoagulation, this may become the standard of care. However, we need to consider burdens vs. benefits, and allow our patients or their decision-makers to make informed decisions about whether such screening is appropriate for an individual patient. If patients are at excessively high risk for bleeding or falls, or if they have substantially limited life expectancy, then perhaps it is of no benefit to know that they may be experiencing AF since anticoagulation would be relatively contraindicated. Antiarrhythmic medications could be considered for some. And for others, nonpharmacological interventions such as radiofrequency ablation might be considered. As long as we keep the individual patient’s goals of care and specific medical profile in mind, this technology has the potential to prevent many strokes. —Karl Steinberg, MD, CMD, HMDC Editor in Chief

Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study.

Despite the frequency of new clinically important atrial fibrillation (AF) after noncardiac surgery and its increased association with the risk of stroke at 30 days, there are limited data informing their prediction, association with outcomes, and management. We used the data from the PeriOperative ISchemic Evaluation trial to determine, in patients undergoing noncardiac surgery, the association of new clinically important AF with 30-day outcomes, and to assess management of these patients. We also aimed to derive a clinical prediction rule for new clinically important AF in this population. We defined new clinically important AF as new AF that resulted in symptoms or required treatment. We recorded an electrocardiogram 6 to 12 hours postoperatively and on the 1st, 2nd, and 30th days after surgery. A total of 211 (2.5% [8351 patients]; 95% confidence interval, 2.2%-2.9%) patients developed new clinically important AF within 30 days of randomization (8140 did not develop new AF). AF was independently associated with an increased length of hospital stay by 6.0 days (95% confidence interval, 3.5-8.5 days) and vascular complications (eg, stroke or congestive heart failure). The usage of an oral anticoagulant at the time of hospital discharge among patients with new AF and a CHADS2 score of 0, 1, 2, 3, and ≥4 was 6.9%, 10.2%, 23.0%, 9.4%, and 33.3%, respectively. Two independent predictors of patients developing new clinically important AF were identified (ie, age and surgery). The prediction rule included the following factors and assigned weights: age ≥85 years (4 points), age 75 to 84 years (3 points), age 65 to 74 years (2 points), intrathoracic surgery (3 points), major vascular surgery (2 points), and intra-abdominal surgery (1 point). The incidence of new AF based on scores of 0 to 1, 2, 3 to 4, and 5 to 6 was 0.5%, 1.0%, 3.1%, and 5.3%, respectively. Age and surgery are independent predictors of new clinically important AF in the perioperative setting. A minority of patients developing new clinically important AF with high CHADS2 scores are discharged on an oral anticoagulant. There is a need to develop effective and safe interventions to prevent this outcome and to optimize the management of this event when it occurs.

Persistence of ibrutinib-associated hypertension in CLL pts treated in a real-world experience.

7525 Background: Cardiovascular (CV) complications associated with ibrutinib (Ibr) include hypertension (HTN) and atrial fibrillation (AFIB) (incidence 26% and 9%, OBrien, ASH 2016). Unlike clinical trials, Ibr toxicities are the most common reasons for its discontinuation in clinical practice. The incidence of HTN in pts treated with Ibr outside of clinical trial setting and its impact on outcomes is unknown. Methods: Retrospective, cohort study of Ibr-treated CLL pts to estimate HTN incidence. Baseline CLL characteristics and co-morbidities were recorded. Blood pressure (BP) measurements were recorded prior to Ibr and sequentially following exposure at specific time points. CV meds were reviewed during a 12 mo follow-up period. The association between Ibr exposure and BP was tested. Results: 153 consecutive CLL pts treated with Ibr at a dose of 420 mg/day were identified. Med age was 57 yr (range: 34-87), relapsed CLL (69%), follow-up 14.5 mo. CV pre-Ibr characteristics included: smoking hx (49%), HTN (42%), hyperlipidemia (39%), diabetes (17%), CAD (12%), AFIB (6.8%). Proportion of pts on ≥1 anti-HTN med increased from 44% pre-Ibr (20% ≥ 2) to 57% during Ibr (30% ≥ 2). Med pre-Ibr BP was 127/70 mmHg (range 90-182/48-95mmHg). At 1, 3, 6, 9, 12 mo, med BPs were 137/73, 141/75, 143/76, 140/75, 142/77 (7 mo to peak BP). There was a significant association between Ibr exposure and increased BP (p&lt;.01). New HTN was observed in 40% of pts and 36% HTN pts had BP increased above baseline (med baseline 135/70 vs peak 161/80). Incidence of new AFIB was 8.1%. In UV analyses, predictive clinical factors for HTN were not identified. Pre-Ibr HTN (OR 3.0, p .05), CAD (OR 4.3, p .03), prior AFIB event (OR 10.8, p.001), hyperlipidemia (OR 3.4, p.05) were associated with post-Ibr AFIB. Conclusions: In the largest real-world series focused on BP in Ibr treated pts, we demonstrate a clear association between Ibr and HTN. Nearly 40% of pts developed HTN within 12 mo of Ibr exposure (vs. 26% in clinical trials over 5 yr). Despite aggressive management (multiple agents), Ibr associated HTN was persistent. These data underscore the critical need for monitoring and management strategies for HTN and follow-up data on future CV events.