Management Of Atrial Fibrillation Research Articles

Role of a National Health Service Electronic Prescriptions Database in the Detection of Prescribing and Dispensing Issues and Adherence Evaluation of Direct Oral Anticoagulants

Background: Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF) by significantly reducing the risk of stroke. Direct oral anticoagulants (DOAC) became preferred over warfarin due to their superior safety and efficacy profile. Assessing adherence to anticoagulation therapy is necessary in clinical practice for optimising patient outcomes and treatment efficacy, thus emphasising its significance. Methods: A retrospective study utilised the Latvian National Health Service reimbursement prescriptions database, covering prescriptions for AF and flutter from January 2012 to December 2022. The proportion of days covered method was selected for adherence assessment, categorising it into three groups: (1) below 80%, (2) between 80% and 90%, and (3) above 90%. Results: A total of 1,646,648 prescriptions were analysed. Dabigatran prescriptions started declining after 2020, coinciding with a decrease in warfarin prescriptions since 2018. The total adherence levels to DOAC therapy were 69.4%. Only 44.2% of users achieved an adherence level exceeding 80%. The rate of paper prescriptions decreased from 98.5% in 2017 to 1.3% in 2022. Additionally, the utilisation of international non-proprietary names reached 79.7% in 2022. Specifically, 16.7% of patients selected a single pharmacy, whereas 27.7% visited one or two pharmacies. Meanwhile, other patients obtained medicines from multiple pharmacies. Conclusions: The total adherence level to DOAC therapy is evaluated as low and there was no significant difference in age, gender, or “switcher” status among adherence groups. Physicians’ prescribing habits have changed over a decade.

Clinical characteristics and atrial fibrillation management in hospitalized patients with heart failure with reduced versus preserved ejection fraction

Abstract Funding Acknowledgements None. Background Non-valvular atrial fibrillation (NVAF) and heart failure (HF) frequently coexist. AF management in HF is currently changing with increasing role of rhythm control. Data about clinical characteristics and AF management in hospitalized patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) are lacking. The purpose of the study was to assess the clinical characteristics and AF management in hospitalized patients with NVAF and HFrEF and compare them to those of NVAF and HFpEF. Methods Consecutive NVAF patients hospitalized with HF decompensation between January 2020 and May 2022 were retrospectively evaluated. Patients were divided into two groups: HFrEF and HFpEF (defined as left ventricular ejection fraction > 40%). Clinical characteristics and AF treatment strategy in both groups were studied and compared. Numerical data are expressed as median (interquartile range). P<0.05 was considered significant. Results In a total of 388 AF-HF patients (age 73.5 years [66-82], 59.3% males), 147 (37.9%) had reduced ejection fraction. Patients with HFrEF compared to those with HFpEF were younger (69.3 vs 74.7 years; P < 0.001), more often male and with a higher rate of NYHA classes III-IV (73.9% vs 63.5%; P < 0.05), N-terminal pro-B-type natriuretic peptide level (2658.5 pg/ml vs 1799.1 pg/ml; p<0.001), sum of B-lines by lung ultrasound (35.2 vs 28.9; P<0.05) and prevalence of non-paroxysmal forms of AF (70.4% vs 50.4%; p < 0.05). Patients with HFrEF had a higher burden of coronary artery disease, chronic kidney disease and prior stroke (31.7% vs 19.2%, 83.9% vs 69.0, 18.5% vs 9.7%, respectively; p< 0.05 for all) than HFpEF patients. Patients with HFpEF were more likely than those with HFrEF to have diabetes mellitus (25.9% vs 37.1%; p< 0.05) The subgroup of patients with HFrEF compared to those with HFpEF had higher bleeding risk (HAS-BLED ≥3 in 32.1% vs 20.4%, P<0.05) due to more frequent abnormal renal/liver function, concomitant antithrombotic treatment/alcohol, prior stroke (24.7% vs 10.6%, 28.4% vs 16.8%, 18.5% vs 9.7%, respectively; P<0.05 for all) but lower thromboembolic risk according to CHA 2 DS 2 -VASc (4.0 vs 4.4; p < 0.05). Oral anticoagulants (OAC) were administered in 88% of patients on discharge. Patterns of anticoagulation administration didn’t differ between the two groups. Patients with HFrEF were less likely to receive first-line rhythm control for AF compared to HFpEF patients (36.1% vs 68.1%; p<0.05). Conclusion Hospitalized patients with NVAF and HFrEF compared to those with HFpEF were younger, with greater severity of HF, higher burden of comorbidities and bleeding risk and slightly lower thromboembolic risk. Despite different clinical characteristics, OAC administration patterns were similar and OAC prescription rate was not optimal in both groups. There is a need for improvement of guideline adherence to first-line rhythm control strategy in AF and HFrEF.

Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management.

This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.

Lipomatous Interatrial Septum Detected During Cardioversion Evaluation for Atrial Fibrillation

Primary cardiac tumors are rare, with an estimated prevalence in autopsy series ranging from 0,001 to 0,28%. Benign tumors are the most common type, with lipoma being the second most frequent among these, following myxoma. Lipoma can pose a differential diagnostic problem with lipomatous hypertrophy of the interatrial septum (IAS). This entity is rare and often asymptomatic, requiring no surgical treatment unless it causes obstruction of surrounding anatomical structures. In practice, cardiac CT and MRI are frequently used to confirm echocardiographic suspicions, both transthoracic and transesophageal. We present the case of a 72-year-old patient referred for management of recent atrial fibrillation, with heart rate control proving difficult despite maximum dose medical treatment. We opted for electrical cardioversion to improve the patient's hemodynamic state in the short term and to prevent progression to atrial cardiomyopathy in the medium and long term. In the transesophageal echocardiogram (TEE), the patient exhibited significant thickening of the interatrial septum, measuring 22 mm, without compression of the superior vena cava, and with the fossa ovalis remaining intact. Through this case, we discuss the diagnostic and therapeutic approaches to lipomatous hypertrophy of the IAS.

Rhythm vs Rate Control Strategy for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials.

Rhythm control, either with antiarrhythmic drugs or catheter ablation, and rate control strategies are the cornerstones of atrial fibrillation (AF) management. Despite the increasing role of rhythm control over the past few years, it remains inconclusive which strategy is superior in improving clinical outcomes. This study summarizes the total and time-varying evidence regarding the efficacy of rhythm- vs rate-control strategies in the management of AF. We systematically perused the MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for randomized controlled trials from inception to November 2023. We included studies that compared the efficacy of rhythm control (ie, antiarrhythmic drugs classes Ia, Ic, or III, AF catheter ablation, and electrical cardioversion) and rate control (ie, beta-blocker, digitalis, or calcium antagonist) strategies among patients with nonvalvular AF. The primary outcome was cardiovascular (CV) death, whereas secondary outcomes included all-cause death, stroke, hospitalization for heart failure (HF), sinus rhythm at the end of the follow-up, and rhythm control-related adverse events. A cumulative meta-analysis to assess temporal trends and a meta-regression analysis using the percentage of ablation use was performed. We identified 18 studies with a total of 17,536 patients (mean age: 68.6 ± 9.7 years, 37.9% females) and a mean follow-up of 28.5months. Of those, 31.9% had paroxysmal AF. A rhythm control strategy reduced CV death (HR: 0.78; 95%CI: 0.62-0.96), stroke (HR: 0.801; 95%CI: 0.643-0.998), and hospitalization for HF (HR: 0.80; 95%CI: 0.69-0.94) but not all-cause death (HR: 0.86; 95%CI: 0.73-1.02) compared with a rate control strategy. This benefit was driven by contemporary studies, whereas more ablation use within the rhythm control arm was associated with improved outcomes, except stroke. In patients with AF, a contemporary rhythm control strategy leads to reduced CV mortality, HF events, and stroke compared with a rate control strategy.

Ischemic Stroke Subtypes: Risk Factors, Treatments, and 1-Month Prognosis – The Lille, France Stroke Registry

ObjectivesFirst, this registry-based study aimed to comprehensively analyze patients' medical histories and treatments based on ischemic strokes’ etiology. We focused on the management of atrial fibrillation among patients diagnosed with cardioembolic stroke. Then, our objective was to identify prognostic factors associated with 28-day mortality. Materials and MethodsAll ischemic strokes occurring in adults between 2014 and 2021 in Lille, France, were categorized using the TOAST classification. Comparative analyses of patients' medical characteristics were conducted across subtypes. Survival rates within 28 days post-stroke were assessed, and factors influencing mortality were identified using a multivariate Cox model. Results1912 ischemic strokes were recorded, due to cardioembolism (36%), large-artery atherosclerosis (10%), small-artery occlusion (9%), other determined causes (6%), or undetermined causes (39%). The median NIHSS score after cardioembolic strokes (6, IQR: 3-13) was twice that after small-artery occlusions (3, IQR: 2-5). Among patients with cardioembolic stroke, 26% were diagnosed post-admission with atrial fibrillation. For the 42% diagnosed pre-admission, only 54% had prior prescriptions for oral anticoagulants. Reperfusion therapies were administered in 21% of cases, with significant variations across subtypes. Mortality rates were higher after cardioembolic strokes (17%) than after small-artery occlusions (3%). Prognostic factors included etiology, high NIHSS score, atrial fibrillation, and previous heparin prescription. ConclusionsWhile atrial fibrillation was underdiagnosed and undertreated, patients with cardioembolic strokes exhibited high severity and elevated mortality rates. Etiology emerged as an independent predictor of early mortality, regardless of NIHSS score upon admission. These findings underscore the importance of targeted prevention to improve patient outcomes after ischemic stroke.

Impact of an Organized Treatment Pathway on Management of Atrial Fibrillation: The ER2EP Study

BackgroundAtrial fibrillation (AF) is the most common arrhythmia reported worldwide. There is significant heterogeneity in AF care pathways for a patient seen in the emergency room, impacting access to guideline-driven therapies. ObjectivesThe purpose of this study was to compare the difference in AF outcomes between those treated with an organized treatment pathway vs routine-care approach. MethodsThe emergency room to electrophysiology service study (ER2EP) is a multicenter, prospective observational registry (NCT04476524) enrolling patients with AF from sites where a pathway for management of AF was put in place compared to sites where a pathway was not in place within the same health system and the same physicians providing services at all sites. Multivariable regression modeling was performed to identify predictors of clinical outcomes. Beta coefficient or odds ratio was reported as appropriate. ResultsA total of 500 patients (ER2EP group, n = 250; control group, n = 250) were included in the study. The mean age was 73.4 ± 12.9 years, and 52.2% were males. There was a statistically significant difference in primary endpoint [time to ablation (56 ± 50.9 days vs 183.3 ± 109.5 days; P < 0.001), time to anticoagulation initiation (2.1 ± 1.6 days vs 19.7 ± 35 days, P < 0.001), antiarrhythmic drug initiation (4.8 ± 7.1 days vs 24.7 ± 44.4 days, P < 0.001) compared to the control group, respectively. As such, this resulted in reduced length of stay in the ER2EP group compared to the control group (2.4 ± 1.4 days vs 3.23 ± 2.5 days, P = 0.002). ConclusionsThis study provides evidence that having an organized pathway from the emergency department for AF patients involving electrophysiology services can improve early access to definitive therapies and clinical outcomes.

[Management and treatment of atrial fibrillation in cancer patients: an important decision-making hub in cardio-oncology].

[Management and treatment of atrial fibrillation in cancer patients: an important decision-making hub in cardio-oncology].

Chinese guidelines for the diagnosis and management of atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Synergistic Effects of Weight Loss and Catheter Ablation: Can microRNAs Serve as Predictive Biomarkers for the Prevention of Atrial Fibrillation Recurrence?

In atrial fibrillation (AF), multifactorial pathologic atrial alterations are manifested by structural and electrophysiological changes known as atrial remodeling. AF frequently develops in the context of underlying cardiac abnormalities. A critical mechanistic role played by atrial stretch is played by abnormal substrates in a number of conditions that predispose to AF, including obesity, heart failure, hypertension, and sleep apnea. The significant role of overweight and obesity in the development of AF is known; however, the differential effect of overweight, obesity, cardiovascular comorbidities, lifestyle, and other modifiable risk factors on the occurrence and recurrence of AF remains to be determined. Reverse remodeling of the atrial substrate and subsequent reduction in the AF burden by conversion into a typical sinus rhythm has been associated with weight loss through lifestyle changes or surgery. This makes it an essential pillar in the management of AF in obese patients. According to recently published research, microRNAs (miRs) may function as post-transcriptional regulators of genes involved in atrial remodeling, potentially contributing to the pathophysiology of AF. The focus of this review is on their modulation by both weight loss and catheter ablation interventions to counteract atrial remodeling in AF. Our analysis outlines the experimental and clinical evidence supporting the synergistic effects of weight loss and catheter ablation (CA) in reversing atrial electrical and structural remodeling in AF onset and in recurrent post-ablation AF by attenuating pro-thrombotic, pro-inflammatory, pro-fibrotic, arrhythmogenic, and male-sex-associated hypertrophic remodeling pathways. Furthermore, we discuss the promising role of miRs with prognostic potential as predictive biomarkers in guiding approaches to AF recurrence prevention.

Outcomes of combined left bundle branch area pacing with atrioventricular nodal ablation in patients with atrial fibrillation and pulmonary disease.

Concomitant left bundle branch area pacing (LBBAP) with atrioventricular (AV) nodal ablation is emerging as a viable management option in atrial fibrillation refractory to medical management. Its viability in patients with pulmonary disease and atrial fibrillation is unknown. This is a retrospective, observational cohort study in consecutive patients who underwent concomitant LBBAP with AV nodal ablation with advanced pulmonary disease at the Cleveland Clinic Fairview Hospital between January 2019 and January 2023. Patient characteristics, comorbidities, and medication use were extracted via chart review. Rates of hospitalizations, medication use, and structural disease seen on echocardiography were compared before and after the procedure. There were 27 patients with group 3 pulmonary hypertension who underwent the procedure. In the 24 months preprocedure, there were 114 admissions for heart failure or atrial fibrillation compared to 9 admissions postprocedure (p<.001). Mean follow up was 17.3±12.1 months. There were no significant complications or lead dislodgements. Echocardiographic characteristics were similar prior to and after pacemaker implantation. Use of medications for rate and rhythm control was common preprocedure, and was reduced dramatically postprocedure. This small, retrospective cohort study suggests concomitant LBBAP with AV nodal ablation may be safe and efficacious for management of atrial fibrillation in patients with advanced pulmonary disease.

Clinical Outcomes of Patients with Atrial Fibrillation who Survived from Bleeding Event: The Results from COOL-AF Thailand Registry

Background Bleeding events are often reported among patients with atrial fibrillation (AF), irrespective of antithrombotic use. This study is to determine clinical outcomes of patients with AF who survived from bleeding event. Methods We analyzed data from COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) Thailand registry. Outcomes of patients who experienced any bleeding were compared with patients who had never bleed. Time updated multivariate Cox-proportional hazard models were used to estimate the risk for clinical outcomes of patients with and without bleeding. Results Of total 3,405 patients (mean age: 67.8 ± 11.3 years; 41.9% female) in COOL-AF registry, 609 patients (17.9%) reported bleeding event occurs and 568 patients (93.3%) survived though hospital discharge. Patients who survived major bleeding (n = 126) were at increased risk for both death (adjusted hazard ratio [HR]: 4.44, 95% confidence interval [CI]: 2.91–6.75, p &lt; 0.001) and stroke/systemic embolism (adjusted HR: 4.49, 95% CI: 2.19–9.24, p &lt; 0.001). Minor bleeding also increased subsequent death (adjusted HR: 2.13, 95% CI: 1.56–2.90, p &lt; 0.001). Up to 30% of patients who survived major bleeding and 6.3% of minor bleedings discontinued oral anticoagulation. Discontinuation was associated with very high death rate (42.1%), whereas patients who resumed oral anticoagulation after bleeding had lower mortality (10%). The most common causes of death in patients who survived a bleeding event were not related to cardiovascular causes nor bleeding. Conclusion Patients with AF who have bleeding events have an increased risk for subsequent death and stroke and systemic embolism. These patients should be identified as vulnerable clinically complex patients and require a holistic approach to their AF management.

Assessment and Management of Atrial Fibrillation in Older Adults with Frailty.

Atrial fibrillation (AF) is a major driver of morbidity and mortality among older adults with frailty. Moreover, frailty is highly prevalent in older adults with AF. Understanding and addressing the needs of frail older adults with AF is imperative to guide clinicians caring for older adults. In this review, we summarize current evidence to support the assessment and management of older adults with AF and frailty, incorporating numerous recent landmark trials and studies in the context of the 2023 US AF guideline.

Incidental and anticipated arrhythmic diagnoses in patients with an implantable cardiac monitor

Aims In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance. Methods We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings. Results The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% [95% confidence interval (CI) 22–55%] at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope [17% (95% CI 7–40%) vs. 8% (95% CI 3–19%), P = 0.229]. For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11–45%) and 42% (95% CI 24–65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope (P = 0.277 vs. P = 0.836). Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%). Conclusion In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope.

Toward More Personalized Management of Device-Detected Atrial Fibrillation

This Viewpoint discusses the need to individualize the management of subclinical atrial fibrillation according to burden (among other factors) by modeling stroke risk.

Wearables in cardiology—Knowledge from current digital atrial fibrillation screening and management studies

Wearables in cardiology—Knowledge from current digital atrial fibrillation screening and management studies

Les techniques ablatives de la fibrillation atriale et leurs résultats

The management of atrial fibrillation has evolved considerably with the development of ablation with isolation of the pulmonary veins in all cases, sometimes with the creation of other lesions in the left atrium. The ablation of the atrial fibrillation is more effective to maintain the sinus rhythm than antiarrhythmic drugs in case of paroxysmal or persistent atrial fibrillation Several techniques have been used to date: radiofrequency, cryoablation and, more recently, electroporation. This article summarizes the ablation procedures and describes the 3 types of energy available.

Atrial Fibrillation Management During Surgical vs Transcatheter Aortic Valve Replacement

BackgroundSocietal guidelines support atrial fibrillation (AF) treatment during surgical aortic valve replacement (SAVR). Recently, many patients with AF at low to intermediate risk are managed by transcatheter aortic valve replacement (TAVR). Therefore, we evaluated longitudinal outcomes in these populations. MethodsThe United States Centers for Medicare and Medicaid Services inpatient claims database was evaluated for all beneficiaries with AF undergoing TAVR or SAVR with/without AF treatment (2018-2020). Treatment of AF included concomitant left atrial appendage obliteration, with/without surgical ablation, or endovascular appendage occlusion and/or catheter ablation at any time. Diagnosis-related group and International Classification of Diseases, 10th Revision, codes defined procedures with doubly robust risk adjustment across each group. ResultsA total of 24,902 patients were evaluated (17,453 TAVR; 7,449 SAVR). Of patients undergoing SAVR, 3176 (42.6%) underwent AF treatment (SAVR+AF). Only 656 TAVR patients (4.5%) received AF treatment. Comparing well-balanced SAVR+AF vs SAVR vs TAVR, there were no differences in the in-hospital incidence of renal failure, bleeding, or stroke, but increased pacemaker requirement (odds ratio [OR], 3.45; P < .0001) and vascular injury (OR, 9.09; P < .0001) were noted in TAVR and higher hospital mortality (OR, 4.02; P < .0001) in SAVR+AF. SAVR+AF was associated with lower readmission for stroke compared with SAVR alone (hazard ratio [HR], 0.87; P = .029) and TAVR (HR, 0.68; P < .0001) and with improved survival vs TAVR (HR, 0.79; P = .019). ConclusionsIn Medicare beneficiaries with AF requiring aortic valve replacement, SAVR+AF was associated with improved longitudinal survival and freedom from stroke compared with TAVR. SAVR+AF treatment should be considered first-line therapy for patients with AF requiring aortic valve replacement.

Relationship between wait times and post–atrial fibrillation ablation outcomes: A population-based study

BackgroundRhythm control is a cornerstone of atrial fibrillation (AF) management. Shorter time between diagnosis of AF and receipt of catheter ablation is associated with greater rates of therapy success. Previous work considered diagnosis-to-ablation time as a binary or categorical variable and did not consider the unique risk profile of patients after a referral for ablation was made. ObjectiveThe purpose of this study was to comprehensively assess the impact of diagnosis-to-ablation and referral-to-ablation time on postprocedural outcomes at a population level. MethodsThis observational cohort study included patients who received catheter ablation to treat AF in Ontario, Canada. Patient demographics, medical comorbidities, AF diagnosis date, ablation referral date, and ablation date were collected. The primary outcomes of interest included a composite of death and hospitalization/emergency department visit for AF, heart failure, or ischemic stroke. Multivariable Cox models assessed the impact of diagnosis-to-ablation and referral-to-ablation times on the primary outcome. ResultsOur cohort included 7472 patients who received ablation for de novo AF between April 1, 2016, and March 31, 2022. Median [interquartile range] diagnosis-to-ablation time was 718 [399–1274] days and median referral-to-ablation time was 221 [117–363] days. Overall, 911 patients (12.2%) had the composite endpoint within 1 year of ablation. Increasing diagnosis-to-ablation time was associated with a greater incidence for the primary outcome (hazard ratio [HR]1.02; 95% confidence interval [CI] 1.01–1.02 per month). Increasing referral-to-ablation time did not impact the primary outcome (HR 1.00; 95% CI 0.98–1.01 per month). ConclusionDelays between AF diagnosis and ablation referral may contribute to adverse postprocedural outcomes and provide an opportunity for health system quality improvements.

A targeted educational intervention increases oral anticoagulation rates in high-risk atrial fibrillation patients

BackgroundAnticoagulation is the cornerstone of atrial fibrillation (AF) management for stroke prevention. Recently, we showed that AF patients’ oral anticoagulation (OAC) rates in a large US multispecialty health system are above 80%. ObjectiveThis study sought to improve OAC rates in AF patients via an educational intervention targeted to primary care providers with low OAC rates. MethodsPrimary care clinicians were stratified by proportions of their AF patients at elevated stroke risk not on anticoagulation medication. Clinicians with the lowest rates of anticoagulation were assigned to a target group receiving an educational program consisting of e-mail messaging summarizing anticoagulation guidelines. All other clinicians were assigned to a comparison group. Data from a six-month lead-in phase were compared with a six-month follow-up period to determine if the proportion of AF patients treated with OACs had changed. ResultsThere were 141 primary care clinicians with patients who met the inclusion criteria, with 36 (25.53%) assigned to the educational intervention (EG) and 105 (74.47%) assigned to the comparison group (CG). At baseline there was a significant difference in percent of high-risk AF patients who were untreated in the EG (20.65%) as compared to the high-risk patients who were untreated in the CG (13.64%, p=0.001). After the educational intervention, high-risk AF patients without anticoagulation decreased in both EG (15.47% p=0.047) and CG (10.14% p=0.07) with greater absolute reduction in the EG (5.19% versus 3.50%). ConclusionA targeted education program was associated with increased anticoagulation rates for AF patients at high risk of stroke.