Mean CHA2DS2-VASc Score Research Articles

Prescription Medication Use and Expenditure of Atrial Fibrillation in the United States.

To study the national trends of anticoagulants, antiarrhythmic drugs (AAD), and expenditures in civilian non-institutionalized AF population. The Medical Expenditure Panel Survey (MEPS) was queried from January 2016 to December 2021 to identify adults (age ≥ 18 years) with a diagnosis of AF utilizing ICD-10-CM code "I48". Prevalence of anticoagulants, AAD, and its expenditure and AF expenditure across clinical settings in the United States were estimated. The predictors of anticoagulant use were identified utilizing multivariate logistic regression analysis. A total of 17.3 million AF adults were identified, of which 46.5% were female, 89.6% were White, and ∼70% were middle/high-income with prevalent comorbidities of hypertension (75.3%) and coronary heart disease (30%). The mean CHA2DS2 VASc score was 3.2, and 40% had a score of ≥4. In the US, an average of $26,103 (2021 inflation-adjusted) was spent per year per adult with AF for health-related expenditures. The prevalence of direct oral anticoagulants (DOAC) and Class I AAD use has increased; in contrast, vitamin K antagonists (VKA) use has declined. DOAC-related per-person annual expenses increased from $849 in 2016 to $1,929 in 2021. In those with a CHA2DS2 VASc score of ≥2, female sex and the presence of coronary heart disease were associated with a lower likelihood of anticoagulant use. AF is a costly condition in which prescription medication use, like DOACs and class III AADs, are significant contributors.

Left Atrial Appendage Closure after Ablation for Atrial Fibrillation.

Oral anticoagulation is recommended after ablation for atrial fibrillation among patients at high risk for stroke. Left atrial appendage closure is a mechanical alternative to anticoagulation, but data regarding its use after atrial fibrillation ablation are lacking. We conducted an international randomized trial involving 1600 patients with atrial fibrillation who had an elevated score (≥2 in men and ≥3 in women) on the CHA2DS2-VASc scale (range, 0 to 9, with higher scores indicating a greater risk of stroke) and who underwent catheter ablation. Patients were randomly assigned in a 1:1 ratio to undergo left atrial appendage closure or receive oral anticoagulation. The primary safety end point, tested for superiority, was non-procedure-related major bleeding or clinically relevant nonmajor bleeding. The primary efficacy end point, tested for noninferiority, was a composite of death from any cause, stroke, or systemic embolism at 36 months. The secondary end point, tested for noninferiority, was major bleeding, including procedure-related bleeding, through 36 months. A total of 803 patients were assigned to undergo left atrial appendage closure, and 797 to receive anticoagulant therapy. The mean (±SD) age of the patients was 69.6±7.7 years, 34.1% of the patients were women, and the mean CHA2DS2-VASc score was 3.5±1.3. At 36 months, a primary safety end-point event had occurred in 65 patients (8.5%) in the left atrial appendage closure group (device group) and in 137 patients (18.1%) in the anticoagulation group (P<0.001 for superiority); a primary efficacy end-point event had occurred in 41 patients (5.3%) and 44 patients (5.8%), respectively (P<0.001 for noninferiority); and a secondary end-point event had occurred in 3.9% and 5.0% (P<0.001 for noninferiority). Complications related to the appendage closure device or procedure occurred in 23 patients. Among patients who underwent catheter-based atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of non-procedure-related major or clinically relevant nonmajor bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to a composite of death from any cause, stroke, or systemic embolism at 36 months. (Funded by Boston Scientific; OPTION ClinicalTrials.gov number, NCT03795298.).

Abstract 4138281: Relationship of Collagen Metabolism Biomarkers, Left Atrial Fibrosis and Ablation Outcome in Atrial Fibrillation

Introduction: Inflammation and fibrinogenesis in the left atrium are hypothesized to play a major role in the development of atrial fibrillation (AF). We previously showed that collagen metabolism biomarkers (CMB) are significantly elevated in patients with AF compared to healthy controls. Objective: We sought to investigate the relationship between CMB, Left Atrial Fibrosis (LAF) and AF recurrence after ablation. Methods: Patients with AF undergoing ablation evaluation (N= 96) were prospectively enrolled between 2015 – 2020. Plasma samples were collected prior to ablation and analyzed for CMB using commercially available ELISA kits. Sixty-four patients underwent AF ablation and were followed for 6 months for AF recurrence. CMR was performed in 48 patients using cine and 3D high resolution, late gadolinium enhancement imaging on 3T MRI to measure LAF. Patients were classified into 2 groups dichotomized by the median LAF value. Results: Mean age was 60.3 ± 10.3 years, mean BMI 29.7 ± 4.9 kg/m2, mean CHA2DS2-VASc score 1.9 ± 1.4 and 27% were women. Paroxysmal AF was present in 52.5%. The median LAF score was 13.6% (IQR 9.8 – 21.7). High PINP, high CITP and low TIMP-2 were associated with high LAF score (Table 1). High CITP was also associated with recurrence of AF after ablation {4.26 ng/ml (IQR 3.22 - 4.65) vs 3.26 ng/ml (IQR1.92 - 4.25), P = 0.02}. Conclusion: Higher levels of PINP and CITP were significantly associated with higher LAF score in AF patients. TIMP-2 was associated with low LAF. Higher CITP was also associated with AF recurrence after ablation. Further larger studies are needed to better understand the relationship between collagen biomarkers, LA fibrosis and their clinical impact on rhythm control in AF.

Abstract 4123899: Stroke Risk in Patients with an Isolated Interventricular Membranous Septal Aneurysm

Aim: This study investigates the prevalence of isolated interventricular membranous septal (IVMS) aneurysms detected via echocardiography and assesses the associated stroke risk without other classical risk factors. Methods: We searched the echocardiography database at Mount Sinai Morningside from January 2017 to September 2023. Identified echocardiograms were reviewed to confirm IVMS aneurysms and exclude sinus of Valsalva aneurysms. Patients with concurrent structural heart anomalies were excluded. Medical records were examined for baseline characteristics, risk factors, and cortical brain infarcts. Results: From 51,732 subjects, 18 were identified with IVMS aneurysms, yielding a prevalence of 0.04%. Four patients with significant structural heart disease were excluded, resulting in a final sample size of 14. Of these, 9 (64%) were female with a mean age of 59.6, and 5 (36%) were male with a mean age of 55.4. The mean BMI was 27.9 kg/m 2 , with 4 classified as obese. All patients were nonsmokers; 2 had a family history of stroke. One patient had diabetes, 8 had hyperlipidemia, and 9 had hypertension. Only one patient had paroxysmal atrial fibrillation, with a CHA2DS2-VASc score of 0. Echocardiography revealed structurally normal hearts with a mean left ventricular ejection fraction of 61% and a mean left atrial volume index of 24.8 mL/m 2 . The mean neck diameter of the aneurysm was 8.7 mm, and the mean diameter was 11.9 mm. Two patients had inter-atrial septal aneurysms, and one had a patent foramen ovale. Out of the 14 patients, 5 had a history of ischemic stroke (4) or transient ischemic attacks (1), all of whom were 64 years or younger with a mean RoPE Score of 6 and a mean CHA2DS2-VASc score of 1.6 at the time of their first neurologic event. All patients were treated with aspirin and statin therapy. Two patients had recurrent strokes, one of whom had four recurrent strokes, all cortical infarcts. These patients were switched to clopidogrel after 3 months of dual antiplatelet therapy. No anticoagulation was used. Conclusion: This retrospective study highlights a notable association between isolated IVMS aneurysms and an increased risk of ischemic stroke (36%) and recurrent ischemic stroke (14%). Despite their rarity, these anomalies should be considered in unexplained strokes. Optimal management strategies remain ambiguous, but anticoagulation may be favored based on presumed stroke mechanisms. Large-scale multicenter studies are needed for validation.

Predictors and outcomes of intracranial hemorrhage in 58,000 patients with atrial fibrillation on oral anticoagulation: insights from COMBINE-AF

Abstract Background Among anticoagulated patients with atrial fibrillation (AF), intracranial hemorrhage (ICH) is the leading cause of bleeding-related death and disability. The COMBINE-AF database has patient-level data from four major randomized-controlled trials [ROCKET-AF (rivaroxaban), RE-LY (dabigatran), ENGAGE-TIMI 48 (edoxaban), ARISTOTLE (apixaban)] of direct oral anticoagulants (DOACs) versus warfarin in patients with AF. Purpose/Methods We investigated the rates, predictors, and mortality of ICH in patients randomized to DOAC (rivaroxaban, dabigatran, edoxaban, apixaban) or warfarin. ICH was subclassified as subdural or non-subdural (intracerebral, intraventricular, subarachnoid, epidural). Multivariable Cox models were used to identify predictors of ICH. Frequencies and fatality rates of ICH were calculated and displayed as Kaplan-Meier curves. Results In COMBINE-AF, there were 58,634 patients randomized to either DOAC (n=29,362) or warfarin (n=29,272). The mean age was 70.5 years, 37% were female, and 81% were White. The mean CHA2DS2-VASc score was 2.6, 43% of patients had a history of smoking, 31% had diabetes, and 29% had prior stroke/TIA. After a mean of 32 months, ICH occurred in 593 patients (1.01%, 0.58 per 100-patient years, 95% CI [0.54, 0.63]). The most significant independent predictors of ICH in order of importance were: treatment with warfarin, older age, prior stroke/TIA, enrollment in Asia, antiplatelet use at randomization, and history/risk of falls (Figure 1). Mortality after ICH was 48.4% (287/593 participants), with a majority of deaths (82%) occurring within 30 days of ICH event. Non-subdural ICH was more common than subdural ICH (73% vs 25%) and had a higher risk of death (Figure 2). Participants randomized to DOAC had a lower risk of both subdural and non-subdural ICH than those treated with warfarin; however, mortality rates after ICH were similar regardless of anticoagulant type. Conclusion ICH is an uncommon but devastating complication of oral anticoagulation in patients with atrial fibrillation. The mortality rate following ICH is high, particularly following non-subdural ICH. To reduce the risk of ICH, clinicians should consider using DOACs over warfarin and carefully evaluate the need for antiplatelet therapy, particularly in patients with other significant predictors of ICH such as prior stroke, advanced age, residence in Asia, and history of falls.Predictors of Intracranial Hemorrhage90-Day Mortality after ICH

Comparing the utility of 3D vs 2D left atrial volumes by echocardiography to predict stroke in the general population

Abstract Background Left atrial (LA) volume dilatation is associated with stroke in the general population. Two-dimensional echocardiography (2DE) is commonly used to measure LA size but is known to underestimate LA volumes compared to three-dimensional echocardiography (3DE). It is unknown whether this difference has clinical significance. Purpose We hypothesized that LA volumes by 3DE are more closely associated with stroke risk than 2DE in the general population. Methods We included 2,085 participants from a longitudinal cohort study from the general population who underwent 3DE and 2DE assessment of maximal and minimal LA volume index (LAVimax and LAVimin, respectively). After excluding participants with poor image quality, low volume rate, atrial fibrillation at baseline and non-sinus-rhythm during examination, a total of 1,956 participants were included for this analysis. The endpoint was stroke. Multivariable Cox regression models were adjusted for the CHA2DS2-VASc stroke risk score (age, sex, heart failure, hypertension, stroke, vascular disease, and diabetes). Results Mean age was 54±17 years, 43% were male, mean CHA2DS2-VASc score was 1.6±1.3. During a median follow-up of 4.8 years (interquartile range 4.3-5.5 years), 36 participants (1.8%) developed stroke. After multivariable adjustment, 2D LA volumes were not associated with stroke, whereas both 3D-LAVimax (HR 1.03 (95% CI 1.00-1.06), p=0.046, per 1 mL/m2 increase) and 3D-LAVimin (HR 1.05 (95% CI 1.02-1.08), p=0.002, per 1 mL/m2 increase) remained significantly associated with stroke (Figure 1). In addition, 3D-LAVimin showed the highest discrimination for predicting stroke with a C-statistic of 0.70 (95% CI: 0.59-0.80), which was significantly higher than 2D-LAVimax (C-statistic: 0.58 (95% CI 0.48-0.69); p=0.02), 2D-LAVimin (C-statistic: 0.54 (95% CI 0.42-0.65); p&amp;lt;0.001) and 3D-LAVimax (C-statistic: 0.62 (95% CI 0.52-0.73); p=0.004). 3D-LAVimin also showed incremental prognostic information when added to the CHA2DS2-VASc risk score (continuous net reclassification index 0.28±0.17; p=0.047). Conclusion Increasing 3D-LA volumes are significantly associated with higher risk of stroke in the general population which was not the case for 2D-derived LA volumes.

Early rhythm control of atrial fibrillation in cancer survivors: a nationwide population-based cohort study

Abstract Background Though early rhythm control (ERC) in patients with atrial fibrillation (AF) is effective in reducing stroke, the benefit of ERC has not been well-elucidated in cancer survivors. This study aimed to compare the risk of ischemic stroke between ERC and usual care in cancer survivors with AF and cancer. Methods This nationwide observational study was conducted using the Korean National Health Insurance Service database. Patients aged 20 years or older with newly diagnosed AF between 2009 and 2018 were included. Patients who received rhythm control therapy within 1-year of AF diagnosis were defined as the ERC group, while the remaining patients were defined as the usual care group. The risk of ischemic stroke in the ERC group compared to the usual care group was evaluated in long-term cancer survivors (cancer diagnosis ≥5 years) and the non-cancer group. Results A total of 591,692 patients were included in the study (18,747 patients [3.2 %] with cancer, mean age 65.7±14.6 years, 53.7% men, mean CHA2DS2-VASc score 3.3±2.0). The proportion of patients receiving ERC was slightly higher in cancer survivors compared to the non-cancer group (28.0% vs 25.3%, p&amp;lt;0.001). During a mean 4-year follow-up, incident stroke occurred in 52,500 patients (1,338 in cancer survivors, 51,182 in non-cancer). The ERC group showed a lower risk of stroke than the usual care group, regardless of the presence of cancer history(Figure); adjusted hazard ratio [95% confidence interval] 0.67 [0.58-0.76] in cancer survivors, 0.76 [0.74-0.78] in the non-cancer group (p-for-interaction=0.125). The effect of ERC on the risk of ischemic stroke in cancer group was consistent across all subgroups, including different cancer types or use of chemotherapy. Conclusion ERC was associated with a lower risk of ischemic stroke among long-term cancer survivors. An integrated approach incorporating appropriate rhythm control strategies should be considered for cancer survivors with newly diagnosed AF.

Procedural outcomes of fluoroscopy-less catheter ablation for atrial fibrillation

Abstract Background Radiofrequency catheter ablation is superior therapy to antiarrhythmic drugs for maintaining sinus rhythm in atrial fibrillation (AF) patients. Traditional fluoroscopy-guided AF ablation poses risks of prolonged radiation exposure for both patients and medical staff. Recent advancements in fluoroscopy-less catheter ablation techniques offer potential solutions, but comprehensive data on their effectiveness and safety are lacking. Purpose To evaluate the procedural outcomes and safety of fluoroscopy-less catheter ablation for AF compared to fluoroscopy-guided ablation. Methods Retrospective observational study of consecutive AF ablations (N=881) conducted at a university teaching hospital (Hamilton Health Sciences, Hamilton, Ontario) from November 2017 to September 2022. An electro-anatomical mapping system and ICE was used in all cases. Baseline characteristics and procedural outcomes between the fluoroscopy-less and fluoroscopy-guided groups were compared. Cases that used &amp;lt;60 seconds of fluoroscopy (occasionally used by operators during the placement of an esophageal probe) were included in the fluoroscopy-less group (N= 68). Results Mean age of individuals was 60.6 ± 11 years, 71.7% were male, 72.6% had paroxysmal AF, mean CHA2DS2-VASc score was 1.6 ± 1.4, 11.1% had prior heart failure, and mean left ventricular ejection fraction was 57.5 ± 15%. There were no significant differences in patient baseline characteristics between the fluoroscopy-less and fluoroscopy groups. Total procedure and fluoroscopy times were lower in the fluoroscopy-less group compared to the fluoroscopy-guided group (169.3 ±42 minutes vs. 192.1 ±54 minutes, p&amp;lt;0.0001 and 0.024 ±0.10 vs. 10.0 ±7.4 minutes , p&amp;lt;0.0001). Fluoroscopy-less AF ablation remained an independent predictor of lower procedure times following adjusting for the use of general anesthesia, high-power short-duration, presence of trainees, AF pattern, redo cases, and type of mapping system. Complication rates were similar between fluoroscopy-less and fluoroscopy-guided ablation (1.9% vs. 3.8%, p=0.11). Conclusion Fluoroscopy-less catheter ablation for AF appears to have similar procedural outcomes and safety than fluoroscopy-guided AF ablation.

Switching from warfarin to a DOAC in frail elderly asian patients with atrial fibrillation: a nationwide population-based study

Abstract Background Recently, switching international normalized ratio guided warfarin management to a direct oral anticoagulant (DOAC) was associated with more bleeding complications than maintaining warfarin in frail elderly patients with atrial fibrillation (AF). However, there is a paucity of information on whether these results could be applied to Asian patients with AF, who are known to have relatively low time in therapeutic range (TTR) levels. Purpose To evaluate the safety and effectiveness of switching from warfarin to a DOAC in frail elderly Asian patients with AF. Methods Using a Korean health insurance database, we included patients with AF who were prescribed warfarin between January 2013 and August 2015 without significant bleeding or thromboembolic events during the window period, specifically those aged 75 or older with a Hospital Frailty Risk Score of 5 or more. Those who switched to DOACs during the window period were categorized as the DOAC group and those who continued with warfarin were categorized as the warfarin group. The primary outcome was defined as the composite of major bleeding (MB) and clinically relevant non-major bleeding (CRNMB), and secondary outcomes were defined as thromboembolic events, all-cause death, the composite of MB, CRNMB and ischemic stroke (so-called net clinical outcome [NCO]). The propensity score weighting method was utilized to compare the two groups. Results A total of 12,162 patients were included (8,108 with maintaining warfarin, 4,054 with switching to a DOAC). Baseline characteristics were well-balanced after the inverse probability of treatment weighting (mean age, 80 years; men, 50%; and mean CHA₂DS₂-VASc score, 5.6). Compared with maintaining warfarin, switching to a DOAC was associated with significantly higher risks of the primary outcome (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.09-1.87, p=0.01), thromboembolic events (1.28, 1.01-1.62, p=0.039), all-cause death (1.38, 1.15-1.66, p&amp;lt;0.001) and the NCO (1.26, 1.01-1.58, p=0.04). (Figure A, Figure B), whereas there was no difference in the risk of intracerebral hemorrhage (0.90, 0.50-1.60, p=0.7157). When comparing each DOAC with maintaining warfarin, switching to rivaroxaban was associated with a higher risk of the composite of MB and CRNMB (1.91, 1.38-2.64, p&amp;lt;0.001) and thromboembolic events (1.40, 1.03-1.91, p=0.034) than maintaining warfarin. Conclusion In line with the non-Asian population, switching to a DOAC was associated with a significantly higher risk of MB or CRNMB, thromboembolic events, all-cause death and NCO compared with maintaining warfarin in frail elderly Asian patients with AF. Therefore, even in Asians, switching to a DOAC should be considered more cautiously in patients who are stably managed on warfarin.

The long-term usage of statin prevents adverse events in patients with atrial fibrillation

Abstract Background The effectiveness of statins in preventing adverse cardiovascular events in individuals with atrial fibrillation (AF) has remained uncertain. This study aimed to assess whether statin use could lead to better outcomes among individuals with AF. Purpose Our study aimed to investigate the relationship between statin use and cardiovascular outcomes in patients with newly-diagnosed AF. Methods This study used the National Health Insurance Research Database (NHIRD) in Taiwan. We enrolled 397,787 patients with AF from January 1st, 2012, to December 31st, 2020. Patients with AF were divided into 2 groups (statin user and statin non-user), and the risks of composite outcomes (ischemic stroke, hemorrhagic stroke and transient ischemic attack [TIA]), all-cause death and major adverse cardiovascular events (MACEs, which encompassed cardiovascular death, non-fatal myocardial infarction and heart failure hospitalization) were analyzed. Propensity score matching with time-dependent analysis was examined. Results We analyzed 288,958 patients with newly diagnosed AF (mean age, 73 years; 44% women; mean CHA2DS2-VASc score, 3.5). Compared with patients without statin use, statin user had a lower risk of composite endpoint, which included ischemic stroke, hemorrhagic stroke and TIA. (adjusted hazard ratio, 0.92; 95% confidence interval, 0.88-0.95; p &amp;lt; 0.01) after adjusting for patients’ age, gender, CHA2DS2-VASc score, cardiovascular medications, and comorbidities. In regard to all-cause mortality, statin users exhibited a 62% risk reduction compared to statin non-users (hazard ratio, 0.38; 95% confidence interval, 0.37-0.39; p &amp;lt; 0.01). Statin use was also associated with reduced incidence of MACEs (hazard ratio, 0.70, 95% confidence interval, 0.68-0.71; p &amp;lt; 0.01). In the subgroups stratified by CHA2DS2 VASc score, statin therapy was particularly effective for patients with CHA2DS2-VASc scores 0-3 for composite endpoints but consistently reduced all-cause mortality and MACEs across all score categories. Conclusions Among patients with newly diagnosed AF, statin use was associated with a lower risk of ischemic stroke, hemorrhagic stroke, TIA, all-cause mortality and MACEs.

Impact of atrial fibrillation on cardiac autonomic function in elderly patients

Abstract Introduction Cardiac autonomic dysfunction has been linked to an increased risk of mortality (1), stroke and silent brain lesions (2) and cognitive impairment (3) in patients with atrial fibrillation (AF). However, the impact of AF on cardiac autonomic function is poorly understood. Purpose We aimed to explore the impact of AF on cardiac autonomic function by comparing AF patients with a matched control cohort without AF. Methods We enrolled patients with and without AF from two ongoing, prospective, multicenter cohort studies (Swiss-AF Cohort and Swiss-AF Control) if they had a high-resolution 16-lead resting ECG recording in sinus rhythm for a duration of 5 minutes at baseline visit. Cardiac autonomic function was quantified by periodic repolarization dynamics (PRD), a marker of repolarization instability associated with sympathetic activity. PRD was quantified by means of wavelet analysis, as validated previously (4). Cardiac autonomic dysfunction was defined present if PRD exceeded the established cut-off of 10.0 deg2 (5). We built multivariable adjusted linear and logistic regression models to explore the association of AF with PRD and cardiac autonomic dysfunction. Results We included 2077 patients, 1113 (54%) from the AF cohort and 964 (46%) from the matched non-AF cohort. Baseline characteristics were well balanced between the groups (mean age 71 vs. 73 years in patients with and without AF, mean CHA2DS2-VASc score 3.0 vs. 3.5, female sex 31.3% vs. 36.6%). The median PRD was 18.2 deg2 (IQR 9.9-25.4) in patients with AF and 15.8 deg2 (IQR 8.1 -23.0) in patients without AF (p&amp;lt;0.001, Figure). 832 (75%) of the AF patients suffered from cardiac autonomic dysfunction, vs. 656 (68%) of the non-AF patients (p&amp;lt;0.001). Multivariable adjusted linear regression analysis revealed an independent association of AF with continuous levels of PRD (beta-coefficient -1.57, 95% CI -2.64 - -0.488, p=0.004). Further, AF was independently associated with the presence of cardiac autonomic dysfunction (Odds Ratio 1.48, 95% CI 1.18-1.87, p&amp;lt;0.001, Table). Conclusion In this cross-sectional analysis of a patient population with and without AF, AF was independently associated with increased PRD values, reflecting sympathetic predominance, and with the presence of cardiac autonomic dysfunction. These findings implicate a relevant role of AF in the development of cardiac autonomic dysfunction in elderly patients.Figure

Improvement of left atrial function after ablation in patients with paroxysmal atrial fibrillation is associated with the presence of heart failure with preserved ejection fraction

Abstract Background Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) often coexist and left atrial (LA) function was impaired in both AF and HFpEF. However, It remains unclear if HFpEF is linked to LA function improvement in paroxysmal atrial fibrillation (pxAF) patients post-ablation. Purpose To investigate whether the improvement of LA function after ablation in patients with pxAF combined with HFpEF is better than that in patients without HFpEF. Methods 147 patients with pxAF were enrolled and HFpEF was ascertained based on the H2FPEF score. All patients underwent transthoracic echocardiography (TTE) at baseline and 3 months after ablation. Left atrial volume index (LAVI), left atrial ejection fraction (LAEF) and left atrial peak reservoir strain (LA RS) were measured. Improvement of left atrial function is defined as the difference in the above 3 indicators at baseline and 3 months after ablation. The change of the above atrial functional parameters was compared between patients with high-probability of HFpEF [hp-HFpEF] and medium/low-probability of HFpEF [lp-HFpEF]) in univariate and multivariate analysis. Statistical analyses were conducted using independent samples t-tests, Mann-Whitney U tests, and ANCOVA. Results 147 patients were included (30 hp-HFpEF, 117 lp-HFpEF, mean age 62.6 years, 63.3% men, mean BMI 25.54kg/㎡, mean disease course 28.2 months, mean CHA2DS2-VASc score 1.97). In the univariate analysis, the following factors were significantly different between hp-HFpEF and lp-HFpEF, including BMI (26.95±3.71 vs. 25.18±3.00, p=0.007), CHA2DS2-VASc score (3[3-4] vs. 2[1-2], p＜0.001), LA function at baseline including LAVI (41.59±11.38 vs. 32.57[27.68-41.10], p=0.003), LAEF (45.97±10.26 vs. 57.23±9.08, p＜0.001), LA RS (26.43±10.68 vs. 34.43±10.60, p＜0.001), and difference at baseline and 3 months after ablation in LA function including LAVI (4.92±1.08 vs. 3.33±1.18, p＜0.001), LAEF (13.41±9.71 vs. 2.98±9.69, p＜0.001), LA RS (23.61±10.23 vs. 7.29±6.91, p＜0.001), and in left ventricular (LV) TTE indicators including E/e’ (3.10±2.30 vs. -0.32±2.68, p＜0.001), LV ejection fraction (10.5[7.0-16.5] vs. 2.0[-5.0-6.0], p＜0.001), LV global longitudinal strain (14.94±4.27 vs. 5.15[2.63-8.30], p＜0.001) and LV mass (17.79±28.67 vs 1.50[-8.75-17.00], p=0.006). After adjusted for BMI, CHA2DS2-VASc score, LA function at baseline and difference at baseline and 3 months after ablation in LV TTE indicators, the improvement of LA function 3 months after ablation in patients with hp-HFpEF is better than that in patients with lp-HFpEF: LAVI significantly decreased (4.24±0.21 vs. 3.46± 0.09, p＜0.001), LAEF significantly increased (12.90±2.13 vs. 3.09±0.86, p＜0.001) and LA RS significantly increased (21.44±1.81 vs. 8.02±0.76, p＜0.001) in hp-HFpEF compared with lp-HFpEF. Conclusion Patients with pxAF with hp-HFpEF showed better improvement in LA function after ablation than those with Ip-HFpEF.

How much does elective cardioversion increase the risk of ischaemic stroke compared to the baseline risk in atrial fibrillation? A nationwide study

Abstract Background Patients with atrial fibrillation (AF) undergoing cardioversion (CV) are exposed to an increased risk for stroke during the post-cardioversion period, but the exact magnitude of this risk after elective CV with preceding appropriate oral anticoagulant (OAC) therapy is unknown. Purpose We explored the rate of ischaemic stroke (IS) after elective CV and compared the IS rate during the post-cardioversion period with the long-term stroke rate in patients with AF using guideline-recommended OAC therapy. Methods This is a nationwide register-based study, including all AF patients undergoing their first-ever elective CV between 2012-18 in Finland. Data were collected from the Finnish health care registers covering uniquely all levels of care. Visual assessment of the survival curve identified a cut-off point in IS rate at 1 week after CV. Therefore, the follow-up time was split into two intervals, the 1-week post-cardioversion period and the subsequent period up to 360 days. Stroke rates were calculated separately for these periods. Unadjusted and adjusted incidence rate ratios were estimated with Poisson regression. Moreover, interaction between the two follow-up periods and conventional IS risk factors as well as OAC treatment was assessed. Results A total of 9625 AF patients undergoing their first elective CV were identified (mean age 67.7±9.9 years, 61.2% men, mean CHA2DS2-VASc score 2.6±1.6). Warfarin was used in 6 245 (64.9%) and non-vitamin K oral anticoagulants in 3 380 (35.1%) patients. Overall, 92 (1.0%) patients suffered an IS during the year after CV. The survival plot displayed a higher incidence of IS within the first week after CV, stabilizing thereafter to a consistent level (Figure). In the adjusted regression analyses, IS rate within the first week after elective CV was 13.6-fold (95% confidence interval [CI]: 8.6-21.5) compared the subsequent rate of IS (Table). We observed no significant interaction between any of the conventional IS risk factors or OAC treatment and the two follow-up time periods, indicating that their association with IS rate did not differ during the post-cardioversion period compared to the subsequent time period. Conclusions In this nationwide study, the rate of IS was roughly 14 times higher during the first week after elective CV compared to the subsequent follow-up time.Cumulative risk of IS after elective CVIncidence rates of IS after elective CV

Same-day discharge after atrial fibrillation ablation: is it equally safe?

Abstract Introduction Same-day discharge after atrial fibrillation (AF) ablation represents a paradigm shift in post-procedure care. This approach allows patients (pts) to return home on the same day after their ablation, promoting comfort and reducing hospitalization duration. Purpose To evaluate safety of same-day discharge in pts submitted to either pulsed field ablation (PFA) or cryoablation (CA). Methods Single-center retrospective study of AF pts submitted to ablation with either PFA or CA from May 2019 to November 2023. Ablation strategy consisted in pulmonary vein isolation complemented with ablation of the cavo-tricuspid isthmus in pts with history of atrial flutter. Pts were considered eligible to same-day discharge if an observation period of at least 6h was assured after the procedure. Safety was defined as 30-day major or minor complications. Chi-square tests were used for the comparison of continuous variables. Results We included 152 pts, 60 were submitted to PFA and 92 to CA, 56.6% males, median age 66±14 years, mean CHA2DS2-VASc score 2.45±1.4. Paroxysmal AF, short and long-standing persistent AF were present in 67%, 16% and 15% of pts respectively. Previous stroke was present in 8.7% of pts and 27 pts had history of heart failure. Acute success rate was 99.3%, concomitant cavo-tricuspid isthmus ablation was performed in 20% of pts, and mean procedure time was 107.5±74 min. Same-day discharge was initially considered in 70% of pts, however of these, 12 pts remained under further observation due to acute complications. No major or minor acute complications were reported in pts with same-day discharge. There were no significant differences in 30 days complications between groups. At 30 days no major complications were reported in pts with same-day discharge. One pts in which same-day discharge was halted died 4 days after ablation from hemorrhagic shock. Regarding minor complications at 30 days, 4 minor femoral hematoma were reported, 2 in each group. Conclusion In our population, same-day discharge proved to be a safe strategy if careful pts selection is assured. This practice enhances overall pt experience, marking a significant paradigm shift in AF management.

Comparing the real-world and clinical trial bleeding rates associated with oral anticoagulation treatment for atrial fibrillation

Abstract Background The prevention of stroke in patients with atrial fibrillation (AF) involves the use of oral anticoagulation, commonly in the form of direct oral anticoagulants (DOAC). However, it comes with an increased risk of bleeding and therefore, counselling patients on their individual risk is important. Although majority of patients initiated on DOAC have been represented within the clinical trials, there are some cohorts which are under-represented in whom clinicians are unable to practice evidence-based medicine. Methods Utilising the pooled clinical trial (CT) data sourced from Medidata Enterprise Data Store, 5 recent open-label industry sponsored AF trials were compared with Real-World data (RWD) was sourced from the HealthVerity Marketplace with the occurrence of bleeding events as the primary outcome of interest. Results A total of 64,421 patients were included in the analysis, with 3207 patients from the clinical DOAC trials and 61,214 patients from the RWD cohort. Overall, the patients from RWD cohort had more co-morbidities, were older (72.2 ± 11.9 vs 65.3 ±10.7 years old, p&amp;lt;0.001), had higher mean CHA2DS2VASc (3.98 ± 1.9 vs 2.87 ± 1.73, p&amp;lt;0.001) and HAD-BLED scores (2.13 ± 1.02 vs 1/04 ± 0.93, p&amp;lt;0.001) when compared to the trial data. When comparing the incidence of first major bleed at 12 months post treatment initiation, rates in the RWD cohort was significantly higher (10.69 vs 18.97 per 100 person-years). The impact of comorbidities such as age, CHA2DS2VASc and HAD-BLED scores were similar in both cohorts, however, there was an under-representation of older, females and more co-morbid patients within the clinical trial cohort. Conclusion DOAC treated patients have higher bleeding incidence rate in the RWD cohort as compared to clinical trials. This can be explained by the older patient age group with more complex medical histories and higher HAS-BLED scores. The under-representation of higher risk patients and lower proportion of females within clinical trials should be addressed to better translate clinical trial data into real world clinical practice.

Incidence, characteristics, and prognostic impact of cancers in patients with atrial fibrillation: a report from the GLORIA-AF registry

Abstract Background Cancers and atrial fibrillation (AF) are all aging-related diseases. Coexistence of the two conditions makes management complex due to increased risk of both thromboembolism and bleeding. Purpose The aim of the present study was to analyze the incidence and prognostic impact of cancers in patients with AF in the GLORIA-AF registry. Methods GLORIA-AF registry is a prospective multi-centered international multi-centered AF cohort studies. We characterized these patients according to the presence or absence of a cancer diagnosis when enrolled. The primary endpoints were all-cause mortality, cardiovascular mortality, and major bleeding; the secondary endpoints were major adverse cardiovascular events (MACEs) including all-cause mortality, stroke, and major bleeding. Results The prevalence of cancers was 9.7%. The mean CHA2DS2-VASc and HAS-BLED scores in cancer patients were higher than in non-cancer patients (mean CHA2DS2-VASc 3.5 vs. 3.2, P&amp;lt;0.001; mean HAS-BLED score 1.6 vs. 1.3, P&amp;lt;0.001). Patients with cancers had higher oral anticoagulant use than non-cancer patients (84.4% vs. 81.0%, P&amp;lt;0.001) and were more likely to receive NOACs (58.4% vs. 54.0%, P&amp;lt;0.001). During a mean follow up period of 3 years, AF patients with cancers had significantly higher all-cause mortality (15.0% vs. 8.3%, P&amp;lt;0.001), major bleeding rate (5.3% vs. 3.1%, P&amp;lt;0.001), the composite of all-cause mortality, stroke, and major bleeding (20.0% vs. 12.0%, P&amp;lt;0.001), and composite of all-cause mortality, thromboembolism, and major bleeding than non-cancer patients (21.0% vs. 12.0%, P&amp;lt;0.001), but nonsignificant differences in cardiovascular mortality (3.6% vs. 3.1%, P=0.2), any stroke, transient ischemic attack, or non-central nervous system embolism (3.2% vs. 2.7%, P=0.1), and OAC discontinuation (29.0% vs. 28%, P=0.2). Among the cancers, hematological cancer was associated the highest risk of all-cause mortality (HR=3.7, 95%CI 2.69-5.0, P&amp;lt;0.001) while respiratory cancer was associated the highest risk of major bleeding (HR=2.62, 95%CI 1.24-5.5, P=0.011). After multivariable adjustment, cancer was independently associated with increased risk of all-cause mortality (HR=1.30, 95%CI 1.05-1.62, P=0.018), composite of all-cause mortality, stroke, and major bleeding (HR=1.32, 95%CI 1.04-1.68, P=0.022), and composite of all-cause mortality, thromboembolism, and major bleeding (HR=1.29, 95%CI 1.04-1.60, P=0.022), but the risk of major bleeding was nonsignificantly different (HR=1.16, 95%CI 0.71-1.87, P=0.6). Conclusions Cancer is a common comorbidity in patients with AF and is independently associated with increased risk of poor outcomes including all-cause mortality and MACEs. However, cancer did not increase the risk of cardiovascular mortality, major bleeding, and discontinuation of OAC. Cancer in patients with AF should receive appropriate treatments for the cancer itself and appropriate OAC, although strategies may vary between different cancers.Distribution of caners in GLORIA-AFKaplan-Meier curves for the outcomes

Cardiac amyloidosis and left atrial appendage closure: a multicenter retrospective study

Abstract Background Thromboembolic stroke risk remains a clinical challenge in cardiac amyloidosis (CA) patients with atrial fibrillation because of the increased prevalence of left atrial appendage thrombi irrespective of CHA2DS2-VASc score and a higher prevalence of factors that increase the risk of bleeding with anticoagulation. Left atrial appendage closure (LAAC) is an effective option in patients with atrial fibrillation and high bleeding risk; however, data describing a LAAC strategy for stroke prevention in patients with CA is limited. Among non-CA patients, procedural success and serious complication rates are around 98% and 3% respectively. Purpose In this multicenter retrospective study, we aimed to investigate whether left atrial appendage closure (LAAC) could reduce the risk of bleeding complications and ischemic cerebrovascular events in patients with CA. Methods In an international multi-center retrospective study, patients with CA that underwent LAAC were included. The diagnosis of CA was established on the basis of histologic confirmation or advanced multimodality cardiac imaging as per current consensus statements. Results A total of 28 patients (93% male; 87% ATTR-CA; 13% AL-CA; mean age 80 years) met inclusion criteria. At baseline, mean CHA2DS2-VASc and HAS-BLED scores were 4 and 3 respectively, mean left ventricular ejection fraction was 50%, and mean indexed left atrial volume was 58 mL/m2. 21% of patients had a prior history of ischemic stroke, 14% prior history of hemorrhagic stroke, 7% prior transient ischemic attack, and 54% had a prior history of major or minor bleeding. Procedural success was achieved in 26 patients (93%) with procedural complications occurring in 2 patients (vascular access site bleeding and cardiac tamponade). Regarding in-hospital and follow-up complications, 0% ischemic stroke, 0% hemorrhagic stroke, and major or minor bleeding in 4% of patients. During follow up, device thrombosis occurred in only 1 patient. Conclusion LAAC is a feasible and effective alternative to anticoagulation in patients with CA and excessive bleeding risk, with procedural success and complication rates similar to reported studies of non-CA patients.

Safety and effectiveness of pulsed field ablation for pulmonary vein isolation in atrial fibrillation patients: a single centre experience

Abstract Introduction Atrial Fibrillation (AF) is the most frequent arrhythmia in the world with an exponentially increasing prevalence. Pulmonary veins (PV) are the primary triggering sites for AF and pulmonary veins isolation (PVI) is currently the standard therapy alongside pharmacological treatment and should be considered as first-line treatment. Pulsed-fieldablation (PFA) is a novel ablation modality that involves the application of electrical pulses causing cellular death, with preferential tissue specificity. Aim In this study, we evaluated the safety and efficacy of single-shot PFA in AF patients. Methods Single-center registry of consecutive patients undergoing PVI using the pentaspline PFA catheter (all with CARTO3D system v.7 and high-density mapping), between June 2022 and November 2023. Data on demographics, procedural characteristics, and electrocardiographic recurrence (assessed after a 3-month blanking period) were analyzed. Results 152 consecutive patients were included (63 ± 10 years, 57% male), with a mean CHA2DS2-VASc score of 2±1 points, median LVEF of 60% (IQR 59-65%), and a median CT-scan derived left atrial volume index of 56 mL/m2(IQR 44-69 mL/m2). A total of 40% had non-paroxysmal AF and a redo procedure was performed in 17% of patients. The median procedure time was 78 min (IQR 58-111 min) and fluoroscopy time was 11.6 min (IQR 8.2-15.6 min). Additionally, posterior wall isolation (PWI) was performed in 63 patients (41%). There were no esophageal complications, phrenic nerve injuries, cerebrovascular events, or procedure-related deaths. Two patients (1.3%) experienced acute cardiac tamponade, immediately treated with pericardiocentesis. Other complications were primarily vascular, in 5% of cases (4 femoral hematomas, 3 femoral pseudoaneurysms, 1 arteriovenous fistula). Over 293 (IQR 170 - 394) days of follow-up, considering electrocardiographic recurrence, 12% of patients had AF recurrence (5 with paroxysmal AF and 10 with persistent AF). These patients were older (69 ± 7y vs. 62 ± 11y, p=0.016), were more likely to undergo a redo procedure (33 vs. 8%, p=0.004), and had a higher percentage of posterior wall isolation (21 vs. 8%, p=0.038). Conclusions PFA for PVI wall ablation is safe and effective, with 100% intraprocedural technical success, a low rate of complications, and a high percentage of patients free from AF in the short-term.

Voltage-Guided and Non-Voltage-Guided Superior Vena Cava Isolation in Patients With Atrial Fibrillation.

In addition to the pulmonary vein, the superior vena cava (SVC) is an important focus of atrial fibrillation (AF). However, SVC isolation may cause serious complications, and appropriate settings and techniques for SVC isolation are lacking. This study enrolled 86 consecutive patients with AF who underwent SVC isolation. Voltage mapping using a multi-electrode catheter and ablation were performed under the guidance of an electro-anatomical mapping system. The lines encircling the SVC were divided into eight anatomic segments on the SVC geometry, and each segment was subjected to voltage-guided (VG) ablation in decreasing order of voltage (starting from the segment with the highest voltage). Non-VG (NVG) ablation was performed anatomically from the anterior wall toward the septum with one-round cautery. A total of 86 cases (66 males, mean age 69 [60, 74], mean CHA2DS2 VASc score 2 [1, 3], 58 paroxysmal AF) with AF were included for ablation. Electrical SVC isolation was successfully achieved in all patients. The length of the myocardial sleeves, as measured from the SVC-RA junction to the end of the local signal, was 37 [28, 45]mm. Major axis of the RA-SVC junction was 15 [13, 17] and minor axis of the RA-SVC junction was 11 [9, 13]. The number of ablation points with VG SVC isolation was fewer than that for NVG SVC isolation (8 [5, 11.5] vs. 11.5 [8.8, 13.3]; p=0.001). The procedure time of VG SVC isolation was greater than that of NVG SVC isolation (259s [154, 379] vs. 167s [115, 222]; p=0.012). There were no significant differences in the complication rates. VG SVC isolation reduced the number of ablation points compared with NVG SVC isolation.

Catheter ablation for atrial fibrillation in patients with prior left atrial appendage occlusion device.

The safety and efficacy of CA for AF and left-sided atrial arrhythmias (AA) in patients with left atrial appendage occlusion (LAAO) devices are lacking. This is a single-center retrospective registry that included all patients with prior LAAO who underwent catheter ablation for AF or left-sided atrial arrhythmia from January 2020-January 2023. The primary outcomes were procedure-related complications, device-related complications, AA recurrence, and stroke. A total of 30 patients with prior LAAO were included in the analysis (mean age 75.1 ± 7.1years old, 50% male, mean CHA2DS2-VASc score 4 ± 1.6, 46.7% paroxysmal AF, 73.3% had prior AF ablation, mean time to ablation 475 ± 365days). 93.3% (n = 28) and 6.6% (n = 2) patients had ablation for AF (46.7% paroxysmal, 36.7% persistent, 10% long-standing persistent) and left-sided atrial tachycardia, respectively. 16.7% (n = 5) patients underwent ablation along the left atrial appendage ostium, and 3.3% (n = 1) underwent Vein of Marshall alcohol ablation. There were 3 (10%) peri-procedural complications (1 access hematoma and two pericardial effusions requiring intervention-none related to left atrial appendage ostium or alcohol ablation). During the mean follow-up of 440 ± 379days, 40% (n = 12) patients had AA recurrence (91.6% AF, 8.3% atrial tachycardia), of which five patients needed repeat ablation, and two patients were readmitted for heart failure. There was no stroke or any device-related complications, including new peri-device leaks or device-related thrombosis in patients who had follow-up imaging studies (n = 11, 36.7%). Catheter ablation for AF (including VoM alcohol ablation) in patients with prior LAAO devices is feasible and safe with favorable outcomes.