Initial Diagnosis Of Atrial Fibrillation Research Articles

Early ablation leads to better outcome in patients < 55 years with persistent atrial fibrillation

The question of optimal timing for catheter ablation of atrial fibrillation (AF) to achieve best outcomes remains a crucial clinical issue. As AF occurs less frequently in younger patients, data regarding Diagnosis-to-Ablation Time (DAT) is especially limited in patients under the age of 55 years with persistent AF. We therefore analyzed the temporal relationship between initial AF presentation and timing of catheter ablation in this cohort. We conducted a retrospective single-centre study of patients ≤ 55 years with persistent AF who underwent first-time catheter ablation at our center. The cohort was divided into patients that underwent catheter ablation after diagnosis of persistent AF within a DAT of ≤ 12 months and patients with a DAT of > 12 months. A total of 101 patients (median age 51 years; female n = 19 (18.8%)) with persistent AF were included. Ablation was performed within 12 months (“early DAT”) in 51 patients and > 12 months (“late DAT”) in 50 patients. Pulmonary vein isolation was performed using high-power short-duration (HPSD) radiofrequency ablation. Median DAT was 5 months (1–12 months) in the early ablation group and 36 months (13–240 months) in the late ablation group. The median follow-up was 11.3 months (0.03–37.1 months). The rate of any atrial arrhythmia recurrence after a 30-day blanking period was significantly lower in the early DAT group (13/51 patients; 25.5%) as compared to the late DAT group (26/50 patients; 52.0%) (log rank test; p = 0.003). Catheter ablation performed > 12 months after the initial AF diagnosis was an independent predictor for the occurrence of any atrial arrythmia (OR: 2.58; (95%-CI: 1.32–5.07). Early first-time catheter ablation (DAT ≤ 12 months) in patients ≤ 55 years with persistent AF is associated with a significantly lower rate of arrhythmia recurrence.

Risk Factors for Treatment Transition in Patients with Low-Risk Atrial Fibrillation Patients Undergoing Anticoagulation Monotherapy: A Large Claims Database Study in Japan.

The global prevalence of atrial fibrillation (AF) is rising, paralleling increased life expectancy. Early rhythm control benefits AF management. However, in low-risk, often asymptomatic, AF patients, anticoagulant monotherapy is the selected treatment, aligning with current guidelines. However, early AF progression in these low-risk individuals is not well-understood. Thus, this study aims to: 1) determine the proportion of low-risk AF patients who worsen within a year of initial AF diagnosis and 2) identify risk factors such treatment transitions. We analyzed data from 18623 AF patients, spanning January 2005 to June 2017. Low-risk patients were those on anticoagulant monotherapy ± rate control, following the JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. We defined 2 patterns of treatment transition for 1) initiating ablation or antiarrhythmic drug therapy and 2) solely using antiarrhythmic drugs. This retrospective cohort study was employed a 12-month study, following a 6-month screening period. We included 1874 patients for all rhythm control (analysis 1) and 1503 for only medication-based control (analysis 2). The primary endpoint, treatment transition of AF under monotherapy, occurred in 28.4% of patients in analysis 1 and 10.8% in analysis 2. Risk factors common to both scenarios were male gender, baseline rate control drug use, and rivaroxaban selection, as identified by multiple logistic regression. These findings suggest a higher AF treatment transition trend in patients starting rivaroxaban, calling for further research. The study highlights the importance of informed early rhythm control initiation decisions in clinical settings.

Abstract 15698: Association of Social Factors on Sex-Specific Management of Atrial Fibrillation

Introduction: Prior studies have reported disparities by sex in managing atrial fibrillation (AF), with many studies having limited analysis of the effects of social risk factors. We examined the effect of social risk factors on sex differences in the management of AF in a large, socially diverse cohort of insured patients. Hypothesis: We hypothesized that women with AF would receive less AF care, including the receipt of AF-related medications, pulmonary vein isolation ablation, and cardiology follow-up, compared to men. Methods: We identified individuals with AF from 2013-2019 captured by Optum’s de-identified Clinformatics® Data Mart Database. Sex was categorized as men and women. Covariates included demographics (age, sex, race, and ethnicity), Elixhauser variables, and social factors such as estimated annual household income and race or ethnicity. We used stepwise multivariable-adjusted Cox proportional hazards models to assess the effect of race, ethnicity, and household annual income on sex-specific differences in the receipt of AF-related medications, pulmonary vein isolation ablation, and cardiology follow-up. Results: We identified 190,760 individuals (age 74.0±11.4 years; 49.9% women) with incident AF. Women with AF were less likely to receive pulmonary vein isolation ablation and cardiology follow-up over a six-year follow-up than men. Prescriptions of antiarrhythmic were identical among both sexes. When stratified by race and ethnicity, women of Black (HR 0.75, 95% CI 0.61,0.92) and White race (HR 0.83, 95% CI 0.78, 0.88) were less likely to receive pulmonary vein isolation ablation than men. Women of Asian (HR 0.90, 95% CI 0.83,0.97) and White race (HR 0.93, 95% CI 0.92,0.94) were less likely to have cardiology follow-up after initial diagnosis of AF than men. Higher household income did not attenuate sex-specific differences in AF care. Across all income categories, women were less likely to have pulmonary vein isolation and cardiology follow-up. Conclusions: We identified sex differences in AF management that were not attenuated when considering race, ethnicity, and annual household income. Our findings suggest continued evidence of sex, racial, ethnic, and socioeconomic inequities in contemporary AF management.

Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes in patients with and without structural heart disease.

Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown. All patients that received a catheter ablation for AF(n = 9979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF ≤ 35% (n = 1024) and EF > 35% (n = 8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n = 1747), 3:546-1825(n = 2941), and 4:>1825(n = 2602) days. The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF > 35%: 3.5 ± 3.8 years, EF ≤ 35%: 3.4 ± 3.8 years, p = .66). In the EF > 35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p < .0001), 2.62(p < .0001), and 4.39(p < .0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:1.11-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤ 35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24). Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease.

Impact of frailty on early rhythm control outcomes in older adults with atrial fibrillation: A nationwide cohort study.

Rhythm-control therapy administered early following the initial diagnosis of atrial fibrillation (AF) has superior cardiovascular outcomes compared to rate-control therapy. Frailty is a key factor in identifying older patients' potential for improvement after rhythm-control therapy. This study evaluated whether frailty affects the outcome of early rhythm-control therapy in older patients with AF. From the Korean National Health Insurance Service database (2005-2015), we collected 20,611 populations aged ≥65 years undergoing rhythm- or rate-control therapy initiated within 1 year of AF diagnosis. Participants were emulated by the EAST-AFNET4 trial, and stratified into non-frail, moderately frail, and highly frail groups based on the hospital frailty risk score (HFRS). A composite outcome of cardiovascular-related mortality, myocardial infarction, hospitalization for heart failure, and ischemic stroke was compared between rhythm- and rate-control. Early rhythm-control strategy showed a 14% lower risk of the primary composite outcome in the non-frail group [weighted incidence 7.3 vs. 8.6 per 100 person-years; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.79-0.93, p < 0.001] than rate-control strategy. A consistent trend toward a lower risk of early rhythm-control was observed in the moderately frail (HR 0.91, 95% CI 0.81-1.02, p = 0.09) and highly frail (HR 0.93, 95% CI 0.75-1.17, p = 0.55) groups. Although the degree attenuated with increasing frailty, the superiority of cardiovascular outcomes of early rhythm-control in AF treatment was maintained without increased risk for safety outcomes. An individualized approach is required on the benefits of early rhythm-control therapy in older patients with AF, regardless of their frailty status.

Atrial fibrillation is associated with a subsequent epilepsy diagnosis independent of stroke: A retrospective matched administrative cohort study on 149,632 patients

Recently there has been a rising interest in the identification and possible prevention of risk factors for epilepsies. In the present study, we investigated the potential association between atrial fibrillation (AF) and epilepsy in a German cohort of ambulatory patients aged ≥18 with an initial diagnosis of atrial fibrillation documented in 1274 general practices in Germany between January 2005 and December 2018.Using the IQVIA Disease Analyzer database, we identified 74,681 ambulatory patients with AF. These were matched 1:1 to patients without AF based on sex, age, index year, yearly consultation frequency, and defined co-diagnoses like stroke. Cox regression models were used to evaluate the association between AF and epilepsy.Within 10 years of the index date, 1.9% of individuals with AF and 1.5% of individuals without AF were diagnosed with epilepsy (log-rank p < 0.001). Atrial fibrillation was significantly associated with an increase in the incidence of epilepsy (Hazard Ratio (HR): 1.51, p < 0.001). The association was significant in all age groups, except in patients >80 years of age (HR: 1.29, p = 0.031).Our study demonstrates that AF is associated with an increased incidence of epilepsy. This finding could help understand the mechanisms of epilepsy in heart disease and to better protect affected individuals in the future.

Abstract 14156: Automated Electronic Medical Record Mapping to Identify Acute Precipitants of Atrial Fibrillation and Oral Anticoagulation Use

Introduction: Atrial fibrillation (AF) that is associated with acute precipitants frequently recurs and is associated with long-term morbidity and mortality. Leveraging a large electronic medical record (EMR) database, we previously reported the performance of an automated EMR-based algorithm to identify the acute precipitants of newly detected-AF, but its validation in other databases has not been performed. Hypothesis: Modified EMR-based algorithm would accurately identify acute precipitants of AF and oral anticoagulation (OAC) use after AF diagnosis Methods: Among all records (inpatient/outpatient/ER) in a single-institution EMR (10/1/17 - 12/31/19), we first identified 4493 records documenting newly-diagnosed AF (ICD 10: I48). We then applied the modified EMR-based algorithm to identify 13 acute AF precipitants (within 30 days of AF diagnosis, Figure 1) and determine OAC use after an AF diagnosis. We manually adjudicated a random subset of identified records (892 of 4493) to derive performance metrics of the EMR algorithm. Results: Of 4493 records with newly-diagnosed AF, the algorithm identified ≥1 acute precipitant in 831 records and ≥2 precipitants in 206 records. The most common precipitants were respiratory failure (38%) and pneumonia (35%). Among patients with CHADS2Vasc ≥2, 44% with an acute precipitant were prescribed an OAC vs. 63% free from a precipitant after initial AF diagnosis. EMR algorithm accurately identified the precipitants and OAC use after AF diagnosis (PPV 89% for both, Figure 1). Conclusions: In this validation study, our novel EMR-based automated algorithm was highly accurate at identifying acute precipitants of AF and OAC use after AF diagnosis. We also observed differential rates of OAC use between those with and without an acute precipitant. Application of the algorithm to multi-institutional datasets could help map the gaps in care (e.g., OAC use) AF patients with acute precipitants often experience.

Risks of Stroke and Mortality in Atrial Fibrillation Patients Treated With Rivaroxaban and Warfarin.

Background and Purpose- Oral anticoagulation therapy is standard of care for patients with nonvalvular atrial fibrillation to prevent stroke. This study compared rivaroxaban and warfarin for stroke and all-cause mortality risk reduction in a real-world setting. Methods- This retrospective cohort study (2011-2017) included de-identified patients from the Optum Clinformatics Database who started treatment with rivaroxaban or warfarin within 30 days following initial diagnosis of nonvalvular atrial fibrillation. Before nonvalvular atrial fibrillation diagnosis, patients had 6 months of continuous health plan enrollment and CHA2DS2-VASc score ≥2. Stroke severity was determined by the National Institutes of Health Stroke Scale, imputed based on machine learning algorithms. Stroke and all-cause mortality risks were compared by treatment using Cox proportional hazard regression, with inverse probability of treatment weighting to balance cohorts for baseline risk factors. Stratified analysis by treatment duration was also performed. Results- During a mean follow-up of 27 months, 175 (1.33/100 patient-years [PY]) rivaroxaban-treated and 536 (1.66/100 PY) warfarin-treated patients developed stroke. The inverse probability of treatment weighting model showed that rivaroxaban reduced stroke risk by 19% (hazard ratio [HR], 0.81 [95% CI, 0.73-0.91]). Analysis by stroke severity revealed risk reductions by rivaroxaban of 48% for severe stroke (National Institutes of Health Stroke Scale score, 16-42; HR, 0.52 [95% CI, 0.33-0.82]) and 19% for minor stroke (National Institutes of Health Stroke Scale score, 1 to <5; HR, 0.81 [95% CI, 0.68-0.96]), but no difference for moderate stroke (National Institutes of Health Stroke Scale score, 5 to <16; HR, 0.93 [95% CI, 0.78-1.10]). A total of 41 (0.31/100 PY) rivaroxaban-treated and 147 (0.44/100 PY) warfarin-treated patients died poststroke, 12 (0.09/100 PY) and 67 (0.20/100 PY) of whom died within 30 days, representing mortality risk reductions by rivaroxaban of 24% (HR, 0.76 [95% CI, 0.61-0.95]) poststroke and 59% (HR, 0.41 [95% CI, 0.28-0.60]) within 30 days. Conclusions- After the initial diagnosis of atrial fibrillation, patients treated with rivaroxaban versus warfarin had significant risk reduction for stroke, especially severe stroke, and all-cause mortality after a stroke. Findings from this observational study may help inform anticoagulant choice for stroke prevention in patients with nonvalvular atrial fibrillation.

The Impact of Atrial Fibrillation Clinical Subtype on Mortality

This study sought to investigate the prognostic implications of the clinical subtype of atrial fibrillation(AF): paroxysmal or persistent. Underlying structural abnormalities of the left atrium may be responsible for the initial clinical presentation of AF in either paroxysmal or persistent form, yet the prognostic implications of the clinical subtype on presentation are unknown. Over a median of 7 years, 1,773 patients (age 64 ± 12 years, 74% males) with nonvalvular AF with index presentations for paroxysmal or persistent AF were followed for the occurrence of all-cause mortality. Clinical information including cardiovascular risk factors, comorbid diseases associated with AF, and CHA2DS2-VASc (congestiveheart failure, hypertension, age≥75 [double weight], diabetes, stroke [double weight], vascular disease, age65-74, and sex category [female]) score was collected and analyzed. In this study, 1,005 patients (57%) had persistent AF. Eighty patients (10%) with paroxysmal AF and 174patients (17%) with persistent AF died during the follow-up period. Persistent AF compared with paroxysmal AF upon initial AF diagnosis was independently associated with worse survival independent of the CHA2DS2-VASc score and otherhigh-risk cardiovascular risk factors (hazard ratio: 1.24; 95% confidence interval: 1.11 to 1.38). In patients with nonvalvular AF, persistent AF compared with paroxysmal AF upon first diagnosisisindependently associated with increased mortality.

Refining Stroke Prediction in Atrial Fibrillation Patients by Addition of African-American Ethnicity to CHA2DS2-VASc Score

BackgroundPrior studies show that African-American patients have a higher risk of stroke compared with Caucasians. ObjectivesThis study hypothesized addition of African-American ethnicity to CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke, vascular disease, age 65 to 74, and female sex) score might improve stroke prediction in patients with atrial fibrillation (AF). MethodsMedicare claims from January 2010 to December 2012 identified patients with newly diagnosed AF. The CHA2DS2-VASc was calculated on the basis of diagnoses in claims incurred during 12 months before first AF diagnosis. Ethnicity was identified from the Beneficiary Summary File. CHA2DS2-VASc-R score was calculated by giving 1 additional point for African-American ethnicity. The primary outcome was stroke, defined by primary diagnosis on acute inpatient admissions after the initial AF diagnosis. We used proportional hazards regression to determine the relationship between stroke and the CHA2DS2-VASc or a revised CHA2DS2-VASc-R score. ResultsOf 460,417 patients with AF, 390,590 (85%) were non-Hispanic whites, 31,702 (7%) were non-Hispanic African Americans, and the remainder were other non-white ethnicities. Mean age was 79.2 ± 8.0 years, with 60% females. Overall, 16,703 stroke events occurred, and 151,441 (32.7%) patients died during a mean follow-up period of 18.0 months. Compared with CHA2DS2-VASc, CHA2DS2-VASc-R score improved the fit of the model significantly as measured by the log likelihood ratio statistic (p < 0.001). Among individual risk factors in CHA2DS2-VASc-R score, only prior stroke, age ≥75 years, and female sex had a stronger association with incident stroke than African-American ethnicity. ConclusionsIn patients >65 years of age with newly diagnosed AF, the addition of ethnicity to CHA2DS2-VASc score significantly improved stroke prediction.

P25 Stroke risk from atrial fibrillation in repaired tetralogy of fallot

Background Atrial fibrillation (AF) has a prevalence of 1.6% in the UK and significantly increases the risk of developing a stroke. Adults with congenital heart disease have an increased risk of developing arrhythmias, a leading cause of morbidity and mortality in these patients. CHADSVASC scoring system is a recommended tool for assessing thromboembolic risk in AF for the general population; its role in adult congenital heart disease is still uncertain. Method All patients with repaired Tetralogy of Fallot (TOF) and atrial fibrillation were identified from our database and their notes were retrospectively reviewed. Results 35 of the 456 (7.7%) patients with repaired TOF under regular follow-up at a large quaternary Specialist Adult Congenital Disease Centre were identified as having AF, mean age 56.5(+/-12.1) years, range 27–77 years, 19 male (54.3%). The average CHADSVASC score was 1.83 (range 0–4). Most were anticoagulated; 28 (80%) received warfarin, 3 (8.6%) took a novel anticoagulant (NOAC) but 4 patients were not anticoagulated. The mean age of initial AF diagnosis was 48(+/-13.7) years. 15 (42.9%) patients were diagnosed with AF before the age of 45 years and 7 (20%) before the age of 35 years. Most patients were symptomatic. 5 (14.3%) patients had either a stroke or a transient ischaemic attack. 2 had multiple strokes. 3 of the patients had strokes when they had known AF but were not anticoagulated having CHADVASC scores of 2 or less. 1 patient had 2 strokes in their twenties but was not diagnosed with AF until their 40s. 1 patient suffered a stroke while prescribed rivaroxaban. Conclusion The risk of stroke in TOF appears high. It is unclear whether the CHADSVASC score is useful for risk stratification. This data suggest that anticoagulation should be considered in all patients with TOF and AF, irrespective of CHADSVASC score. The role of NOACs in this population is unclear.

Race- and sex-related differences in care for patients newly diagnosed with atrial fibrillation.

Atrial fibrillation (AF) is associated with an increased risk of stroke and death. Uniform utilization of appropriate therapies for AF may help reduce those risks. We sought to determine whether significant race and sex differences exist in the treatment of newly diagnosed AF in Medicare beneficiaries. We used administrative encounter data for Medicare beneficiaries to identify patients with newly diagnosed AF during 2010-2011. Services received after initial AF diagnosis were cataloged, including visits with a cardiologist or electrophysiologist, catheter ablation procedures, and use of oral anticoagulants, rate control agents, and antiarrhythmic drugs. Overall, 517,941 patients met study criteria, of whom 452,986 (87%) were white, 36,425 (7%) black, and 28,530 (6%) Hispanic. Male patients comprised 209,788 (41%) of the cohort. In multivariate analysis, there were statistically significant differences in the use of AF-related services by both race and sex, with white patients and male patients receiving the most care. The most notable disparities were for catheter ablation (Hispanic vs white: adjusted hazard ratio [AHR] 0.70; 95% confidence interval [CI] 0.63-0.79; P < .001; female vs male: AHR 0.65; 95% CI 0.63-0.68; P < .001) and receipt of oral anticoagulation (black vs white: AHR 0.94; 95% CI 0.92-0.95; P < .001; Hispanic vs white: AHR 0.94; 95% CI 0.93-0.97; P < .001; female vs male: AHR 0.93; 95% CI 0.93-0.94; P < .001). Race and sex appear to have a significant effect on the health care provided to this cohort of Medicare beneficiaries diagnosed with AF. Possible explanations include racial differences in access, patient preferences, treatment bias, and unmeasured clinical characteristics.

Pacemaker diagnostics in atrial fibrillation: limited usefulness for therapy initiation in a pacemaker practice.

We aimed to determine the practical value of pacemaker diagnostics for atrial fibrillation (AF) in an unselected general pacemaker practice, specifically workflow and initiation of anticoagulation or antiarrhythmic drug (AAD) therapy. We prospectively followed consecutive pacemaker interrogations over a period of 1 year to identify patients with AF (burden from 1% to 99%). We contacted referring physicians with AF details, and then determined whether the information resulted in therapeutic changes. Of the 1,100 pacemakers interrogated, 728 were dual chamber (DDDs) with AF diagnostic capability. AF was recorded in 73 (10%) but seven had limited information, leaving 66 patients; of these, 42 (63%) patients were already anticoagulated and in five (7%) patients, anticoagulation had been stopped because of complications. Initial diagnosis of AF was made by the pacemaker in 17 patients (26% of 66; 2% of 728); four (6% of 66) patients were newly initiated on anticoagulation. Of the 66 patients, 17 patients were already on AADs; 49 (74%) had satisfactory rate control or had other issues; only two (3% of 66; 0.3% of 728) received new AADs. Of 728 patients with DDD pacemakers, only 17 were newly discovered to have AF, and six (0.8%) had changes in medications based on the pacemaker data. Adding pacemaker-derived data to existing clinical information had little therapeutic impact, due to a combination of cumbersome workflow, and because AF was usually known to practitioners. Developments in automated monitoring systems may provide more accessible and therapeutically useful information.

Atrial Fibrillation and Cardiovascular Comorbidities, Survival and Mortality: A Real-Life Observational Study.

BackgroundAtrial fibrillation (AF) is the most common cardiac tachyarrhythmia encountered in clinical practice affecting up to 10% of the population over 60 years old and its prevalence rises with age. The main goals were to characterize the AF patient population after the initial diagnosis of AF and to determine overall survival.MethodsIt is a real-life observational study of 269 subjects with an AF diagnosis over 60 years old randomly selected. The collected variables were: sociodemographic, cardiovascular complications/comorbidities (CVCs) included in the CHA2DS2-VASc and HAS_BLED scores, drug assigned as clinical treatment, mean range INR and CVCs and death dates (all-cause mortality). The survival curve and the risk of death were assessed using Kaplan-Meier survival curve and comparisons with log-rank.ResultsThe average following time was 6.2 ± 3.7 years (0.2-20.4). Eleven point five percent died. Sixty-five point four percent had some CVCs. There were no differences in the overall incidence of CVCs by gender. The survival probability was 0.86 ± DE 0.03 among men and 0.90 ± DE 0.04 among women without differences. Thirty-six point eight percent (95% CI: 30.8 - 42.7) were diagnosed vascular complications before AF diagnosis, being ischemic cardiopathy (24.2%) and ischemic stroke (23.2%) the most frequent. The mortality is higher (P < 0.036) among those who suffered ≥ 3 vascular complications and significantly lower among those treated with statins (P = 0.032). After AF diagnosis, the most frequent was the cardiac heart failure (46.7%), significantly higher among women (P = 0.037). The mortality is significantly lower in those treated with OAC (P = 0.003).ConclusionsAF is associated with ischemic heart disease, ischemic stroke and congestive heart failure, but the average mortality age is not different from the global population in Spain and Catalonia.

Patient preferences at ten years following initial diagnosis of atrial fibrillation: the Belgrade Atrial Fibrillation Study

BackgroundMany atrial fibrillation (AF) patients have a poor understanding of the management of this condition. We investigated patient attitudes towards AF and a potential invasive treatment following an average 10-year period of prospective rhythm control in a cohort of newly diagnosed AF patients.MethodsThis was a prospective registry-based study. At the regular annual visit in 2007, patients were asked at random to answer several AF-related questions.ResultsOf 390 patients, 277 (71.0%) reported symptom reduction over time, but only 45 (11.5%) reported that they had “got used” to AF; 201 patients (51.5%) stated they would always prefer sinus rhythm, and 280 (71.2%) would accept an invasive AF treatment. Independent predictors for choosing an invasive procedure were younger age, impaired career/working capacity, and male gender (all P < 0.05).ConclusionOur findings suggest that most AF patients prefer sinus rhythm and would readily accept an invasive procedure if it offered the possibility of a cure for their AF.

Improving outcomes in patients with atrial fibrillation: Rationale and design of the Early treatment of Atrial fibrillation for Stroke prevention Trial

Even on optimal therapy including anticoagulation and rate control, major cardiovascular complications (stroke, cardiovascular death, and acute heart failure) are common in patients with atrial fibrillation (AF). Conceptually, maintenance of sinus rhythm could prevent adverse outcomes related to AF. Rhythm control therapy has been only moderately effective in published trials, and its potential benefit was offset by side effects of repeated interventions. Rhythm control therapy applied early after the first diagnosis of AF could preserve atrial structure and function and maintain sinus rhythm more effectively than the current practice of delayed rhythm control (when symptoms persist after otherwise effective rate control). Furthermore, catheter ablation and new antiarrhythmic drugs have enhanced the potential effectiveness and safety of rhythm control therapy. The EAST will test whether an early, modern rhythm control therapy can reduce cardiovascular complications in AF. The EAST (Early treatment of Atrial fibrillation for Stroke prevention Trial) will randomize approximately 3,000 patients with recent onset AF at risk for stroke (CHA₂DS₂VASc score ≥2) to either guideline-mandated usual care or to usual care plus early rhythm control therapy in a prospective, randomized, open, blinded outcome assessment trial. All patients will be followed up until the end of the trial for the composite primary outcome of cardiovascular death, stroke, worsening of heart failure, and myocardial infarction. Nights spent in hospital will be counted as a coprimary outcome. Usual care will consist of anticoagulation, therapy of underlying heart disease, and rate control as an initial approach. Early rhythm control therapy will consist of usual care plus rhythm control therapy by antiarrhythmic drugs, catheter ablation, and a patient-operated electrocardiographic device to monitor the ongoing rhythm. Key secondary outcomes include cognitive function and quality of life. EAST will determine whether rhythm control therapy, when applied early after the initial diagnosis of AF, can prevent cardiovascular complications associated with AF.

Left Atrial Function Assessed by Doppler Echocardiography Rather Than Left Atrial Volume Predicts Recurrence in Patients With Paroxysmal Atrial Fibrillation

Paroxysmal atrial fibrillation (PaAF) may present as a single self-terminating episode of atrial fibrillation (AF) or a more persistent form after sinus conversion. We investigated predictors of recurrence in patients with PaAF. Left atrial function would be an useful parameter for predicting PaAF recurrence. The study population included 228 PaAF patients (131 males, age 64±14 years) who underwent transthoracic echocardiography immediately after spontaneous sinus conversion at initial AF diagnosis. We followed the study patients for AF recurrence. AF recurrence was demonstrated in 45 patients (20%, age 68±13 years) after spontaneous sinus conversion. Patients with recurrence had larger left atrial volume index (32±12 vs 25±10 mL/m2, P<0.001), left ventricle mass index (107±34 vs 93±25 g/m2, P=0.012), and left ventricle filling pressure (E/e'') (14±7 vs 12±5, P=0.012), whereas early diastolic mitral annular velocity (e') (5±2 vs 6±3 cm/s, P=0.021), late diastolic mitral annular velocity (A') (7±3 vs 9±2 cm/s, P<0.001), and peak systolic mitral annular velocity (7±2 vs 8±2 cm/s, P=0.045) were significantly lower. In multivariate Cox regression analysis detecting independent predictors of PaAF recurrence, lower A' (hazard ratio: 0.623, 95% confidence interval: 0.476-0.815, P=0.001) was a significant predictor of AF recurrence. A', which indicates left atrial (LA) contractile function after sinus conversion, was the independent predictor of PaAF recurrence, whereas LA volume was not. LA function may be more important than LA volume in predicting recurrence particularly in patients with PaAF.

Abstract TP388: Timing Of Diagnosis Of Atrial Fibrillation Relative To Ischemic Stroke And Transient Ischemic Attack

OBJECTIVES: To determine the frequency of initial atrial fibrillation (AF) diagnosis prior to, concurrent with, or subsequent to incident ischemic stroke and ischemic stroke or transient ischemic attack (TIA). METHODS: A large healthcare claims database (MarketScan) was queried to identify adult patients with an inpatient diagnosis of ischemic stroke between 2004 and 2010. Inpatient or outpatient diagnoses of AF were identified on claims prior to hospitalization admission for stroke, during the hospital stay, or following discharge. Stroke patients were categorized as to whether initial AF diagnosis occurred prior, concurrent, or subsequent to stroke or diagnosis was never made. Restrictions on minimum health plan pre-enrollment prior to incident stroke were applied for sensitivity analysis of estimates of patients diagnosed with AF. Additional estimates of prior, concurrent and subsequent initial AF diagnosis were performed for patients with either incident inpatient stroke/TIA or outpatient TIA diagnosis. RESULTS: Of the 303,555 patients identified with an inpatient diagnosis of stroke and 795,612 patients with either inpatient stroke/TIA or outpatient TIA, 48.4% and 45.1% were male, respectively. Average ages were 68.2 (SD 15.8) and 66.1 (SD 15.6), respectively. The majority of patients never had a diagnosis of AF; a minority had a concurrent diagnosis, while a larger percentage had a subsequent diagnosis (Table). CONCLUSIONS: A proportion of the 12.4% of stroke and 8.9% of stroke/TIA patients with concurrent or subsequent AF diagnosis may have had undetected / paroxysmal AF at the incident stroke or TIA. Concurrent AF diagnoses alone may underestimate the percentage of patients with undetected AF at the time of stroke or TIA. More aggressive efforts to diagnose AF may be beneficial, although additional research is needed to better quantify the current burden of undiagnosed AF among stroke patients.

Completion of Guideline‐Recommended Initial Evaluation of Atrial Fibrillation

Guidelines recommend evaluation of cardiac function, valvular and ischemic heart disease, and thyroid, kidney, and liver function on initial diagnosis of atrial fibrillation (AF). We hypothesized that initial workup of patients with newly identified AF would vary by age, sex, and burden of comorbid illness. In a retrospective analysis of a large sample of commercially insured patients 18 to 64 years old (n = 40 245) and a nationally representative 5% cohort of Medicare beneficiaries 65 years or older (n = 204 676), we measured claims for guideline-recommended services for initial evaluation of AF among patients with a new diagnosis between 2000 and 2008. From 30 days before through 90 days after AF diagnosis, basic evaluation, including physician visit, electrocardiogram, and echocardiography, was completed in up to 66.6% of patients. Completion rates for all guideline-recommended evaluations were 17.4% in the commercially insured sample and 18.5% in the Medicare cohort in 2007. Evaluation rates increased over time. Blood tests assessing thyroid function were documented for approximately one-third of patients in each cohort. Increasing the observation period to 1 year before through 3 months after the AF diagnosis markedly increased completion rates, but rates of thyroid function testing remained low (50%-60%). There were minor differences in evaluation completeness by sex, race, and geographic region. Differences in guideline-recommended evaluation rates by demographic characteristics after a new diagnosis of AF were of minor clinical importance. Basic evaluation had satisfactory completion rates; however, rates of laboratory testing were low.

Atrial Fibrillation

Atrial fibrillation (AF) is an increasingly common problem in primary care, but little is known about its prevalence and the distribution of AF risk factors in the general population. We determined the prevalence of AF and the distribution of known AF risk factors among persons participating in the population-based Gutenberg Health Study. To this end, we used interview data about the medical diagnosis of AF and electrocardiograms (ECGs) that were performed for the study in 5000 persons aged 35 to 74. The response rate was 60.4%. There were 5000 persons in the study sample (age 52.2 ± 11 years; 50.6% were women). The prevalence of AF, weighted for the age and sex distribution of the general population, was 2.5%. AF was found to be more common in older persons, with a more pronounced increase in men: whereas its prevalence was 0.7% in 35- to 44-year-old men, the corresponding figure for the age group 65- to 74 was as high as 10.6%. Twenty five participants (15.5% of AF cases) received their initial diagnosis of AF on the basis of the study ECG. Compared to persons without AF, persons with AF were older and more commonly male, and they had a higher burden of cardiovascular risk factors. 14.3% of persons with AF had none of the well-established risk factors for AF (systolic blood pressure, antihypertensive medication, increased body-mass-index, heart failure). 42.7% of persons with AF were not taking either anticoagulants or platelet inhibitors. These data indicate that the prevalence of AF in the middle-aged general population is 2.5% overall, and higher in the elderly. AF is thus a significant public health problem, and greater awareness of it is needed.