Incidence Of Atrial Fibrillation Research Articles

Testosterone and the risk of incident atrial fibrillation in older men: further analysis of the ASPREE study

A cardiovascular safety trial of testosterone in men with cardiovascular risk factors or disease found no difference in rates of major adverse cardiovascular events (MACE) or death but noted more atrial fibrillation (AF) events in testosterone-treated men. We investigated the relationship between endogenous testosterone concentrations with risk of developing AF in healthy older men. Post-hoc analysis of 4570 male participants in the ASPirin in Reducing Events in the Elderly (ASPREE) study. Men were aged ≥ 70 years, had no history of cardiovascular disease (including AF), thyroid disease, prostate cancer, dementia, or life-threatening illnesses. Risk of AF was modelled using Cox proportional hazards regression. Median (IQR) age was 73.7 (71.6-77.1) years and median (IQR) follow-up 4.4 (3.3-5.5) years, during which 286 men developed AF (15.3 per 1000 participant-years). Baseline testosterone was higher in men who developed incident AF compared men who did not [17.0 (12.4-21.2) vs 15.7 (12.2-20.0) nmol/L]. There was a non-linear association of baseline testosterone with incident AF. The risk for AF was higher in men with testosterone in quintiles (Q) 4&5 (Q4:Q3, HR=1.91; 95%CI=1.29-2.83 and Q5:Q3HR=1.98; 95%CI=1.33-2.94). Results were similar after excluding men who experienced MACE or heart failure during follow-up. Circulating testosterone concentrations within the high-normal range are independently associated with an increased risk of incident AF amongst healthy older men. This suggests that AF may be an adverse consequence of high-normal total testosterone concentrations. National Institute on Aging and National Cancer Institute at the National Institutes of Health; Australian Government (NHMRC, CSIRO); Monash University; and AlfredHealth.

Genetically predicted systemic inflammation and the risk of atrial fibrillation: A bidirectional two-sample Mendelian randomization study

BackgroundSystemic inflammation has been proposed to be associated with the incidence of atrial fibrillation (AF), but whether it is a cause or a consequence of AF remains uncertain. We sought to explore the causal associations between systemic inflammation and AF using bidirectional Mendelian randomization (MR) analysis. MethodsIndependent genetic variants strongly associated with AF were selected as instrumental variables from the largest genome-wide association study (GWAS) with up to 1,030,836 individuals. Regarding inflammation traits, genetic associations with 41 inflammatory cytokines and 5 inflammatory biomarkers were obtained from their corresponding GWASs databases. Effect estimates were primarily evaluated using the inverse-variance weighted (IVW) method, supplemented by sensitivity analyses using MR-Egger, weighted median, and MR-PRESSO methods. ResultsIn our initial MR analyses, we observed suggestive associations of genetically predicted interleukin-17 (IL-17), interleukin-2 receptor subunit alpha (IL-2rα), and procalcitonin (PCT) with AF. One standard deviation (SD) increase in IL-17, IL-2rα, and PCT caused an increase in AF risk by 6.3 % (OR 1.063, 95 %CI 1.011–––1.118, p = 0.018), 4.9 % (OR 1.049, 95 %CI 1.007–––1.094, p = 0.023) and 3.4 % (OR 1.034, 95 %CI 1.005–––1.064, p = 0.022), respectively. Furthermore, our reverse MR analyses indicated that genetically predicted AF contributed to a suggestive increase in the levels of macrophage inflammatory protein-1β (MIP1β) (β 0.055, 95 %CI 0.006 to 0.103, p = 0.028), while a decrease in the levels of fibrinogen (Fbg) (β −0.091, 95 %CI −0.140 to −0.041, p < 0.001), which remained significant after multiple test correction. ConclusionsOur MR study identified several inflammatory biomarkers with suggestive causal associations regarding the upstream and downstream regulation of AF occurrence, offering new insights for therapeutic exploitation of AF. Further research is required to validate the underlying link between systemic inflammation and AF in larger cohorts.

Prediction of paroxysmal atrial fibrillation using a convolutional neural network and electrocardiogram signals

Atrial fibrillation (AF) is the most clinically diagnosed arrhythmia in cardiac pathology. The incidence of AF begins at a very early age and its initial state is paroxysmal atrial fibrillation (PAF). This type of heart disease can be detected and predicted by analyzing the spectrogram of a surface electrocardiogram (ECG) signal. In many studies, different ECG signal formats and convolutional neural network (CNN) architectures have been used. However, the lack of good signal preprocessing or signal adequacy may have affected the accuracy, especially on short-term ECG signals. In this study, we analyzed a preprocessed ECG signal, determined the optimal set to predict PAF, and evaluated the accuracy using ECG signals of different durations. The PAF Prediction Challenge–PhysioNet database was used to extract spectrograms in 30-sec and 5-sec windows for two classes (Normal, PAF) and 3 classes (Normal, Close-AF, Distant-AF). Then, the AlexNet architecture was used. The proposed method achieved a two-class accuracy of 99.92% with a 30-sec window and 99.42% with a 5-sec window, improving the PAF prediction performance compared with similar works. In addition, the three-class accuracies were 96.92% and 97.43% with windows of 30-sec, and 5-sec, respectively. These results prove the efficacy of the method for the early diagnosis of PAF, even based on short-term ECG signals.

A nationwide study on new onset atrial fibrillation risk factors and its association with hospital mortality in sepsis patients

Atrial fibrillation (AF) is the most common arrhythmia and its incidence increases with sepsis. However, data on new-onset AF during sepsis hospitalization remain limited in China. We aimed to evaluate the incidence, risk factors, and associated mortality of new-onset AF in sepsis patients in China. We conducted a retrospective study using the National Data Center for Medical Service system, from 1923 tertiary and 2363 secondary hospitals from 31 provinces in China from 2017 to 2019.In total we included 1,425,055 sepsis patients ≥ 18 years without prior AF. The incidence of new-onset AF was 1.49%. Older age, male sex, hypertension, heart failure, coronary disease, valvular disease, and mechanical ventilation were independent risk factor. New-onset AF was associated with a slight increased risk of mortality (adjusted RR 1.03, 95% CI 1.01–1.06). Population attributable fraction suggested AF accounted for 0.2% of sepsis deaths. In this large nationwide cohort, new-onset AF occurred in 1.49% of sepsis admissions and was associated with a small mortality increase. Further research should examine whether optimized AF management can improve sepsis outcomes in China.

Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter.

Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

Continuing evaluation of atrial fibrillation detection after cryptogenic stroke: one-year findings from a multi-center study with confirm Rx ICM

Abstract Background The detection of atrial fibrillation (AF) after a cryptogenic stroke (CS) carries crucial therapeutic implications. While clinical trials have meticulously explored the incidence of AF in CS patients, real-world data on this topic remain relatively sparse. In this study, we aimed to assess the incidence of AF among patients with cryptogenic stroke, who underwent the implantation of an insertable cardiac monitor (ICM). The abstract reports the interim results from the CS sub-study of the Smart Registry. Methods A prospective, single-arm, multi-center registry was conducted to identify AF in patients with cryptogenic stroke using the Confirm R ICM. Inclusion criteria comprised participants aged 40 years or older who had experienced cryptogenic strokes within a 90-day window. Prior to enrollment, comprehensive diagnostic assessments were performed to meticulously rule out all potential sources of embolism, in accordance with the minimal standards of the American and European Guidelines. At each follow-up visit, expert electrophysiologists reviewed and adjudicated ICM detected AF episodes. The primary endpoint was the cumulative incidence of true device-detected AF (lasting more than 30 seconds) at 6 months. Kaplan-Meier curves were employed to assess the cumulative incidence of true device-detected AF through 12 months. Results In our study, 117 patients were enrolled across 19 global sites from September 2021 to August 31, 2023. Kaplan-Meier analysis revealed a 21.3% probability (confidence interval (CI): 14.5%, 30.7%) of true AF episodes lasting more than 30 seconds at 6 months, increasing to 31.0% (CI: 22.0%, 42.5%) at 12 months. Similar results were observed in episodes lasting over 120 seconds at both 6 months (20.7%) and 12 months (30.5%). In average, 14.4 true AF episodes per patient were detected per year. The median time from implantation to AF detection (&amp;gt; 30 seconds) was 31.5 days (interquartile range, 7 to 191). Conclusion Our ongoing study illustrates the effectiveness of the Confirm Rx ICM in detecting atrial fibrillation after cryptogenic stroke. These results confirm the diagnostics value of long-term continuous AF monitoring in cryptogenic stroke patients.

Left atrial function and polygenic risk scores for predicting atrial fibrillation and related stroke/systemic embolism

Abstract Objective To explore whether the addition of left atrial (LA) function, polygenic risk score (PRS), or both to clinical risk scores improves predictions of atrial fibrillation (AF) and related stroke/systemic embolism (SSE). Methods A total of 36,919 individuals without AF who were assessed for LA emptying fraction and AF-PRS were included from the UK Biobank imgaing enhancement. The primary aims were incident AF and AF-related SSE. AF-related SSE was ascertained when previously undiagnosed AF was identified at the time of an SSE or up to 1-year after an SSE. Results Among the 36,919 participants (median 64 years; 52.4% women), 535 incident AF and 27 AF-related SSE developed over a median follow-up of 2.9 years. Both LA emptying fraction and AF-PRS were associated with the risk of incident AF (hazard ratio [HR] per standard deviation [SD] decrease in LA emptying fraction; 2.13; 95% CI, 1.99-2.27 and HR per SD increase in AF-PRS [95% CI]; 1.65 [1.52-1.79]) and AF-related SSE (HR per SD decrease in LA emptying fraction [95% CI]; 3.52 [2.85-4.35] vs. HR per SD increase in AF-PRS [95% CI]; 1.86 [1.30-2.68]). The addition of LA emptying fraction to a clinical risk score was associated with a significant improvement in C-statistics for incident AF (C-index; 0.704 to 0.788, p for difference in C-index &amp;lt;0.001) and AF-related SSE (C-index; 0.666 to 0.868, p&amp;lt;0.001) but not for AF-PRS (p for difference in C-index &amp;gt; 0.05). The addition of LA emptying fraction was associated with a net reclassification of 26.2% and 21.8% for incident AF and AF-related SSE whereas 11.5% and none with the addition of AF-PRS, respectively. There was limited additive predictive utility with the combination of the two markers over LA emptying fraction alone for both incident AF and AF-related SSE (p for difference in C-index &amp;gt; 0.05). Conclusions Adding LA function to a clinical risk score was associated with statistically significant and clinically meaningful improvements in risk predictions of AF and AF-related SSE compared with adding AF-PRS. The addition of both LA function and AF-PRS to a clinical risk score had limited additive predictive utility compared with the addition of LA function alone.

A polygenic risk score predicts future atrial fibrillation-related stroke/systemic embolism

Abstract Background Novel strategies to identify patients at risk of stroke/systemic embolism (SSE) earlier before development of clinical atrial fibrillation (AF) might be useful. We examined whether the AF polygenic risk score (PRS) added to a clinical risk model would improve prediction of AF-related SSE in people without prevalent AF. Methods A total of 62,145 individuals (≥65 years) without prevalent AF who had additional risk factors for stroke (hypertension, diabetes, heart failure, myocardial infarction, stroke or transient ischemic attack, and peripheral artery disease) were included from the UK Biobank. The primary endpoint was AF-related SSE and the secondary endpoint was incident AF. SSE event was considered AF-related when previously undiagnosed AF was identified at the time of SSE or up to 1-year after the SSE. Results For a median of 11.5 (10.6-12.4) years, 334 AF-related SSE and 7,428 incident AF events developed. After adjusting for the clinical risk model, AF-PRS identified a significant gradient for AF-related SSE and incident AF with a 4.59-fold (HR 4.59, 95% CI 3.12-6.75, p&amp;lt;0.001) and 3.14-fold (HR 3.14, 95% CI 2.90-3.40, p&amp;lt;0.001) higher risk in the top quintile of the AF-PRS. The number needed for 5-years of AF screening at the index age of 75 years to find 1 AF-related SSE and incident AF was 91 and 10 for high AF-PRS and 500 and 22 for low AF-PRS, respectively. AF-PRS added to a clinical risk model resulted in a significant improvement in C-statistics for AF-related SSE (C-index; 0.66 to 0.72, p for difference in C-index &amp;lt;0.001) and incident AF (C-index; 0.65 to 0.68, p for difference in C-index &amp;lt;0.001). Conclusions AF screening strategy based on AF-PRS added to a clinical risk model might detect and potentially prevent more cases of AF-related SSE.

Atrial high-rate episodes detected by cardiac implantable electronic devices: arrhythmic burden and progression towards de-novo clinical atrial fibrillation

Abstract Background Atrial high rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) are associated with a higher risk of thromboembolic events, but whether oral anticoagulants (OACs) improve patient outcomes is still debated. On the other hand, OACs benefits in patients with clinical atrial fibrillation (AF) are well established. Therefore, the potential progression of AHRE towards clinical AF should be promptly recognized. Purpose To evaluate the incidence of de-novo clinical AF and its potential predictors. Methods Consecutive CIED patients presenting AHRE (with confirmation of an arrhythmia lasting 5 min–23 h 59 min, atrial rate 175/min, with no AF at 12-lead ECG and no prior clinical AF) were retrospectively enrolled. Potential predictors of incident clinical AF were investigated by building six different multivariable Cox’s regression analyses, and the duration of the single longest AHRE episode during follow-up was used as a time-dependent covariate. Results 126 patients (median age 79.7 (73.8-84.6), 34.1% female) had available follow-up data. Detailed patients' characteristics are provided in Figure 1. Over a median follow-up of 1128 (580-1646) days, 41/126 (32.5%) patients developed incident clinical AF. A single longest AHRE episode lasting ≥ 6 hours (h) was found associated with a higher risk of incident clinical AF after adjusting for HATCH score, female sex, and coronary artery disease (CAD) (Hazard ratio (HR) 2.82; 95%CI 1.32-6.04) and also in the model adjusting for CHA2DS2-VASc score and CKD (HR 3.13; 95%CI 11.57-6.25). Similar results were found for a single longest AHRE episode lasting ≥ 12 hours (HR 4.91; 95%CI 2.31-10.42 and HR 4.90; 95%CI 2.50-9.60, respectively), and lasting ≥ 24h (HR 4.40; 95%CI 1.82-10.60 and HR 4.56; 95%CI 2.05-10.14, respectively) (Figure 2). On the other hand, HATCH score and CHA2DS2-VASc score were independently associated with a higher risk of incident clinical AF only in multivariable models adjusting for episodes of AHRE lasting ≥6 h (HR 1.42; 95%CI 1.02-1.97 and HR 1.37; 95%CI 1.03-1.83, respectively) but this association was not confirmed after adjusting for AHRE of longer duration. Conclusions In patients with AHRE, the incidence of de-novo clinical AF is high in a three-year follow-up. Baseline patients’ characteristics (HATCH and CHA2DS2-VASc scores) and AHRE duration during follow-up may help to intensify monitoring and decision-making, being independently associated with incident clinical AF at follow-up.Baseline characteristicsMultivariate Cox's regression analysis

Associations of fat and muscle mass indices with incident atrial fibrillation: data of PREVEND

Abstract Background Whether the association between body mass and atrial fibrillation (AF) risk is driven by fat mass or muscle mass remains unclear. Objective To examine the association of relative fat mass (RFM, a novel marker of whole-body fat percentage) and 24-hour urinary creatinine excretion (a marker of total muscle mass) with incident AF. Participants: We included 8120 community-dwelling adults from the PREVEND cohort without prevalent AF. Results The mean age of the population was 49.8±12.6 years and 50.0% (n=4060) were women. The mean RFM was 30.2±7.4 % and the mean creatinine excretion was 12.3±3.5 mmol/24h. During a mean follow-up period of 9.7±2.4 years, 261 AF events (3.2%) occurred. We included RFM, creatinine excretion, age, sex, height, heart rate, hypertension and cardiovascular disease history in a multivariable Cox regression model. The association between RFM and AF risk was linear, and the hazard ratio per 1 SD increase in RFM was 1.40; 95%CI: 1.17-1.66 (P&amp;lt;0.001). The association between creatinine excretion and AF risk was non-linear (P-value quadratic trend=0.006): compared with individuals in tertile 2 of creatinine excretion, those in tertile 1 had a HR of 1.70; 95%CI: 1.21-2.29 (P=0.002) and those in tertile 3 also had a HR of 1.74; 95%CI: 1.22-2.47 (P=0.002). Conclusion In the general population, both fat mass and muscle mass are associated with incident AF. While obesity should be considered as a major risk factor for AF, increased AF risk in individuals with low and high muscle mass warrants further investigation.

A novel score predictor for atrial fibrillation in cardiac implantable electronic device patients

Abstract Background Atrial fibrillation (AF) in individuals with cardiac implantable electronic devices is associated with heightened risks of adverse outcomes. Despite this, risk stratification for AF development in this patient cohort remains unexplored. Consequently, we present the development and validation of a simplified multi-parameter risk-based scoring system for predicting AF in patients with cardiac implantable electronic devices. Methods and Results A cohort of 226 consecutive patients with cardiac implantable electronic devices at Rajavithi Hospital underwent comprehensive follow-up to observe AF development, defined by 12-lead EKG evidence of AF. Analysis encompassed risk factors and AF incidence. The resulting V-DASH score integrated a History of vascular disease, including coronary artery disease (CAD) and peripheral arterial disease (PAD) (1.5 points), Diabetes (1 point), Apical lead position (1 point), Sex (female gender (1.5 points)), and Hypertension (1 point). Predictive value assessment revealed that Diabetes, Female gender, and a history of vascular disease were significantly associated with AF incidence. Apical lead position and Hypertension emerged as robust risk factors for AF development. Over a median follow-up duration of 13 months, 8 (3.53%) patients developed AF. The incidence of AF exhibited a noteworthy escalation in correlation with the V-DASH score (4.68 times higher risk per point increase). Among patients with a V-DASH score ≥4, the probability of AF occurrence was 97.34%. The V-DASH score demonstrated exceptional predictive capability (area under the curve, 0.90; 95% CI, 0.79–1.00), calibration ability (Hosmer-Lemeshow goodness-of-fit P=0.552), and accuracy (sensitivity 87.50% and specificity 83.94%), surpassing other clinical scores such as the C2HEST score. Conclusions The V-DASH score emerged as a robust predictor of AF incidence in patients with cardiac implantable electronic devices, with the highest risk observed in those with a V-DASH score ≥4. The potential clinical utility of the V-DASH score in this patient population warrants further investigation.ROC curve for predicting AFPerformance calibration plot

Long-term time-course of atrial sensing and incidence of atrial fibrillation in patients with VDD versus DDD pacemakers

Abstract Introduction VDD pacemakers (PM) theoretically have the same advantages with respect to maintaining atrioventricular (AV) synchrony as dual-chamber (DDD) pacemakers, with lower costs and simpler implantation procedure. However, their use is often limited by concerns about the maintenance of atrial sensing (AS) and the occurrence of atrial fibrillation (AF). Purpose We aimed to compare long-term atrial sensing stability, the incidence of AF and complications in VDD and DDD systems. Methods We retrospectively enrolled patients who underwent VDD or DDD PM implantation for AV block between 2014 and 2021 from 2 centers. Clinical, analytical and electrical variables at implantation, their evolution and events at follow-up (25.2±16.2 months) were collected, comparing the groups by Kaplan-Meier and Cox multivariate analysis. Results 487 patients who underwent PM implantation were included, 189 (38,8%) received a VDD PM and 298 (61,2%) a DDD PM. Patients with VDD were older and had a higher prevalence of risk factors and lower atrial voltage at implantation (Table). Complications at implantation and early complications were scarce and without significant differences in both groups. During follow-up, there was a reduction in atrial voltage in the VDD group (implant 1.4+0.8 mV; follow-up 1.2+0.9 mV; p&amp;lt;0.01), with stability in the DDD group (3.8+2.1 vs 3.9+2.2 mV). Total percentages of AS loss were 23.2% (VDD) vs 2.3% (DDD); p&amp;lt;0.01) (Figure 1). In the Cox multivariate analysis the risk of late AS loss was higher in the VDD group (HR=7.6; 95% CI 2.86-20.3; p&amp;lt;0.001) together with the AS values at implant (HR=0.72; 95% CI 0.52-1.00; p=0.052). AS loss was corrected with reprogramming in 23 patients, reintervention was needed in 1 (2%) and VVI was abandoned in 27 (53%). The risk of AF occurrence was lower in the VDD group (HR=0.39 CI 95% 0.18-0.87; p=0.021) (Figure 2). Conclusions In the long term, AS is significantly reduced in VDD MPs, leading to its loss in a quarter of VDD patients. It is usually correctable with reprogramming, rarely requiring abandonment to VVI. AS at implantation is crucial as it is directed related to the AS during follow-up. DDD PMs were independently associated with a higher incidence of AF, with no differences in the remaining complications.TableFigure

Surgical treatment for obstructive sleep apnea prevents arrhythmic events: a nationwide population-based study

Abstract Background/Introduction Obstructive sleep apnoea (OSA) is a well-established risk factor for the development and exacerbation of cardiac arrhythmias. Continuous positive airway pressure therapy is recommended as the primary non-invasive treatment for OSA. However, suboptimal patient compliance remains a common challenge. Purpose This study explores the benefits of surgery in reducing the occurrence of arrhythmias associated with OSA. The study aims to investigate the impact of surgery in managing OSA-associated arrhythmias. Methods Data from the Korean Health Insurance, from January 2009 to December 2020, were retrospectively compiled and analysed to investigate the clinical outcomes of 359,851 individuals with OSA. Propensity score matching (PSM) at a 1:4 ratio was employed to compare patients who underwent surgery with those who did not. A final cohort of 117,665 participants (85.4% men, aged 60 years old or younger: 94.2%) was established, with 23,533 having undergone surgery for OSA and 94,132 receiving non-surgical management. Over a five-year follow-up period, the occurrence rates of atrial fibrillation (AF), premature beats (premature atrial contractions or premature ventricular contractions), ventricular arrhythmias, sudden cardiac arrest, atrioventricular block, and sinus node dysfunction were evaluated. Results Across the six types of arrhythmias, the cohort that underwent surgery for OSA consistently exhibited a lower incidence of arrhythmias than the non-surgical cohort. In the PSM analysis, a statistically significant reduction in the incidence of AF, premature beats, and sudden cardiac arrest was observed in groups of patients who underwent surgery for OSA. Among those who developed AF, the group that underwent surgery for OSA had a fivefold higher incidence than the non-surgical group (hazard ratio [HR] 5.384, 95% confidence interval [CI] 3.459-8.381). The incidence of premature beats was more than four times higher in the non-surgical group (HR 4.284, 95% CI 2.96-6.177, p&amp;lt;0.0001), and sudden arrest was more than 24x higher in the non-surgical group (HR 24.089, 95% CI 3.348-173.312). Conclusion This study suggests a potential causative relationship between OSA and arrhythmias. Additionally, surgical intervention for OSA may be considered an effective strategy for preventing arrhythmias in young patients. Further clinical research is warranted to validate and refine these observations.Figure 1Figure 2

Investigating the relationship between the leukocyte telomere length and the incidence of atrial fibrillation: a study utilizing data from the UK Biobank

Abstract Background Atrial fibrillation (AF) is a common cardiac arrhythmia linked to a higher risk of stroke, heart failure, and death. Telomeres are DNA-protein complexes located at the end of chromosomes, and telomere length is known to be associated with biological aging and age-related disease. However, the relationship between leukocyte telomere length (LTL) and AF has been inconsistent in the literature. This study aims to clarify the relationship between LTL and AF risk using UK Biobank data and to examine the link between AF and both biological and chronological aging. Methods The UK Biobank cohort of 502,421 participants aged 40-70 was recruited across 22 UK centers from 2006-2010. After excluding i) missing values (n=32,219), ii) previous AF history (n=6,746) and iii) valvular heart disease (n=3,204), a total of 460,252 participants without AF (median age, 58.0 [interquartile range (IQR), 50.0–64.0] years; 208,543 [45.3%] male) were included. Participants were categorized into four groups based on the LTL, as determined by the adjusted T/S ratio from whole blood test. To investigate the intermediate phenotype prior to the onset of atrial fibrillation, we compared each group with LA maximum volume, LA minimum volume, LA stroke volume, and LA ejection fraction. Throughout the follow-up period, new-onset atrial fibrillation was documented. Survival analysis was conducted using Kaplan-Meier analysis and Cox proportional regression analysis. Results Among 460,252 participants without AF, the new-onset AF group had more comorbidities and lower mean LTL. Groups with shorter LTL tend to be older, and new-onset AF is more prevalent in these groups. Additionally, the incidence of comorbidities is generally higher in the groups with shorter LTL. It was observed that as the LTL shortens, the LA stroke volume decreases. The Kaplan-Meier curve demonstrated that shorter LTL correlated with increased new-onset AF risk. (Log-rank P &amp;lt; 0.001) However, upon examination through a multivariable univariate Cox proportional regression analysis, telomere length did not show as an independent risk factor for new-onset AF. (aHR 1.00, 95% CI 1.00-1.00, P=0.099, Adjusted T/S ratio). Conclusion Even though the incidence of AF increased as LTL shortened, there was no relationship between LTL and new-onset AF when the covariate was adjusted.

Screening for atrial fibrillation in patients with symptoms of cognitive impairment

Abstract Introduction A diagnosis of atrial fibrillation increases the risk for dementia (1). Large register studies including approximately 400,000 patients with atrial fibrillation, have suggested that oral anti-coagulation treatment is associated with a 30-50% reduction of dementia development (2). Still, there are no studies investigating the true prevalence of atrial fibrillation in patients with cognitive problems. Purpose We studied the incidence of silent atrial fibrillation in patients with symptoms of cognitive impairment, participation rate in atrial fibrillation screening and the tolerance of the screening method in this specific population. Method Patients ≥70 years of age, referred from primary care for cognitive investigation at a specialised memory clinic, were invited to undergo a long-term ECG recording using an ECG-patch for two weeks. Patients with a known diagnosis of atrial fibrillation or who already were prescribed oral anti-coagulation treatment were excluded. Participants with detected atrial fibrillation (&amp;gt;30 seconds) were referred to a cardiologist for follow-up and oral anti-coagulation treatment was initiated according to clinical guidelines. Results During the inclusion period n=734 patients were examined for symptoms of cognitive impairment at a memory clinic. Of those, n=191 (26%) had already known atrial fibrillation and n=2 (0.3%) had oral anti-coagulation treatment for other reasons. Of the patients eligible for inclusion n=255/541 (47%) agreed to participate in screening for atrial fibrillation. Participants had a median age of 77 (IQR 74-82) years and median CHA2DS2-VASc score 3 (IQR 3-5). Long-term ECG was recorded for a median of 13.7 (IQR 12.6-14.0) days. Among the 255 participants n=14 (6%) had new atrial fibrillation detected. Total prevalence of atrial fibrillation in the population undergoing cognitive investigation increased with two percent units after screening to 28%. Conclusion The incidence of atrial fibrillation is remarkably high in patients with symptoms of cognitive impairment. Participation rate in screening is high in the selected population and the screening method is well-tolerated.

Temporal trends of ischemic stroke rates in atrial fibrillation without anticoagulation: a nationwide cohort study from 2007 to 2018

Abstract Background Atrial fibrillation (AF) is a major risk factor for ischemic stroke (IS), but whether the magnitude of this risk has changed over time is unknown. Purpose To evaluate temporal trends in IS rates in patients with AF who have not initiated oral anticoagulant (OAC) therapy. Methods The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study covers all patients with incident AF in Finland from 2007 to 2018. A four-week quarantine period from AF diagnosis was applied and only follow-up time without OAC therapy was included. IS incidence rates were computed in four-year intervals. Results In total, 129 789 patients with new-onset AF (49.2% women; mean age 71.4 years) were identified. The IS incidence rate trends according to sex and the CHA2DS2-VA score are depicted in the Figure, along with the previously estimated treatment thresholds for direct oral anticoagulants (red broken line) and warfarin therapy (blue broken line). Between the calendar year intervals of 2007-2010 and 2015-2018, their mean CHA2DS2-VA score increased from 2.5 to 3.0, while concurrently the overall IS rate decreased by 25% from 36.7 (95% CI 34.5-39.0) to 27.6 (95% CI 26.1-29.0) events per 1000 patient years. This trend was driven by a 32% decrease in women, particularly among those with high CHA2DS2-VA scores. The overall IS rate in patients with a CHA2DS2-VA score of 1 was 8.2 (95% CI 7.2-9.4) events per 1000 patient years and it remained stable across the study period. Conclusions The IS rates in AF patients without OAC therapy have decreased by 25% between 2007 and 2018, despite their rising stroke risk scores. In patients with a CHA2DS2-VA score of 1 the IS rate appears to be lower than previously assumed and approximately at the threshold at which the potential benefits and harms of OAC therapy have been estimated to overlap.

Feasibility and procedural safety of the pentaspline pulsed field ablation catheter for atrial lesions beyond pulmonary vein isolation

Abstract Background The pentaspline multi-electrode pulsed-field ablation (PFA) catheter is widely used for the ablation of atrial fibrillation (AF). Given the favorable safety profile of PFA, lesions beyond pulmonary vein isolation (PVI) are increasingly performed. Purpose We aimed to assess the feasibility and safety of PFA beyond PVI with the pentaspline PFA catheter. Methods We retrospectively studied all patients who underwent PFA for atrial arrhythmias in our center between January and October 2023. Procedural characteristics and complications were compared between patients undergoing only PVI (PVI-only group) and those receiving extra-venous applications (extra-PVI group). Results We analysed 202 PFA cases. Indications for ablation included paroxysmal AF (34.7%), persistent AF (57.4%), long-standing persistent AF (5.9%) and atypical atrial flutter (2%). Redo procedures accounted for 18.8% of the total cases. PFA beyond PVI was performed in 142 (70.3%) patients. Patients in the extra-PVI group had a higher incidence of persistent AF (76.8% vs 11.7%, p&amp;lt;0.001), a higher BMI (29±5 vs 26±5 kg/m2, p=0.001) and a more dilated left atrium (LAVI: 73±24 vs 52±20 ml/m2, p&amp;lt;0.001, Table 1). PFA in this group consisted of PVI (98.6%), posterior wall isolation (PWI) (93%), mitral isthmus (MI) ablation (56.3%), a roof line (2.1%), ablation of dispersion electrograms (10.6%) and cavotricuspid isthmus (CTI) ablation (0.7%). In 22 (15.5%) patients, additional CTI ablation with radiofrequency (RF) was performed, while alcohol ablation of the vein of Marshall and RF ablation in the coronary sinus were required in 9 (6.3%) and 2 (1.4%) patients, respectively, to achieve MI block. Compared to the PVI-only group, PFA beyond PVI required a mean of 43 additional applications, a longer procedural (84±29 vs 65±22 min, p&amp;lt;0.001) and fluoroscopy time (25±10 vs 18±6 min, p&amp;lt;0.001) and had a higher fluoroscopy dose (24±35 vs 16.4±28.5 Gy.cm2, p=0.001). A three-dimensional electroanatomic map was used in 12% of cases. Acute success rates were 99% for PVI and PWI, 89% for MI ablation and 100% for roof lines and CTI ablation. Overall complication rates were similar in both groups (16.2% vs 13.3%, p=0.68, Table 2). One cardiac tamponade was observed in the extra-PVI group (0.7%) compared to 4 in the PVI-only group (6.7%, p=0.03). Among the latter, 2 incidents occurred during PVI in patients with long-standing persistent AF, precluding further extra-venous ablation. A small pericardial effusion (without hemodynamic compromise) and/or pericarditis were seen in 9.2% of patients in the extra-PVI group compared to 6.7% in the PVI-only group (p=0.78). No deaths occurred in either group. Conclusions Ablation beyond PVI with the pentaspline PFA catheter is feasible with high success rates and no apparent increase in procedural complications. However, it increases procedural duration and fluoroscopy. Notably, the majority of cardiac tamponades in this cohort occurred during PVI.

Primary prevention of atrial fibrillation with pharmacological therapy

Abstract Background Primary prevention of atrial fibrillation (AF) is important given its rising incidence, associated disease burden, and cost (1-3). The effect of pharmacological therapies on incidence of new-onset AF is uncertain, (1) leading to an absence of clear guideline recommendations for prevention of AF (3). Purpose To perform a meta-analysis of the effect of pharmacological therapies on new-onset AF as reported in published randomised clinical trials (RCTs), and investigate for changes by individual agents and clinically relevant subgroups. Methods We performed a systematic review of RCTs that evaluated the relationship between a pharmacological therapy and the development of new-onset AF in a non-hospitalised patient cohort, using Medline, Embase and Cochrane-controlled Trials Register from inception through 19 July 2023. Results of the AF outcome are expressed as relative ratio (RR) with 95% confidence interval (CI) between the intervention and control group for each study. A fixed-effect model was used to combine results from studies when I2&amp;lt;50% and random-effect model when I2&amp;gt;50%. Risk of bias was assessed using the Cochrane RoB2 tool. Meta-regression was performed by mean age of study participants, percentage of men, follow-up duration, indication (e.g. heart failure) and each agent. Results From 11872 unique records we included 101 RCTs with 794775 patients. Overall, risk of bias was considerable (48% high, 35% medium); driven by outcome measurement (67% high/medium) as AF was not the primary outcome of studies. Of pharmacological therapies, patients treated with angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) demonstrated a lower risk of AF compared with controls (RR 0.87, 95% CI 0.78-0.98), and patients treated with omega-3 fatty acids demonstrated a higher risk of AF (RR 1.26, 95% CI 1.11-1.42) (Figure 1). Analysis by indication demonstrated that the reduction in AF risk with treatment with ACEIs/ARBs was only for patients with heart failure with reduced ejection fraction (HFrEF) (RR 0.57, 95% CI 0.34-0.94). Amongst individual ACEIs/ARBs, only treatment with valsartan (RR 0.79, 95% CI 0.66-0.95) and olmesartan (RR 0.87, 95% CI 0.45-0.99) led to a lower risk of AF. On meta-regression each year of increased age increased AF risk when treated with ACE-I/ARB therapy (RR 1.08, 95% CI 1.04-1.13). Whilst no reduction in AF was observed for other pharmacological classes overall, treatment with Semaglutide demonstrated a 40% lower risk of AF compared with controls (RR 0.60, 95% CI 0.45-0.80) (Figure 2). Conclusions ACEIs and ARBs appear to be effective in the primary prevention of AF, but this benefit may be limited to patients with HFrEF, especially younger patients. Effect on AF occurrence varies within pharmacological classes, and Semaglutide specifically may be an effective in preventing new-onset AF. Appropriately powered RCTs with new-onset AF as the primary outcome are required.Figure 1:Forest plot by pharmacotherapyFigure 2:Forest plot by GLP-1RA agent

Incidence and outcome of periinterventional atrial fibrillation in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention

Abstract Background Peri-interventional atrial fibrillation (AF) may be detected in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). Data on the thromboembolic risk and long-term clinical outcome in patients with AF limited to the peri-interventional period is scarce. Purpose To assess the incidence and impact on long-term clinical outcome of peri-interventional de-novo AF in STEMI patients. Methods and Results This retrospective single-center cohort study included all patients who underwent PCI between January 2016 and November 2020 (n=491) due to STEMI. Patients were stratified to three cohorts of AF status: Pre-existing AF: n=42 [8.6%], newly diagnosed peri-interventional AF: n=56 [11.4%] and no AF: n=393 [80.0%]. Patients with newly diagnosed peri-interventional AF as well as patients with pre-existing AF had in median a mild-moderately reduced left ventricular ejection fraction (LVEF), patients in sinus rhythm in median a normal LVEF. During the average follow-up time of 4.7 years (min. 2 years, max. 7 years) the rate for readmission for AF or occurrence of AF without hospital admission was increased in patients with peri-interventional de-novo AF or pre-existing AF (n=6 [10.7%], n=10 [23.8%]) compared to those in sinus rhythm n=22 [5.6%] (p&amp;lt;0,001) The occurrence of ischemic stroke was higher in patients with peri-interventional de-novo AF (n=2 [3.6%] or with pre-existing AF (n=2 [4.8%]) compared to those in sinus rhythm (n=6 [1.5%]. (p=0.256) The risk of cardiovascular death was significantly higher in patients with newly diagnosed peri- interventional AF compared to patients with pre-existing or no AF (n=13 [23.2%], n=5 [11.9%], n= 37 [9.4%]) (p=0.009). In the patient group with peri-interventional de-novo AF, only 25.0% (n=13) received long-term oral anticoagulation therapy (OAK). The rate of stroke in patients who received OAK after peri- interventional de-novo AF was 7.7% (n=1) compared to those without OAK 2.6% (n=1). Conclusion Peri-interventional AF is a frequent finding in STEMI patients undergoing primary PCI. Patients with peri-interventional AF had a significantly increased risk for an adverse cardiovascular outcome. Optimal secondary prophylactic measures appear mandatory in this patient population. The significance of long-term OAK therapy is to be determined.

Right atrial endomysial fibrosis is associated with higher POAF-burden

Abstract Background Atrial endomysial fibrosis, rather than overall connective tissue content, determines the complexity of conduction in human atrial fibrillation (AF). Moreover, the AF-specific blood biomarker BMP10 is associated with atrial endomysial fibrosis, but not overall connective tissue content. It is unclear whether pre-operative atrial endomysial fibrosis predicts post-operative AF (POAF) incidence and burden. Objective To determine the predictive value of atrial fibrosis for early and late POAF burden. Methods Patients with and without AF history were included in the RACE V tissue bank study (n=134). Post-operative rhythm was monitored continuously for 2.5 years with implantable loop recorders. Late POAF-burden was investigated following a 90-day blanking period. Left (n=89) and/or right (n=92) atrial appendage biopsies (LAA/RAA) were snap-frozen and histologically investigated following WGA-staining. Results Logistic regression, corrected for age, sex and AF history, showed that left (st.β = 0.54 [0.23-0.85], p=0.001) and right (st.β=0.35 [0.07-0.64], p=0.017) atrial endomysial fibrosis were associated with early POAF burden in the blanking period. Only right atrial endomysial fibrosis, however, predicted late POAF-burden (st.β=0.44 [-], p=0.009). Adjusted Cox proportional hazards analyses indicated that patients in the highest tertile of right atrial endomysial fibrosis, in particular, are at risk for late POAF (HR T3 vs T1: 2.47 [1.18-5.17], p=0.016, Fig 1). Overall connective tissue content in both atria was not associated with POAF-burden. Conclusion Patients with higher levels of right atrial endomysial fibrosis are at risk for developing late POAF with a higher POAF-burden.Figure 1