Low CHA2DS2-VASc Score Research Articles

Clinical significance of echocardiographic left ventricular hypertrophy for predicting left atrial appendage thrombotic milieu in patients with atrial fibrillation and CHA2DS2-VASc scores of 0-2

Abstract Background Even in patients with atrial fibrillation (AF) and low CHA2DS2-VASc scores, it is not always possible to completely rule out left atrial appendage (LAA) thrombus. Further stratification of the risk of LAA thrombosis in these patients remains an important yet unresolved issue. Left ventricular hypertrophy (LVH) is a prognostic risk factor in AF and has been associated with a worse prognosis, particularly in those with low CHA2DS2-VASc scores. Purpose To investigate the clinical significance of echocardiographic LVH for risk stratifying LAA thrombogenic milieu as a surrogate for cardioembolic risk in patients with AF and CHA2DS2-VASc scores of 0–2. Methods This was a single-center, retrospective study. We enrolled 707 consecutive patients with AF and CHA2DS2-VASc scores of 0–2 who underwent transesophageal echocardiography. The patients were divided into two groups based on the presence or absence of LVH. Owing to the racial differences in normative left ventricular mass index (LVMI) reference values, LVH was defined in this study using Japanese reference values. LVH was defined as LVMI ≥108 g/m2 for men and ≥98 g/m2 for women. LAA thrombogenic milieu was defined by any of the following findings: (1) thrombus, (2) severe spontaneous echo contrast or sludge, or (3) average LAA flow velocity ≤20 cm/s. Alongside conventional parameters, longitudinal strain values for the left ventricle (LV) and left atrium (LA) were obtained using transthoracic echocardiography. Results The mean age was 61 ± 10 years, and 12.2% were female. Overall, 77 (10.9%) patients were classified into the LVH group, and 41 (5.8%) of patients had LAA thrombogenic milieu. The LVH group exhibited a significantly higher prevalence of LAA thrombogenic milieu than the non-LVH (32.5% vs. 2.5%, p<0.001). Figure 1 illustrates the details of the patients with the LAA thrombogenic milieu based on LVH presence and CHA2DS2-VASc scores. The LVH group included six patients with LAA thrombus, even with CHA2DS2-VASc scores of 2, whereas the non-LVH group had no patient with LAA thrombus. Table shows the association of LAA thrombogenic milieu and clinical and echocardiographic parameters by logistic regression analysis; LVH independently associated with LAA thrombogenic milieu after adjusting for clinical factors (including CHA2DS2-VASc score, AF type, and serum brain natriuretic peptide levels) and conventional echocardiographic parameters (including LV ejection fraction, LV end-diastolic volume index, and LA volume index). Moreover, LVH provided incremental prognostic value for predicting LAA thrombogenic milieu, even when added to the longitudinal strain of the LV and LA reservoir strains (p<0.001). These findings are summarized in Figure 2. Conclusion Echocardiographic LVH significantly improves the prediction of LAA thrombogenic milieu, offering potential utility in further cardioembolic risk stratification for patients with AF and CHA2DS2-VASc scores of 0–2.

The association of NT-proBNP levels in atrial fibrillation patients and 3-year risk of heart hospitalization and death

Abstract Background NT-proBNP-levels are often elevated in patients with atrial fibrillation (AF), but their clinical use and interpretation for predicting subsequent cardiovascular events has not been explored in an all-comers setting. Aim To determine whether NT-proBNP levels are associated with the risk of subsequent heart failure (CHF) and/or death in patients with AF and its relation to prior CHF diagnosis Method All patients with new-onset AF (defined by ICD-code I48) who had an NT-proBNP-level within +/- 14 days of the date of the AF date measured in a regional laboratory repository between 2000-2021 were included in the analysis cohort. Patients were categorized into NT-proBNP level (pg/mL) <1000, 1000-1999, ≥2000. If several NT-proBNP-levels were measured, the maximal value was used. The association between NT-proBNP level and the outcome CHF hospitalization and/or death within 3 years of diagnosis was assessed in Cox regression analyses adjusted for baseline characteristic and medications. Since there was an interaction (p<0.001) between Nt-proBNP-level and prior/new-onset CHF at time of AF diagnosis and no known CHF, two separate analyses were performed in patients with or new-onset CHF and those without prior CHF. Results There were 10559 patients with AF and no CHF, and 11 257 with AF and CHF. There were 14% of patients with new-onset CHF at time of new-onset AF diagnosis. These were grouped together with patients with known CHF. Patients with no prior CHF were younger (76 years (95% CI 68-83) vs 80 (72-87), p<0.001), and healthier with less often diabetes (18.4% vs 24.5%, p<0.001), prior myocardial infarction (12.0% vs 24.3%), a lower CHA2DS2-VASc score (3.0 vs 5.0, p<0.001) and a lower median NT-proBNP level (1650 pg/mL (95% CI 702-3549) vs 4240 pg/mL (2160-8860), p<0.001). Among patients with AF and no prior CHF, the incidence rate in the lowest NT-proBNP level was low, but increased with higher levels (Table). Adjusting for covariates and medications, the risk of both CHF hospitalization and CHF/death compared to the reference category NTproBNP< 1000 pg/mL was nearly 2 and 3 times higher among those who with initial NT-proBNP level 1000-1999 and ≥ 2000. Among patients with AF and known CHF, the incidence rate of CHF hospitalization or CHF hospitalization/death at the same NT-proBNP-strata was several times higher compared to patients without known CHF. Adjusting for covariates, the risk increased for CHF hospitalization or CHF/hospitalization similarly for each strata as for patients without known CHF. AF patients without known HF but with the highest elevation of NTproBNP-level had a risk of subsequent hospitalization of heart failure which was higher than those with known heart failure and lowest NTproBNP-level. Conclusion A higher NTproBNP-level in patients with AF identifies patients at higher risk of CHF hospitalization and/or death in both patients with no and prior CHF.Table

Usefulness of the CHA2DS2-VASc Score in Predicting the Outcome in Subjects Hospitalized with COVID-19—A Subanalysis of the COLOS Study

Background: The aim of this study was to see if the CHA2DS2-VASc score (Cardiac failure or dysfunction, Hypertension, Age ≥ 75 [Doubled], Diabetes, Stroke [Doubled]—Vascular disease, Age 65–74 and Sex category [Female] score) could have potential clinical relevance in predicting the outcome of hospitalization time, need for ICU hospitalization, survival time, in-hospital mortality, and mortality at 3 and 6 months after discharge home. Materials: A retrospective analysis of 2183 patients with COVID-19 hospitalized at the COVID-19 Centre of the University Hospital in Wrocław, Poland, between February 2020 and June 2021, was performed. All medical records were collected as part of the COronavirus in LOwer Silesia—the COLOS registry project. The CHA2DS2-VASc score was applied for all subjects, and the patients were observed from admission to hospital until the day of discharge or death. Further information on patient deaths was prospectively collected following the 90 and 180 days after admission. The new risk stratification derived from differences in survival curves and long-term follow-up of our patients was obtained. Primary outcomes measured included in-hospital mortality and 3-month and 6-month all-cause mortality, whereas secondary outcomes included termination of hospitalization from causes other than death (home discharges/transfer to another facility or deterioration/referral to rehabilitation) and non-fatal adverse events during hospitalization. Results: It was shown that gender had no effect on mortality. Significantly shorter hospitalization time was observed in the group of patients with low CHA2DS2-VASc scores. Among secondary outcomes, CHA2DS2-VASc score revealed predictive value in both genders for cardiogenic (5.79% vs. 0.69%; p < 0.0001), stroke/TIA (0.48% vs. 9.92%; p < 0.0001), acute heart failure (0.97% vs. 18.18%; p < 0.0001), pneumonia (43% vs. 63.64%; p < 0.0001), and acute renal failure (7.04% vs. 23.97%; p < 0.0001). This study points at the usefulness of the CHA2DS2-VASc score in predicting the severity of the course of COVID-19. Conclusions: Routine use of this scale in clinical practice may suggest the legitimacy of extending its application to the assessment of not only the risk of thromboembolic events in the COVID-19 cohort.

Differences between atrial fibrillation diagnosed before and after stroke: A large real-world cohort study.

The clinical characteristics and long-term outcomes of patients with ischemic stroke (IS) and atrial fibrillation detected after stroke (AFDAS) have not been clearly established. Previous studies evaluating patients with AFDAS were limited by the low prescription rates of anticoagulants and short follow-up periods. Consecutive patients hospitalized for IS between 2014 and 2017 were identified from a National Health Insurance Research Database. The included patients were categorized into three groups: (1) known diagnosis of AF (KAF) before the index stroke, (2) AFDAS, and (3) without AF (non-AF). Univariable and multivariable Cox regression analyses were performed to estimate the hazard ratio (HR) for independent variables and recurrent IS, hemorrhagic stroke, or all-cause mortality. We identified 158,909 patients with IS of whom 16,699 (10.5%) had KAF and 7,826 (4.9%) had AFDAS. The patients with AFDAS were younger, more often male, and had lower CHA2DS2-VASc scores (3.8 ± 1.9 versus 4.9 ± 1.8, p < 0.001) than the patients with KAF. Anticoagulant treatment significantly reduced the risks of all outcomes. The standardized mortality rates were 40.4, 28.6, and 18.4 (per 100 person-years) for the patients with KAF, AFDAS, and non-AF, respectively. Compared with AFDAS, KAF was associated with lower risks of recurrent IS [hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.86-0.97, p < 0.01] and hemorrhagic stroke (HR: 0.88, 95% CI: 0.79-0.99, p < 0.01) and a higher risk of all-cause mortality (HR: 1.11, 95% CI: 1.07-1.16, p < 0.001). The risks of recurrent IS and hemorrhagic stroke were higher and of all-cause mortality was lower for patients with AFDAS than with KAF. There is a strong need to refine treatment modalities to reduce the high mortality in patients with KAF and AFDAS.

Atrial fibrillation fact sheet in Korea 2024 (part 3): treatment for atrial fibrillation in Korea: medicines and ablation

BackgroundAtrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with significant morbidity and mortality, posing a considerable burden on healthcare systems. In Republic of Korea, the prevalence and incidence of AF have increased in recent years. There have also been significant changes in the trends of antiarrhythmic drug (AAD) use and procedural treatments for AF.ObjectivesThis study aims to review the trends in AF treatment strategies in Republic of Korea, particularly focusing on the utilization of antiarrhythmic drugs and catheter ablation.MethodsThe Korean National Health Insurance Service (K-NHIS) data were used to identify AF patients from 2013 to 2022. AAD usage and catheter ablation procedures were analyzed annually. AADs were classified into Class IC and III drugs. Trends in beta-blockers, calcium channel blockers, and digoxin prescriptions were also examined. The primary endpoint was the trend of AAD use and AF catheter ablation (AFCA) over 10 years.ResultsIn 2022, 940,063 patients had a prior diagnosis of AF. From 2013 to 2022, the use of AADs increased from 12.1 to 16.4% among prevalent AF patients. Beta-blockers were the most commonly prescribed rate control medication, while the use of calcium channel blockers and digoxin declined. The frequency of AFCA procedures also increased, from 0.5% of prevalent AF patients in 2013 to 0.7% in 2022. Younger patients, males, and those with lower CHA2DS2-VASc scores were more likely to receive AFCA. Regional variations in treatment patterns were observed, with Seoul exhibiting higher rates of procedural treatments and AAD prescriptions.ConclusionsOver the past decade, there has been a significant increase in the use of AADs and AFCA procedures in Republic of Korea. These trends reflect recent advancements in AF management advocating a refined rhythm control strategy.

Prevalence of left atrial appendage thrombus and spontaneous echo contrast on transesophageal echocardiography in patients scheduled for pulmonary vein isolation.

To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior to the procedure. Despite being on anticoagulants, some patients develop a left atrial appendage thrombus (LAAT). To exclude the presence of LAAT, transesophageal ultrasound (TEE) is performed in all patients prior to the procedure. We hypothesized continuous treatment with anticoagulants would result in a low prevalence of LAAT, in patients with low CHA2DS2-VASc score. Medical records of consecutive patients planned to undergo AF ablation at Lund University Hospital during the years 2018-2020 were reviewed retrospectively. Examination protocols from transesophageal and transthoracic echocardiography were examined for LAAT and spontaneous echo contrast (SEC). Patients with LAAT and SEC were compared to patients without using Mann-Whitney U-test and Pearson Chi-squared analysis to test for correlation. Of 553 patients, three patients (0.54%) had LAAT, and 18 (3.25%) had spontaneous contrast (SEC). Patients with LAAT or SEC had a higher CHA2DS2-VASc score, more often presented in AF at TEE and less often had a normal sized left atrium. There is a low prevalence of LAAT and SEC in patients with AF scheduled for pulmonary vein isolation. Patients with SEC or LAAT tend to have paroxysmal AF less often and more often presented in AF at admission. No patients with CHA2DS2-VASc 0, paroxysmal AF, normal sized left atrium and sinus rhythm at TEE were found to have LAAT or SEC.

Both HFpEF and HFmrEF should be included in calculating CHA2DS2-VASc score: A Taiwanese longitudinal cohort

BackgroundCongestive heart failure (CHF) as a risk of stroke in patients with atrial fibrillation (AF) mainly referred to patients with left ventricular systolic dysfunction. Whether this should include patients with preserved ejection fraction is debatable. ObjectiveThe study aimed to investigate the variation in stroke risk of AF patients with heart failure with preserved ejection fraction (HFpEF), heart failure with mid-range ejection fraction (HFmrEF), and heart failure with reduced ejection fraction (HFrEF) for enhancing risk assessment and subsequent management strategies. MethodsIn a longitudinal study using the National Taiwan University Hospital integrated Medical Database, 8358 patients with AF were observed for 10 years (mean follow-up, 3.76 years). The study evaluated the risk of ischemic stroke in patients with differing ejection fractions and CHA2DS2-VASc score, further using Cox models adjusted for risk factors of AF-related stroke. ResultsPatients with HFpEF and HFmrEF had a higher mean CHA2DS2-VASc score compared with patients with HFrEF (4.30 ± 1.729 vs 4.15 ± 1.736 vs 3.73 ± 1.712; P < .001) and higher risk of stroke during follow-up (hazard ratio [HR], 1.40 [1.161–1.688; P < .001] for HFmrEF; HR, 1.184 [1.075–1.303; P = .001] for HFpEF vs no CHF) after multivariate adjustment). In patients with lower CHA2DS2-VASc score (0–4), presence of any type of CHF increased ischemic stroke risk (HFrEF HR, 1.568 [1.189–2.068; P = .001]; HFmrEF HR, 1.890 [1.372–2.603; P < .001]; HFpEF HR, 1.800 [1.526–2.123; P < .001] vs no CHF). ConclusionAfter multivariate adjustment, HFpEF and HFmrEF showed a similar risk of stroke in AF patients. Therefore, it is important to extend the criteria for C in the CHA2DS2-VASc score to include patients with HFpEF and HFmrEF. In patients with fewer concomitant stroke risk factors, the presence of any subtype of CHF increases risk for ischemic stroke.

Predictive value of lipoprotein(a) for left atrial thrombus or spontaneous echo contrast in non-valvular atrial fibrillation patients with low CHA2DS2-VASc scores: a cross-sectional study

ObjectiveCurrent guidelines are debated when it comes to starting anticoagulant therapy in patients with non-valvular atrial fibrillation (NVAF) and low CHA2DS2-VASc scores (1–2 in women and 0–1 in men). However, these individuals still have a high likelihood of developing left atrial thrombus/spontaneous echo contrast (LAT/SEC) and experiencing subsequent thromboembolism. Recent research has demonstrated that lipoprotein(a) [Lp(a)] may increase the risk of thrombosis, but the relationship between Lp(a) and LAT/SEC in NVAF patients is not clearly established. Therefore, this study sought to evaluate the predictive ability of Lp(a) for LAT/SEC among NVAF patients with low CHA2DS2-VASc scores.MethodsNVAF patients with available transesophageal echocardiography (TEE) data were evaluated. Based on the TEE results, the subjects were classified into non-LAT/SEC and LAT/SEC groups. The risk factors for LAT/SEC were examined using binary logistic regression analyses and were validated by using 1:1 propensity score matching (PSM). Subsequently, novel predictive models for LAT/SEC were developed by integrating the CHA2DS2-VASc score with the identified factors, and the accuracy of these models was tested using receiver operating characteristic (ROC) analysis.ResultsIn total, 481 NVAF patients were enrolled. The LAT/SEC group displayed higher Lp(a) concentrations. It was found that enlarged left atrial diameter (LAD), high concentrations of Lp(a), and a history of coronary heart disease (CHD) were independent predictors of LAT/SEC. Lp(a) and LAD still had predictive values for LAT/SEC after adjusting for PSM. In both the highest quartile groups of Lp(a) (>266 mg/L) and LAD (>39.5 mm), the occurrence of LAT/SEC was higher than that in the corresponding lowest quartile. By incorporating Lp(a) and the LAD, the predictive value of the CHA2DS2-VASc score for LAT/SEC was significantly improved.ConclusionElevated Lp(a) and enlarged LAD were independent risk factors for LAT/SEC among NVAF patients with low CHA2DS2-VASc scores. The prediction accuracy of the CHA2DS2-VASc score for LAT/SEC was significantly improved by the addition of Lp(a) and LAD. When evaluating the stroke risk in patients with NVAF, Lp(a) and LAD should be taken into account together with the CHA2DS2-VASc score.Trial registrationRetrospectively registered.

The Risk of Left Atrial Appendage Thrombus in Patients With Atrial Flutter Versus Atrial Fibrillation.

Patients with atrial fibrillation (AF) are at increased risk of thromboembolic events originating mainly from left atrial appendage thrombus (LAAT). Patients with atrial flutter (AFL) are treated with anticoagulation based on the same criteria as patients with AF. However, whether patients with AFL have similar thromboembolic risk as AF is unclear. In the current study we aimed to estimate the prevalence of LAAT in patients with AFL undergoing trans-esophageal echocardiography (TEE). We included 438 patients (404 with AF and 34 with AFL) scheduled for TEE to rule out LAAT before cardioversion (patients who reported no or inadequate anticoagulation before cardioversion). Demographic and echocardiographic data were compared between patients with and without LAAT. Despite a similar CHA2DS2-VASC score (3.8 ± 1.3 vs 3.4 ± 1.5 in the AF and AFL groups, respectively, P = .09), LAAT was documented in 12 (2.8%) in the AF group and in no patient in the AFL group (P < .0001). Based on our results and previous studies, it seems reasonable to re-evaluate the need for oral anticoagulation in specific populations with AFL such as those with solitary AFL (without a history of AF episodes) undergoing successful ablation and in those with low CHA2DS2-VASC score.

Can transesophageal echocardiography be safely omitted in patients scheduled for elective ablation of atrial arrhythmias? Data based on the LATTEE registry.

According to the present guidelines, transesophageal echocardiography (TEE) before scheduled catheter ablation (CA) for atrial arrhythmias (atrial fibrillation [AF] or atrial flutter [AFL]) is not deemed obligatory for optimally anticoagulated patients. However, daily clinical practice significantly differs from the recommendations. We aimed to identify transthoracic echocardiographic parameters that could be useful in identifying patients without left atrial thrombus (LAT), which makes it possible to avoid unnecessary TEE before scheduled CA. This is a sub-analysis of a multicenter, prospective, observational study - the LATTEE registry. A total of 1346 patients referred for TEE before scheduled CA of AF/AFL were included. LAT was present in 44 patients (3.3%) and absent in the remaining 1302, who were younger, more likely to have paroxysmal AF, and displayed sinus rhythm during TEE. Additionally, they exhibited a lower incidence of heart failure, diabetes, systemic connective tissue disease, and chronic obstructive pulmonary disease. Furthermore, they had a lower CHA2DS2-VASc score and a higher prevalence of direct oral anticoagulants. Echocardiographic parameters, including left ventricular ejection fraction (LVEF) >65%, left atrial diameter (LAD) <40 mm, left atrial area (LAA) <20 cm2, left atrial volume (LAV) <113 ml, and left atrial volume index (LAVI) <51 ml/m2, demonstrated 100% sensitivity and 100% negative predictive value for the absence of LAT and were met by 417 patients. Additional echocardiographic indices: LVEF/LAD ≥1.4, LVEF/LAVI ≥1.6, and LVEF/LAA ≥2.7 identified 57 additional patients, bringing the total of predicted LAT-free patients to 474 (35%). Simple echocardiographic parameters could help identify individuals for whom TEE could be safely omitted before elective CA due to atrial arrhythmias.

Investigation of Stroke Risk Factors and Prognostic Indicators in NVAF Patients with Low CHA2DS2-VASc Scores.

The prognosis of patients with nonvalvular atrial fibrillation (NVAF) with a low CHA2DS2-VASc score (0-1) following a stroke is not well studied. In this investigation, stroke risk factors and prognostic markers in low-risk NVAF patients who are nonetheless at risk for stroke were examined.From January 2012 to January 2022, we retrospectively assessed atrial fibrillation (AF) patients at Xiamen University's Zhongshan Hospital for ischemic stroke. Along with a control group of patients with CHA2DS2-VASc scores of 0-1 who weren't suffering from a stroke, patients with CHA2DS2-VASc scores of 0-1 at the time of stroke were included in the study. Using multivariate logistic regression, independent risk factors were identified. To assess the cumulative occurrences of in-hospital mortality in patients with NVAF-related stroke, the Kaplan-Meier method was used.The study included 156 out of 3.237 inpatients with AF-related stroke who had CHA2DS2-VASc ratings of 0-1. Left atrial diameter (LAD) (odds ratio [OR]: 1.858, 95% confidence interval (CI) 1.136-3.036, P = 0.013), D-dimer (OR: 2.569, 95% CI 1.274-5.179, P = 0.008), and NT-proBNP (OR: 4.558, 95% CI 2.060-10.087, P = 0.000) were found to be independent risk factors for stroke in NVAF patients with a low CHA2DS2-VASc score. During hospitalization, nine patients with NVAF-related stroke died. In patients with NVAF-related stroke, NT-proBNP (hazard ratio: 3.504, 95% CI 1.079-11.379, P = 0.037) was an indicator of mortality risk.Patients with NVAF and CHA2DS2-VASc scores of 0-1 had independent risk factors for stroke in the form of LAD, D-dimer, and NT-proBNP. Notably, in low-risk NVAF patients with stroke, NT-proBNP was discovered to be a potent predictor of in-hospital death.

Quality of life before and after pulmonary vein isolation for atrial fibrillation: results of a multicenter cohort study in the Netherlands

Abstract Background In the treatment of patients with symptomatic atrial fibrillation (AF) reducing AF-related symptoms and improving health-related quality of life (HRQol) are important drivers in the decision for pulmonary vein isolation (PVI). Eventhought the majority of PVI patients has improved HRQoL after PVI, up to a third of patients do not. We aim to assess the association between various patient characteristics, intervention and outcome variables and HRQol both prior to and one-year after PVI with specific attention for those groups that did not improve or were still impaired in HRQoL after PVI. Methods In this observational, retrospective multicenter cohort study, we used data from 8 hospitals participating within the Netherlands Heart Registration (NHR), a non-profit organisation facilitating high-quality registration of patients undergoing cardiac interventions within the Netherlands. Patients who underwent PVI between January 2016 and December 2019 and completed the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire both prior to and one-year after were included (N=2534). To interpret the relevance of findings, accepted cut-off values for the AFEQT Overall summary score were used; &amp;lt;80 points for impaired HRQoL and a delta of ≥5 points for clinically meaningful improvement. Results The majority of the population were men (65.7%) with normal left ventricular ejection fraction (87.1%), paroxysmal AF (77.1%) and a low median CHA₂DS₂-VASc score of 1 (interquartile range, 1–2). The mean AFEQT score was 55.6 ± 19.7 prior to intervention and 79.8 ± 20.2 one-year after PVI. Despite this major increase in mean AFEQT score, we found 39.5% of the population still impaired in HRQol (&amp;lt;80 points) one-year after PVI and 19.2% of the population failed to achieve a clinically meaningful improvement (delta of ≥5 points). Lower baseline AFEQT score (odds ratio [OR], 0.96 [per 1-point increase]; 95% CI, 0.96-0.97; P&amp;lt;0.001) and female sex (odds ratio [OR], 1.42; 95% CI, 1.16-1.75; P&amp;lt;0.001) found to be the most prominent related factors with impaired HRQol one-year after PVI. For failure to achieve clinically meaningful improvement higher baseline AFEQT score (odds ratio [OR], 1.04 [per 1-point increase]; 95% CI, 1.04-1.05; P&amp;lt;0.001) was strongly associated. Other independent risk factors were age (impaired HRQol); BMI (impaired HRQOL); CHA₂DS₂-VASc score (failure to achieve clinically meaningful improvement) and prior catheter ablation for AF (impaired HRQOL and failure to achieve clinically meaningful improvement). Conclusion Despite a major increase in HRQol across the population after PVI, over one third of patients were still impaired in HRQoL after PVI. Several factors were identified which could guide patient counseling for the best fitting treatment for atrial fibrillation.

Abstract 12536: Occurrence of New-Onset Atrial Fibrillation in Patients After Left Atrial Appendage Closure

Introduction: Left atrial appendage closure (LAAC) has evolved as a non-pharmacological alternative for stroke prevention in patients with Atrial fibrillation (AF). The occurrence of post-operative AF is well described after cardiac and percutaneous procedures. But, there is limited understanding of the possibility of new-onset AF as a result of LAAC. Aims: To investigate the incidence of, and factors associated with, AF after LAAC. Methods: We conducted a retrospective analysis of 121 patients with i) paroxysmal AF, 2) had undergone LAAC, and 3) had an implantable electronic devices (CIEDs): pacemaker, defibrillator or implantable loop recorder. Patients with persistent AF and those presenting in AF on the day of LAAC were excluded. Data were collected on baseline characteristics, Colchicine use, antiarrhythmic drugs and prior history of AF ablation. Remote transmissions and device interrogations were analyzed to ascertain new-onset AF during the 6 months follow up period after LAAC. Univariate and multivariable analyses were performed to analyze factors associated with the occurrence of AF after LAAC. Results: Of the total 121 patients, 39 (32.2%) developed AF during the 6 month follow up period after LAAC. On univariate analysis, a lower CHA2DS2-Vasc score was associated with a lower incidence of AF post LAAC (OR 0.74, 95% CI 0.55-0.98, p = 0.04). On multivariable analysis, including variables of age, gender, CHA2DS2-Vasc score, use of Colchicine and history of AF Ablation, we observed a statistical trend towards the protective effect of prior AF ablation on occurrence of AF after LAAC (adjusted OR 0.32, 95% CI 0.10-1.05, p =0.06). There was also a statistical trend towards the protective effect of Colchicine on occurrence of AF after LAAC (adjusted OR 0.15, 95% CI 0.02-1.29, p =0.08). Conclusions: In our study of paroxysmal AF patients undergoing LAAC, who presented in sinus rhythm on the day of the procedure, the incidence of CIED detected post-procedural AF was 32.2%. We observed statistical trends towards protective effects of prior AF Ablation and use of Colchicine during the peri-LAAC period on occurrence of AF after LAAC.

Abstract 19180: Early Rhythm Control is Associated With Improved Outcomes in Hypertrophic Cardiomyopathy Patients With Atrial Fibrillation

Background: Atrial fibrillation in hypertrophic cardiomyopathy (HCM) patients is associated with worse outcomes with regards to stroke, heart failure hospitalization and death. Contemporary data on Rhythm control (RyC) strategies and outcomes in HCM patients is limited. Objectives: We aimed to assess the clinical characteristics of HCM patients with AF receiving RyC (antiarrhythmic drug and/or catheter ablation) vs no rhythm control (NRC) and compare clinical outcomes between the two groups. Methods: We analyzed the electronic health records of the University of Pittsburgh Medical Center, a large multi-hospital system, between 2010 and 2022. Differences between baseline demographics, cardiovascular risk factors, and comorbidity burden were evaluated with t tests. Adjusted Cox proportional hazards and Kaplan-Meier analyses were performed to evaluate associations between use of rhythm control and all-cause age-adjusted mortality. Results: A total of 552 patients with HCM and AF were analyzed, of which 118 received RyC and 434 NRC. The RyC group was relatively younger (age 64 vs 70), received initial evaluation by a cardiologist (70% vs 57%), had lower CHA2DS2VASC scores (mean 2.5 vs 3.1) and fewer comorbidities (mean Elixhauser scores 3.0 vs 4.7). There were no significant differences in either ejection fraction or left atrial diameter between the groups. Among RyC patients, 38 received catheter ablation and 80 received antiarrhythmic drug as the initial RyC strategy. Over a median follow up of 2.9 years (IQR 0.96-6.0), use of RyC was associated with decreased mortality after adjustment for age, Elixhauser score, and CHA2DS2VASC score (HR 0.54, 95% CI 0.30-0.95, p&lt;0.05, figure 1). Conclusion: Rhythm control in HCM and AF patients is associated with better outcomes as suggested by decreased overall mortality. Prospective studies are needed to establish the best RyC strategy in this cohort.

Same-day discharge after atrial fibrillation ablation

BackgroundAtrial fibrillation (AF) catheter ablation has become an increasingly effective and safe strategy for the management of AF. With increased safety of catheter ablation, same-day discharge (SDD) is a potential way to minimize health care resource utilization and improve patient experience. ObjectiveTo evaluate the safety and patient satisfaction of SDD after contemporary AF ablation. MethodsConsecutive patient undergoing AF ablation at our institution between 1/2020 and 10/2021 were enrolled in registry for clinical, quality, procedural and outcomes data. Patients were considered for SDD per physician discretion and patients’ preference based upon clinical evaluation. Adjudicated ninety-day major complications, thirty-day adverse events, and thirty-day re-admissions were collected in a prospective registry for all patients. ResultsA total of 2142 consecutive patients underwent elective AF ablation during the study period. After excluding cases with missing data, 1830 patients were included in the analysis. Of those, 350 (19 %) patients were discharged the same day (SDD group) and 1480 (81 %) stayed overnight. Patients in the SDD group compared to overnight stay group were younger, more likely to be male, White patients, lower CHA2DS2-VASc score and to be on lower rates of warfarin as an anticoagulation strategy. After propensity score matching, SDD was associated with lower rate of major complications and higher patient satisfaction. The majority of life-treating complications occurred interprocedurally or within 6 h of procedure termination. ConclusionThe present study demonstrated that SDD after contemporary AF ablation is feasible, safe and associated with higher patient satisfaction using a proposed SDD pathway and criteria.

Clinical significance of substrate characteristics and ablation outcomes in patients with atrial fibrillation and significant functional mitral regurgitation

BackgroundAtrial fibrillation (AF) and mitral regurgitation (MR) have a complex interplay. Catheter ablation (CA) of AF may be a potential method to improve the severity of MR in AF patients.MethodsPatients with symptomatic AF and moderate to severe MR who underwent catheter ablation from 2011 to 2021 were retrospectively included in the study. Patients' baseline characteristics and electrophysiological features were examined. These patients were classified as group 1 with improved MR and group 2 with refractory MR after CA.ResultsFifty patients (age 60.2 ± 11.6 years, 29 males) were included in the study (32 in group 1 and 18 in group 2). Group 1 patients had a lower CHA2DS2-VASc score (1.7 ± 1.5 vs. 2.7 ± 1.5, P = 0.005) and had a lower incidence of hypertension (28.1% vs. 66.7%, P = 0.007) and diabetes mellitus (3.1% vs. 22.2%, P = 0.031) as compared to group 2 patients. Electroanatomic three-dimensional (3D) mapping showed that group 1 patients demonstrated less scars on the posterior bottom of the left atrium compared to group 2 patients (12.5% vs. 66.7%, P &amp;lt; 0.001). AF recurrence was not different between the two groups. After multivariate logistic regression analysis, a posterior bottom scar in the left atrium independently predicted refractory MR despite successful AF ablation.ConclusionMost patients with AF and MR showed improvement of MR after AF ablation. A scar involving the posterior bottom of the left atrium is associated with poor recovery of MR.

Patients with atrial fibrillation and a low risk of thromboembolic events: prescription rate of anticoagulant therapy according to a retrospective analysis

Aim. To conduct a retrospective analysis of the prevalence of main risk factors for thromboembolic events (TEEs) and the prescription rate of anticoagulant therapy (ACT) in patients with atrial fibrillation (AF) and a low CHA2DS2-VASc score in certain Russian regions using artificial intelligence technologies.Material and methods. The information was obtained from the Webiomed predictive analytics platform. The sample included 87601 patients with AF aged 18-74 years (men, 49,5%, mean age, 59,3±12,3 years, mean CHA2DS2-VASc score, 2,3±1,5) who received care in medical organizations in 6 constituent entities of the Russian Federation in the period from 2016 to 2019. CHA2DS2VASc score of 1 and 2 in a man and a woman, respectively, was regarded as a moderate risk, while score of 0 and 1, respectively, as a low risk of TEEs.Results. There were 22337 (25,5%) patients with AF at moderate risk and 18366 (21,0%) patients at low risk of TEEs. With a moderate risk of TEEs, CHA2DS2-VASc score of 1 in 70,4% of cases was determined by hypertension, while in 15,7% — by age 65-74 years, in 9,0% — by heart failure, in 2,9% — by myocardial infarction and/or peripheral arterial disease, in 2,0% — by type 2 diabetes. In patients with AF and a moderate risk of TEEs, ACT was prescribed in 4927 (22,1%) patients, while with a low risk of TEEs — in 1833 (10,0%). Among patients with AF and a high risk of TEEs (n=46898, 53,5%), 1216 (24,6%) patients with ischemic stroke (IS) did not initially have a high CHA2DS2-VASc risk.Conclusion. In clinical practice, among patients with AF aged 18-74 years, there are quite often individuals with CHA2DS2-VASc score of 1 not associated with sex. These patients need an individualized approach in ACT, which is the basis for prospective studies in order to optimize the assessment of cardioembolic IS risk, as well as to analyze the efficacy and safety of long-term ACT.

Use of the CHA2DS2-VASc score to predict subsequent myocardial infarction in atrial fibrillation

BackgroundThe risk of subsequent myocardial infarction (MI) varies widely in patients with atrial fibrillation (AF). No convenient scoring system currently exists to identify MI in AF. While each element of the CHA2DS2-VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke or thromboembolism [doubled]; vascular disease; age 65–75 years; and sex category) score can increase the likelihood of MI, this retrospective longitudinal study aimed to determine the accuracy of the CHA2DS2-VASc score in predicting subsequent MI risk in AF. MethodsA total of 29,341 patients with AF were enrolled and followed up from January 2010 until the first occurrence of MI or until December 2020. The primary endpoint was the occurrence of subsequent MI. ResultsThe average age of the study population was 71 years, and 43.2% were male. The mean CHA2DS2-VASc score was found to be higher in patients with AF who had experienced an MI than in those who had not (3.56 ± 1.92 vs. 3.32 ± 1.81, p < 0.001). During the long-term follow-up, the risk of subsequent MI increased by 22% with every one-point increase in the CHA2DS2-VASc score (hazard ratio 1.22, 95% confidence interval 1.19–1.25; p < 0.001). Kaplan–Meier analysis revealed that high CHA2DS2-VASc scores were more likely to experience an MI than those with low CHA2DS2-VASc scores (log-rank p < 0.001). Furthermore, the CHA2DS2-VASc score was a significant predictor of MI in multivariate regression analysis. ConclusionThe CHA2DS2-VASc score is a valuable predictor of subsequent MI risk in patients with AF.

Atrial Fibrillation in Adult Congenital Heart Increase Ischemic Stroke Risk Even at Low CHA2DS2-VASc Score.

The population of adults with congenital heart diseases (ACHDs) is expanding, and atrial fibrillation (AF) emerges as a crucial risk factor for ischemic stroke. However, the evidence regarding the impact of AF on the incidence of ischemic stroke in ACHDs remains limited. In this study, we aimed to investigate the prevalence and effect of AF among ACHDs and assess the suitability of the traditional CHA₂DS₂-VASc score in this specific population. Data of ACHDs from 2000 to 2010 were retrospectively collected from the Taiwan National Health Insurance Research Database. We divided ACHDs into those with and without AF, and ischemic stroke incidence was studied among ACHD subtypes and those who received anticoagulant therapy with warfarin or not according to CHA₂DS₂-VASc score. 36,530 ACHDs were retrieved from the database. ACHDs had a 4.7-15.3 times higher AF risk than did the general population, which varied based on the age group. ACHDs with AF had 1.45 times higher ischemic stroke risk than those without AF (p = 0.009). Ischemic stroke incidence among ACHDs with AF aged 50 years was 1.46 times higher than those without AF (p = 0.207). Ischemic stroke incidence was over 1.47% even in those with a low CHA₂DS₂-VASc score (0-1) with or without anticoagulant therapy. During the 12-year follow-up, ACHDs with AF were found to have an increased risk of ischemic stroke. The ischemic stroke incidence was high, even in those with a low CHA₂DS₂-VASc score (0-1).

#4130 CHA2DS2-VASC SCORE AS A PREDICTOR OF CARDIOVASCULAR MORBIDITY AND MORTALITY AND ALL-CAUSE MORTALITY IN PATIENTS UNDERGOING CHRONIC HEMODIALYSIS

Abstract Background and Aims End stage kidney disease (ESKD) is a well-recognized risk factor for cardiovascular and all-cause mortality. The recognition of high-risk patients could lead to a different approach and better treatment of the patients undergoing chronic hemodialysis. The CHA2DS2-VASc score was originally used to predict the annual cerebral infarction in patients with atrial fibrillation. However, it is also a useful predictor of outcome in other cardiovascular conditions, independent of atrial fibrillation. The aim of this study was to assess whether CHA2DS2-VASc score may be used as a risk stratification tool for ESKD patients undergoing chronic hemodialysis. Method We performed a single-centre retrospective study of 201 adult patients undergoing chronic hemodialysis in our institution from January 2020 to December 2022 with a follow up period of at least 12 months. CHA2DS2-VASc score was calculated for each patient according to the data from January 1st 2020 or at the moment of haemodialysis initiation, if the date of the first dialysis was after that date. Patients were followed until January 1st 2023, or until their death or kidney transplantation. Demographic, clinical and laboratory parameters, as well as used medications, were analyzed. Occurrences of myocardial infarction, stroke, revascularization procedure, new hospitalization for heart failure, cardiovascular death, or all-cause mortality were recorded for each patient. Patients were divided into three groups according to their CHA2DS2-VASc score: low (0-2), intermediate (3), high (≥4). Results The group with a low CHA2DS2-VASc score (0-2)-group I included 80 (39.8%) patients, the group with a intermediate score (3)-group II included 62 (30.8%) patients, and the group with a high score (≥4)-group III included 59 (29.4%) patients. Mean follow-up time was 918±317 days. Patients in the group with higher CHA2DS2-VASc scores (group III) were predominantly females (group III 62.7% vs group II 45.2% vs group I 23.8%; p&amp;lt;0.01) and older (group III 74.9±7.4 years vs group II 68.7±7.6 years vs group I 55.2±11.3 years; p&amp;lt;0.01). They also had a higher prevalence of diabetes mellitus (group III 61.0% vs group II 45.2% vs group I 21.3%; p&amp;lt;0.01) and vascular disease (group III 30.5% vs group II 12.9% vs group I 3.8%; p&amp;lt;0.01). Major adverse cardiovascular events (MACE) were significantly more prevalent in patients with higher CHA2DS2-VASc scores (p&amp;lt;0.01) (Fig. 1). All-cause mortality was significantly higher in group II and group III, compared to the group I (p&amp;lt;0.05) (Fig. 1). The patients in the group II and group III had a significantly higher risk of all-cause mortality and cardiovascular mortality than the patients in the group I (p&amp;lt;0.05) (Fig. 2). Using a group I as a reference, group II and group III had a higher risk of all-cause mortality (HR 1.92, 95% CI 1.01-3.66, p&amp;lt;0.05 and HR 2.47, 95% CI 1.32- 4.63, p&amp;lt;0.01, respectively) and cardiovascular mortality (HR 3.56, 95% CI 1.18-9.53, p&amp;lt;0.05 and HR 6.58, 95% CI 2.48-17.46, p&amp;lt;0.001, respectively). Each one-point increase in CHA2DS2-VASc score was associated with a two-fold increased risk of MACE and a 47% increased risk of all-cause mortality. Conclusion The CHA2DS2-VASc score is a simple, easy-to-calculate tool that can be used to identify high-risk ESKD patients undergoing chronic hemodialysis. Clinical utilization of the CHA2DS2-VASc score in risk stratification of these patients could intensify patient care and lead to better outcomes by reducing cardiovascular morbidity and mortality and all-cause mortality.