Management Of Atrial Fibrillation Patients Research Articles

Micro-Costing Analysis for the Treatment of Atrial Fibrillation: An Economic Evaluation of the First Italian Experience of Same-Day Discharge Protocol for Cryoballoon Atrial Fibrillation Ablation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is expected to increase further due to the aging population, increasing prevalence of risk factors, improving detection methods, and broadening of catheter ablation indications. Along with limited healthcare resources and bed availability, these reasons led to the development of a same-day discharge (SDD) protocol. The aim of this study was to evaluate the health and economic impact of a routine adoption of same-day discharge after cryoballoon AF ablation. Methods: Consecutive patients with symptomatic and drug-refractory AF scheduled for first-time AF ablation were screened, and if deemed suitable, the SDD protocol was proposed and, if accepted, enrolled in the protocol. Results: A total of 324 patients were screened, and 118 were considered eligible for the SDD pathway. Fifty-two patients accepted the SDD pathway and were included in this study. The analysis showed that the variation in resource consumption associated with cryoablation in SDD is equal to EUR 739.85/patient. The analysis showed that the main cost driver for ordinary hospitalization was represented by the hospital stay, which was calculated to be 36% of the total cost. In total, there was a cost reduction of EUR 38.472 thanks to optimized AF patient management from the standard recovery setting to SDD. Conclusions: SDD after cryoballoon ablation of AF is feasible in selected patients with a standardized protocol.

Clinical decisions for appropriate management of patients with atrial fibrillation.

The management of patients with atrial fibrillation (AF) requires intricate clinical decision-making to optimize outcomes. In everyday clinical practice, physicians undergo difficult choices to better manage patients with AF. They need to balance thromboembolic and bleeding risk to focus on patients' symptoms and to manage a variety of multiple comorbidities. In this review, we aimed to explore the multifaceted dimensions of clinical decision-making in AF patients, encompassing the definition and diagnosis of clinical AF, stroke risk stratification, oral anticoagulant therapy selection, consideration of bleeding risk, and the ongoing debate between rhythm and rate control strategies. We will also focus on possible grey zones for the management of AF patients. In navigating this intricate landscape, clinicians must reconcile the dynamic interplay of patient-specific factors, evolving guidelines, and emerging therapies. The review underscores the need for personalized, evidence-based clinical decision-making to tailor interventions for optimal outcomes according to specific AF patient profiles.

Impact of Sarcoidosis on In-hospital Outcomes Among Patients with Atrial Fibrillation: A Nationwide Readmissions Database Analysis.

Sarcoidosis is a disease that involves multiple organs, including the cardiovascular system. While cardiac sarcoidosis has been increasingly recognized, the impact of sarcoidosis on atrial fibrillation (AF) is not well established. This study aimed to analyze the impact of sarcoidosis on in-hospital outcomes among patients who were admitted for a primary diagnosis of AF. Using the all-payer, nationally representative Nationwide Readmissions Database, our study included patients aged ≥18 years who were admitted for AF between 2017-2020. We stratified the cohort into two groups depending on the presence of sarcoidosis diagnosis. The in-hospital outcomes were assessed between the two groups via propensity score analysis. A total of 1031 (0.27%) AF patients with sarcoidosis and 387,380 (99.73%) AF patients without sarcoidosis were identified in our analysis. Our propensity score analysis of 1031 (50%) patients with AF and sarcoidosis and 1031 (50%) patients with AF but without sarcoidosis revealed comparable outcomes in early mortality (1.55% vs. 1.55%, P = 1.000), prolonged hospital stay (9.51% vs. 9.70%, P = .874), non-home discharge (7.95% vs. 9.89%, P = .108), and 30-day readmission (13.29% vs. 13.69%, P = .797) between the two groups. The cumulative cost of hospitalization was also similar in both groups ($12,632.25 vs. $12,532.63, P = .839). The in-hospital adverse event rates were comparable in both groups. Sarcoidosis is not a risk factor for poorer in-hospital outcomes following AF admission. These findings provide valuable insights into the effectiveness of the current guideline for AF management in patients with concomitant sarcoidosis and AF.

IMPACT OF THYROID DYSFUNCTION IN PATIENTS WITH ATRIAL FIBRILLATION

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice, affecting approximately 2% of the general population and increasing the risk of stroke, heart failure and mortality. AF is often associated with several clinical conditions, including thyroid dysfunction, which can alter metabolism, function and cardiac structure. Thyroid dysfunction can be classified as hypothyroidism (low production of thyroid hormones) or hyperthyroidism (excess production of thyroid hormones), both of which can cause or worsen AF. The mechanism by which thyroid dysfunction affects AF is complex and involves electrophysiological, hemodynamic, inflammatory and structural changes in the atria. Appropriate diagnosis and treatment of thyroid dysfunction can improve AF control and reduce thromboembolic and hemorrhagic complications. However, the prevalence, incidence, risk factors, prognosis and management of AF in patients with thyroid dysfunction are still controversial topics in the literature. Objective: to evaluate the impact of thyroid dysfunction in patients with AF, addressing the following aspects: epidemiology, pathophysiology, diagnosis, treatment and clinical outcomes. Methodology: This review was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol. The PubMed, Scielo and Web of Science databases were searched, using the following descriptors: "atrial fibrillation", "thyroid dysfunction", "hypothyroidism", "hyperthyroidism" and "thyrotoxicosis". Articles published in the last 10 years, in Portuguese, English or Spanish, that addressed the proposed topic were included. Articles that were not original, did not have sufficient data or were not relevant to the research question were excluded. Results: 18 studies were selected. The diagnosis of AF in patients with thyroid dysfunction requires confirmation of the heart rhythm by electrocardiogram (ECG) and assessment of serum thyroid hormone levels (TSH, free T4 and free T3). Treatment of AF in patients with thyroid dysfunction aims to restore and maintain sinus rhythm, control ventricular rate, prevent thromboembolic events, and correct thyroid dysfunction. Therapeutic options include antiarrhythmic drugs, antithyroid drugs, anticoagulant drugs, electrical cardioversion, catheter ablation, and surgical thyroid treatment. The clinical outcomes of AF in patients with thyroid dysfunction are influenced by the type, severity and duration of thyroid dysfunction, as well as rhythm, frequency and anticoagulation control. AF in patients with thyroid dysfunction is associated with a higher risk of arrhythmia recurrence, heart failure, stroke and mortality. Conclusion: Thyroid dysfunction is a frequent and important clinical condition in patients with AF, as it can cause or worsen arrhythmia, as well as increase the risk of complications. Appropriate diagnosis and treatment of thyroid dysfunction can improve AF control and reduce adverse outcomes. However, there are still gaps in knowledge about the epidemiology, pathophysiology, prognosis and management of AF in patients with thyroid dysfunction, which require further studies of high quality and clinical relevance.

A New Player in the Game: Can Exergame Be of Support in the Management of Atrial Fibrillation?

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, currently affecting 2-3% of the world's population. Traditional exercise and physical activity interventions have been successfully implemented in the management of AF, with the aim of improving patients' quality of life and their exercise capacity, as well as reducing their mortality rate. Currently, new technology-mediated approaches to exercise, defined as exergame, have been shown to be successful in the delivery of exercise home-based interventions in patients with cardiovascular diseases. However, data on the effects of exergame on AF are not yet available. In this paper, we summarise the current literature on the role of traditional exercise in AF and how it affects the pathophysiology of this condition. We also review the current literature on exergame and its employment in cardiac rehabilitation and suggest its potential role in the management of AF patients. A review of the evidence suggests that traditional exercise (of light-to-moderate intensity) is beneficial in patients with AF. Additionally, exergame seems to be a promising approach for delivering exercise interventions in patients with cardiovascular diseases. Exergame may be a promising tool to improve the quality of life and exercise capacity in patients with AF, with the additional advantage of being remotely delivered, and the potential to increase patients' engagement. Proper guidelines are required to prescribe exergame interventions, considering the principles of traditional exercise prescription and applying them to this new e-health approach. Further studies are needed to validate the use of exergame in patients with AF.

Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy and Cardiac Amyloidosis: From Clinical Management to Catheter Ablation Indication.

Atrial fibrillation (AF) is the most common arrhythmia in patients affected by cardiomyopathies. Reports estimate a prevalence of 27% in patients with hypertrophic cardiomyopathy (HCM) and 40% in patients with cardiac amyloidosis (CA). The presence of AF typically results in progressive functional decline, an increased frequency of hospitalizations for heart failure, and a higher thromboembolic risk. Medical management using mainly beta-blockers or amiodarone has produced variable outcomes and a high rate of recurrence. Catheter ablation reduces symptom burden and complications despite a moderate rate of recurrence. Recent evidence suggests that an early rhythm control strategy may lead to more favorable short- and long-term outcomes. In this review, we summarize contemporary data on the management of AF in patients with cardiomyopathy (HCM and CA) with particular reference to the timing and outcomes of ablation procedures.

Risk of Atrial Fibrillation and Adverse Outcomes in Patients With Cardiac Implantable Electronic Devices.

Comprehensive epidemiological data are lacking on the incident atrial fibrillation (AF) in patients with cardiac implantable electronic devices (CIEDs). This study aimed to examine the incidence, risk factors, and AF-related adverse outcomes of patients with CIEDs. This was an observational cohort study that analyzed patients without prevalent AF who underwent CIED implantation in 2009-2018 using a Korean nationwide claims database. The subjects were divided into three groups by CIED type and indication: pacemaker (n=21,438), implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy (CRT) with heart failure (HF) (n=3,450), and ICD for secondary prevention without HF (n=2,146). The incidence of AF, AF-associated predictors, and adverse outcomes were evaluated. During follow-up, the incidence of AF was 4.3, 7.3, and 5.1 per 100 person-years in the pacemaker, ICD/CRT with HF, and ICD without HF cohorts, respectively. Across the three cohorts, older age and valvular heart disease were commonly associated with incident AF. Incident AF was consistently associated with an increased risk of ischemic stroke (3.8-11.4-fold), admission for HF (2.6-10.5-fold), hospitalization for any cause (2.4-2.7-fold), all-cause death (4.1-5.0-fold), and composite outcomes (3.4-5.7-fold). Oral anticoagulation rates were suboptimal in patients with incident AF (pacemaker, 51.3%; ICD/CRT with HF, 51.7%; and ICD without HF, 33.8%, respectively). A substantial proportion of patients implanted CIED developed newly diagnosed AF. Incident AF was associated with a higher risk of adverse events. The importance of awareness, early detection, and appropriate management of AF in patients with CIED should be emphasized.

Prevalence of atrial fibrillation in patients with atrial septal defect and its impact on in-hospital outcomes

Abstract Background Atrial septal defect (ASD) is one of the most common congenital heart diseases in adulthood. ASDs have left-to-right shunt and primarily right-sided volume overload. This leads to electrical remodeling that may predispose patients to atrial fibrillation (AF). There is limited data on the impact of AF on clinical outcomes in patients with ASD. Purpose To study the prevalence of AF and its impact on in-hospital outcomes in adult patients with ASD. Methods This is a retrospective cohort analysis of all ASD related hospitalizations between January 1, 2016, and December 31, 2020, from the National Inpatient Sample, the largest publicly available all-payer inpatient care database in the United States. Our study population included adult patients (≥ 18 years) with ASD using ICD-10 diagnostic codes. Patients with a diagnosis of acquired ASD were excluded. ASD patients were divided into two groups: with and without AF. We used Chi square test for categorical variables and t-test for continuous variables to compare group differences between ASD with AF and ASD without AF. Univariate and multivariate logistic regression were used to analyze the clinical outcomes between the two groups. Results From 2016 to 2020, we identified 82,574 hospitalizations with primary diagnosis of ASD, of which 23,907 (29%) had coexisting AF. The mean age was 71 years. Among them, 48% were female. Racial distributions were: 81% Whites, 8.8% Blacks, 5.9% Hispanics and 2.1% Asians. Compared to ASD without AF, ASD with AF hospitalizations were older in age (mean age: 71 vs 59, p<0.001), had higher prevalence of chronic heart failure (56% vs 25%, p<0.001), hypertension (71% vs 61%, p<0.001), obstructive sleep apnea (16% vs 9%, p<0.001), and higher Charlson comorbidity index (CCI) of ≥3 (52% vs 46%, p<0.001). ASD patients with AF had higher in-hospital mortality (aOR: 1.25, 95% CI: 1.14, 1.37, p<0.001), longer length of stay (beta coefficient: 0.15, 95% CI 0.13, 0.17, p<0.001), higher odds of acute heart failure (aOR:3, 95% CI: 2.86, 3.15, p<0.001), cardiogenic shock (aOR: 2.68, 95% CI: 2.42, 2.97, p<0.001), acute kidney injury (aOR:1.4, 95% CI: 1.35, 1.46, p<0.001) and requirement of permanent pacemaker (PPM) (aOR: 2.51, 95% CI: 2.16, 2.92, p<0.001) compared to ASD without AF after controlling for age, race, CCI, obesity, COPD and pulmonary hypertension. Conclusions Our study showed that a significant percentage of hospitalized patients with ASD had concomitant AF. AF can contribute to higher in-hospital mortality and worse clinical outcomes in patients with ASD. This highlights the importance of optimal management of AF in patients with ASD.

Risk of major cardiovascular events and bleeding in atrial fibrillation patients with chronic obstructive pulmonary disease treated with low dose azithromycin prophylaxis

Abstract Background Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of cardiovascular events in patients with atrial fibrillation (AF). Low Dose Azithromycin Prophylaxis (LDAP) is associated with improved outcomes in people suffering frequent exacerbations of COPD, but the widespread use of macrolides in patients with underlying cardiovascular disease has been debated due to safety concerns. Aims and Objectives To investigate the safety and efficacy of LDAP in AF patients with COPD in a large global federated dataset. Methods We conducted a retrospective cohort study within the global TriNetX Platform, including AF patients with COPD exacerbations. Risks for all-cause death, major adverse cardiovascular events (MACE: acute coronary syndrome, thromboembolic events, severe ventricular arrhythmias, and heart failure), intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding were recorded up to 30 days post-COPD exacerbations and compared between LDAP users (at least 3 months use and using LDAP at index) and an active control group (non-Azithromycin users receiving inhaled corticosteroids (ICS)). Cox regression analyses compared outcomes between groups after propensity-score-matching (PSM) for cardiovascular risk factors. Results We identified 2791 LDAP users with COPD and AF (mean age 71.5±10.6 years, 48.9% female), and 61054 controls. Before PSM, LDAP users showed a lower prevalence of cardiovascular risk factors and were less likely to be prescribed oral anticoagulation (68.1% vs 76.1%, p<0.001). After PSM no significant baseline differences were found between two groups. After COPD exacerbation, LDAP users were associated with a lower 30-day risk of all-cause death (HR: 0.72, 95%CI 0.60-0.97), MACE (HR 0.72, 95%CI 0.57-0.90), ICH (0.48, 95%CI 0.27-0.88) and GI bleeding (HR 0.69,95%CI 0.46-0.89) compared to the conventional treatment with ICS. Analysing the different time frames, the lower risk of thrombotic events was observed during the second week after COPD exacerbation while the magnitude of the bleeding risk reduction was more evident in the first 7 days (Figure 1). Conclusion LDAP use is associated with a lower risk of all-cause death, MACE and bleeding in AF patients with COPD. Further studies are needed to investigate the possible role of LDAP as part of the integrated care management of AF patients with COPD.

Chronic Kidney Disease is a Predictor of Recurrent Bleeding in Patients With Atrial Fibrillation After Resuming Anticoagulant Therapy (based on REGistry of Long-term AnTithrombotic TherApy (REGATA-2).

Patients with atrial fibrillation (AF) at high risk of thromboembolic complications who have had bleeding should strive to resume anticoagulant therapy. Existing traditional scales for assessing the risk of hemorrhagic complications are not highly specific for the risk of recurrent bleeding. Thus, searching is needed for clinical and laboratory predictors to identify patients who require a personalized monitoring regimen. The aim of the study was to assess the incidence rate and predictors of recurrent major and clinically significant bleeding in patients with AF after resumption of the anticoagulant therapy, as well as the contribution of changing the anticoagulant to the treatment safety. Based on a 5-year follow-up of 95 patients with AF who have had major and clinically significant bleeding, the incidence and clinical factors determining the recurrence of hemorrhagic complications were assessed.Results According to the data of the 5-year follow-up, the recurrence rate of major/clinically significant bleeding was 16.9/100 patient-years. Changing the oral anticoagulant significantly reduced the risk of relapse after clinically significant bleeding and did not affect the risk of recurrence of major bleeding. The predictor for relapse of major/clinically significant bleeding during the therapy resumption was chronic kidney disease with a decrease in creatinine clearance to less than 60 ml/ min, which increased the risk of relapse 2.27 times (95% confidence interval: 1.1253-4.6163; p=0.0221). The development of serious bleeding in a patient at high risk of thrombotic complications always requires a reassessment of risk factors and an adequate choice and dosage of the anticoagulant. Development of a unified protocol for the management of AF patients receiving anticoagulants and having a high risk of bleeding is essential and will reduce the risk of adverse outcomes.

Abstract 18368: Management of Incident AF in Hospitalized Patients - Deficient, Delayed, Detrimental

Introduction: Atrial fibrillation (AF) is potentially associated with significant complications including stroke and cardiac decompensation. Early appropriate AF management mitigates this risk. However, intervention is frequently delayed - a median of 1.5 days from AF onset in the ICU to clinical response. We sought to better understand delays in detection and management of AF in patients admitted to a cardiology bed and the consequences of delays. Methods: We undertook a retrospective review of 498 patients admitted to cardiology beds at the University of Virginia Medical Center who had automated algorithmic detection of AF episodes lasting ≥6 min. Time from algorithmic detection to clinical identification, AF burden, AF interventions and complications, medical history, and demographics were identified in each patient’s chart. Results: Of the 498 patients, 171 had an algorithmically detected episode of AF that was not acknowledged medically. These undetected episodes were generally shorter relative to episodes that were acknowledged (median 8 min vs. 52 min). 96 of the 498 patients had initial clinical detection of AF following algorithm detection; of the 96, 21 received early intervention (within 60 min), 51 received late intervention (after 60 min), and 24 received no intervention at all. Patients with early intervention experienced less AF burden compared to late and no intervention groups (median 8.6 hrs vs 21.75 hrs vs 29.35 hrs). Late intervention patients had more AF related complications compared to early intervention patients (9.8% vs. 4.8%). 20.8% of patients with clinical acknowledgement of AF but no intervention suffered a complication. Patients with a history of AF were more likely to have delays in intervention and over twice as likely to suffer an AF complication compared to those with no history (15.6% vs. 7.4%). Patients of lower socioeconomic status (SES) were also more likely to experience a complication. Conclusions: In summary, cardiology inpatients at our hospital commonly experience delays in management of AF that are considerable in duration, resulting in greater AF burden and higher complication rates. Differences in management, and subsequent outcomes, following AF appear to be impacted by prior history of AF and patient SES.

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

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

Usage and the effect on knowledge about atrial fibrillation of an educational application, AF-EduApp

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The AF-EduApp study is supported by an BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA) grant. Introduction As the management of atrial fibrillation patients (AF) is complex, an integrated care approach is suggested, including tackling modifying risk factors together with rate and rhythm control and anticoagulation therapy. Patients often underestimate the effect of these pillars on their health and often have poor knowledge about these aspects. As smart devices have become more important in the past decades, they create opportunities to educate patients and improve the follow-up of these patients. Purpose We aimed to evaluate the usage of an in-house developed application, AF-EduApp, and its effect on patients’ AF knowledge levels. Methods A total of 152 patients with AF were included in this multicenter study with a follow-up of 12 to 15 months. One of the modules of the AF-EduApp contains information on AF, its treatment and related self-care. Knowledge about AF and its treatment was assessed through the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) with direct feedback on incorrectly answered questions. The JAKQ (and immediate feedback) were given to the patients via the application at baseline and after 1, 3, 6 and 12 months. Patients are free to decide how frequently they want to use the app (except when questionnaires are available). Results The 152 patients had a total follow-up of 386.8±108.1 days and used the application on 130.1±144.7 days (33.6%). The education module was visited by 135 patients with a median time of 3.1 (IQR: 1.3-21.8) min (mean: 18.6±32.9 min) spent on education. The most visited education chapters were AF treatment (3.1 (0.4-9.5) min) and selfcare (3.1 (0.9-7.1) min)(Fig1). A significant increase in the knowledge level was seen in the 130 patients who completed all 5 moments (p<0.001, Fig 2A). This increase was driven by a significant increase during the first month of follow-up (baseline: 70.4±14.4 vs FU1: 82.4±14.4; p<0.001). The number that one of the 8 questions on AF in general was correctly answered at these 5 time points ranged from 2.7±1.6 to 4.8±0.7 (p<0.001, Fig 2B). The questions ‘Why are most patients with AF prescribed with oral anticoagulation?’ and ‘What is AF?’ were answered best, whereas the questions ‘Is AF always accompanied by symptoms?’ and ‘Can medication prevent AF?’ were most difficult to get right. Conclusion The AF application was reasonably used, about 1 out of every 3 days. Targeted education focused on JAKQ answers that were answered incorrectly significantly improved knowledge level over time. Stronger incentives need to be developed to have patients effectively look at the educational sections that pertain to incomplete knowledge.

Management of anticoagulation in atrial fibrillation patients in Italy: insight from the <i>Atrial Fibrillation-Survey on Anticoagulated Patients Register</i> (AF-START)

The survey on anticoagulated patients register (START-Register) is an independent, prospective, inception-cohort observational study aimed at providing information on patients on vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) in Italy. In this study, we describe the cohort of atrial fibrillation (AF) patients in the START-Register and report outcomes and changes in anticoagulant prescription from 2011 to 2021. The study included 11,078 AF patients, enrolled in 47 Italian centers distributed all over the Country; the median age was 77 years (range 18-99 years); 6029 (54.3%) were men; 5135 (46.4%) were on VKAs, and 5943 (53.6%) were on DOACs. Warfarin was the most prescribed VKA (98.4%), and apixaban was the most prescribed DOAC (31.6%). Among DOAC users, 4022 (67.7%) patients were naive to anticoagulation, and 2562 (43.1%) patients were treated with a reduced dose. DOAC patients were significantly older than VKA patients (median age 79 years vs 76 years respectively, P<0.001), but no gender difference was detected. The mean CHA2DS2VASc score was higher in DOAC users than in VKA users (3.7 vs 3.6; P=0.03). The mean HAS-BLED score was not different between the two groups. During follow-up, 542 bleeding events were recorded [2.44 per 100 patient-years (pt-yrs)]; 240 were major (1.08 per 100 pt-yrs), and 301 were clinically relevant non-major bleedings (1.34 per 100 pt-yrs). 146 thrombotic events were recorded during follow-up (0.66 per 100 pt-yrs). The total mortality rate was 3.5 per 100 pt-yrs; the mortality rate was 4.54 per 100 pt-yrs among patients on VKAs and 2.31 per 100 pt-yrs among patients on DOACs. During the last 10 years, in Italy, AF patient management has changed with the large spread of DOACs all over the Country. DOAC patients are frequently treated with reduced doses and show a lower mortality rate in comparison to patients on VKAs.

Transesophageal Echocardiogram Before Cardioversion in Atrial Fibrillation Patients.

Transesophageal echocardiography (TEE) offers an invaluable, non-invasive avenue for diagnosing and managing various cardiac conditions, including atrial fibrillation (AF). As the most common cardiac arrhythmia, AF affects millions and can lead to severe complications. Cardioversion, a procedure to restore the heart's normal rhythm, is frequently conducted on AF patients resistant to medication. Due to inconclusive data, TEE's utility prior to cardioversion in AF patients remains ambiguous. Understanding TEE's potential benefits and limitations in this population could significantly influence clinical practice. This review aims to scrutinize the current literature on the use of TEE before cardioversion in AF patients. The principal objective is to understand TEE's potential benefits and limitations comprehensively. The study seeks to offer a clear understanding and practical recommendations for clinical practice, thereby improving the management of AF patients before cardioversion using TEE. A literature search of databases was conducted using the keywords "Atrial Fibrillation," "Cardioversion" and "Transesophageal echocardiography," resulting in 640 articles. These were narrowed to 103 following title and abstract reviews. After applying exclusion and inclusion criteria with a quality assessment, 20 papers were included: seven retrospective studies, 12 prospective observational studies, and one randomized controlled trial (RCT). Stroke risk associated with direct-current cardioversion (DCC) potentially results from post-cardioversion atrial stunning. Thromboembolic events occur post cardioversion, with or without prior atrial thrombus or cardioversion complications. Generally, cardiac thrombus localizes in the left atrial appendage (LAA), a clear contraindication to cardioversion. Atrial sludge without LAA thrombus in TEE is a relative contraindication. TEE before electrical cardioversion (ECV) in anticoagulated AF individuals is uncommon. In AF patients planned for cardioversion, contrast enhancement facilitates thrombus exclusion in TEE images, reducing embolic events. Left atrial thrombus (LAT) frequently occurs in AF patients, necessitating TEE examination. Despite the increased use of pre-cardioversion TEE, thromboembolic events persist. Notably, patients with post-DCC thromboembolic events had no LA thrombus or LAA sludge. The use of TEE-guided DCC has grown due to its ability to detect atrial thrombi pre-cardioversion, aiding risk stratification. Thrombus in the left atrium also signals an elevated risk of future thromboembolic events in AF patients. While atrial stunning post cardioversion detected by TEE is a significant risk factor for future thromboembolic events, further evidence is required. Therapeutic anticoagulation is essential during and post cardioversion, even if no atrial thrombus is detected. Current data recommends cardioversion guided by TEE, particularly in outpatient settings.

Effects of the ABC pathway on clinical outcomes in a secondary prevention population of Chinese patients with atrial fibrillation: A report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry.

The atrial fibrillation better care (ABC) pathway is a simple, comprehensive framework that facilitates provision of integrated care for atrial fibrillation (AF) patients. We evaluated management of AF patients in a secondary prevention cohort using the ABC pathway and examined the impact of ABC adherence on clinical outcomes. The Chinese Patients with Atrial Fibrillation registry is a prospective registry conducted in 44 sites across China between October 2014 and December 2018. The primary outcome was the composite of all-cause mortality/any thromboembolism (TE), all-cause death, any TE and major bleeding at 1 year. Of the 6420 patients, 1588 (24.7%) had a prior stroke or transient ischemic attack and were identified as the secondary prevention cohort. After excluding 793 patients due to insufficient data, 358 (22.5%) were ABC compliant and 437 (27.5%) ABC noncompliant. ABC adherence was associated with a significantly lower risk of the composite outcome of all-cause death/TE, odds ratio (OR) 0.28 (95% confidence interval [CI]: 0.11-0.71) and all-cause death, OR 0.29 (95% CI: 0.09-0.90). Significant differences were not observed for TE, OR 0.27 (95% CI: 0.06-1.27) and major bleeding, OR 2.09 (95% CI: 0.55-7.97). Age and prior major bleeding were significant predictors of ABC noncompliance. Health-related quality of life (QOL) was higher in the ABC compliant group versus the noncompliant group (EQ score 0.83 ± 0.17 vs. 0.78 ± 0.20; p = .004). ABC pathway adherence in secondary prevention AF patients was associated with a significantly lower risk of the composite outcome of all-cause death/TE and all-cause death, as well as better health-related QOL.

The Association Between Rheumatoid Arthritis and Atrial Fibrillation: Epidemiology, Pathophysiology and Management.

Atrial fibrillation (AF) is the most common cardiac arrhythmia with a significant increase in morbidity and mortality worldwide. Rheumatoid arthritis (RA), as a systemic inflammatory disease, affecting 0.5-1.0% of the adult population, is associated with increased incidence of cardiac arrhythmias such as AF. Several epidemiologic studies find that the risk of AF is increased in RA when compared with the general population. Other studies are inconsistent. Considering that inflammation plays an important role in AF, RA may be involved in the occurrence and development of AF. This review summarizes the epidemiology, pathophysiology, and management of AF in patients with RA.

Left atrial appendage closure in end-stage renal disease and hemodialysis: Data from a German multicenter registry.

Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). OAC treatment has been proven feasible in mild-to-moderate chronic kidney disease (CKD). In contrast, the optimal antithrombotic management of AF patients with end-stage renal disease (ESRD) is unknown and LAAC has not been proven in these patients in prospective randomized clinical trials. The objective of this study is to evaluate safety and efficacy of LAAC in patients with ESRD. Patients undergoing LAAC were collected in a German multicenter real-world observational registry. A composite endpoint consisting of the occurrence of ischemic stroke/transient ischemic attack, systemic embolism, and/or major clinical bleeding was assessed. Patients with ESRD were compared with propensity score-matched patients without severe CKD. ESRD was defined as a glomerular filtration rate < 15 ml/min/1.73 m2 or chronic hemodialysis treatment. A total of 604 patients were analyzed, including 57 with ESRD and 57 propensity-matched patients. Overall, 596 endocardial and 8 epicardial LAAC procedures were performed. Frequency of major complications was 7.0% (42/604 patients) in the overall cohort, 8.8% (5/57 patients) in patients with ESRD, and 10.5% (6/57 patients) in matched controls (p = 0.75). The estimated event-free survival of the combined endpoint after 500 days was 90.7 ± 4.5% in patients with ESRD and 90.2 ± 5.5% in matched controls (p = 0.33). LAAC had comparable procedural safety and clinical efficacy in patients with ESRD and patients without severe CKD.

Review article: diagnosis, pathophysiology and management of atrial fibrillation in cirrhosis and portal hypertension.

Atrial fibrillation (AF) is the most common arrhythmia and its management in cirrhosis can be challenging due to the altered hepatic metabolism of medications and increased risk of bleeding. To provide a comprehensive overview of the diagnosis, pathophysiology and management of AF in patients with cirrhosis from both a cardiology and a hepatology perspective. An extensive literature search was performed using the terms 'atrial fibrillation' and 'cirrhosis'. Guideline documents and consensus statements were explored. The prevalence of AF in patients with cirrhosis ranges between 6.6% and 14.2%, while the incidence of new-onset AF in the post-operative period after liver transplant ranged between 6.8% and 10.2%. AF in patients with cirrhosis is associated with adverse outcomes in both pre-transplant and post-transplant settings, including an increased risk of stroke when compared to the general population. We review the pathogenesis of AF in general and in cirrhosis. This review also provides guidance on the management of AF, including the use of anticoagulation and rate versus rhythm control. In the absence of strict contraindications, all patients with cirrhosis and AF should be anticoagulated. The use of DOACs is preferred over vitamin K antagonists. In patients with a high bleeding risk, a DOAC with an approved antidote may be preferred. Atrial fibrillation is increased in patients with cirrhosis. AF management requires careful consideration of treatment options. Since patients with cirrhosis were excluded from all major randomised clinical trials, dedicated research on the pathophysiology and management of AF in cirrhosis is needed.

Evolution of and Evidence-Practice Gaps in Antithrombotic Management of Atrial Fibrillation Patients After Percutaneous Coronary Intervention

BackgroundThe management of atrial fibrillation and flutter (AF) patients undergoing percutaneous coronary intervention (PCI) has evolved rapidly in the past decade. We determine whether the publication of the 2016 Canadian Cardiovascular Society AF guidelines were associated with a shift in practice patterns. MethodsUsing Quebec provincial administrative database information for the period from 2010-2017, a retrospective cohort of patients with inpatient or outpatient coding for AF, who subsequently underwent PCI with placement of a coronary stent, was created and analyzed for the antithrombotic regimen received in the following year. Prescribing behavior was compared among 3 time periods (2010-2011, 2012-2015, 2016-2017), and use of antithrombotics was compared to guideline-predicted therapy using the χ2 test. Predictors of oral anticoagulation (OAC) prescription were identified using adjusted logistic regression. ResultsA total of 3740 AF patients undergoing PCI were included. The proportion of OAC prescription increased over time (2010-2011 = 51.4%; 2012-2015 = 54.3%; 2016-2017 = 56.6%; P = 0.13), with a significant increase in direct OAC prescription (P < 0.01). A substantial treatment gap in OAC prescription persisted after publication of the 2016 guidelines (56.6% observed vs 89.7% predicted; P < 0.01). Previous stroke, CHADS2 score, Charlson Comorbidity Index ≥ 4, and prior use of direct OAC or warfarin were predictors of being exposed to OAC claims; previous major bleeding, and low-dose acetylsalicylic acid or P2Y12 inhibitor use were predictors of not being exposed to OACs. ConclusionExpert guidance contributed to an increase in OAC prescription following PCI, but up to 2017, substantial further changes in practice patterns would have been required to achieve the recommended rates of OAC prescription.