New-onset Atrial Fibrillation Research Articles

Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery.

The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation.

Recurrent Ischemic Stroke/Transient Ischemic Attack After Patent Foramen Ovale Closure: A cohort study.

Patent foramen ovale (PFO) has been associated with ischemic stroke and transient ischemic attack (TIA). Guidelines recommend PFO closure for stroke prevention in selected patients, but the risk of recurrent stroke remains high compared to the background population. We aimed to evaluate the causes of recurrent stroke/TIA and post-interventional complications in patients after PFO closure. Patients from the Central Denmark Region who underwent PFO closure at Aarhus University Hospital between November 5, 2018, and May 12, 2023, following an ischemic stroke, TIA, amaurosis fugax or retinal emboli were included. Data on patient demographics, risk factors, procedural details, post-interventional complications and recurrent stroke/TIA were collected from electronic medical records. PFO closure was performed in 310 patients (median age: 49 years). During a median follow-up of 2.6 years (interquartile range: 1.5-3.6, 814 total patient years), recurrent stroke/TIA was observed in 8 patients (2.6%) or 0.98 recurrent strokes per 100 patient years. Recurrent stroke/TIA was more frequent in patients with hypertension (50.0% vs 16.9%, p = 0.039). Recurrent stroke/TIA was related to thrombophilia or haematological conditions entailing hypercoagulability in 62.5% of patients. New-onset atrial fibrillation was observed in 9.4% of patients within 45 days after the procedure. None of these patients subsequently developed an ischemic event. Other adverse outcomes were uncommon. Rates of recurrent ischaemic stroke/TIA after PFO closure were comparable to findings in previous trials. Pre-existing vascular risk factors (hypertension), and a hypercoagulable state were associated with recurrent ischaemic stroke/TIA.

Transthoracic Cross Clamp versus Endoaortic Balloon Occlusion in Minimally Invasive Mitral Valve Surgery: A Pooled Study with Subgroup Analyses.

Objective: We assessed the available literature regarding patients undergoing minimally invasive mitral valve surgery (MIMVS) with either transthoracic clamping (TTC) or endoaortic balloon occlusion (EABO). Methods: Original research studies that evaluated the perioperative outcomes of TTC versus EABO group were identified from 2000 to 2024. The incidence of all-cause mortality, cerebrovascular accidents (CVA), and aortic dissections were the primary endpoints. The cardiopulmonary bypass (CPB), cross-clamp, and ventilation time, along with the incidence of conversion to sternotomy, re-exploration, new-onset atrial fibrillation (AF), postoperative acute kidney injury (AKI), ICU stay, and LOS were the secondary endpoints. Subgroup analyses were performed regarding the EABO cannulation approach (femoral and aortic) and MIMVS approach (video-assisted and robotic-assisted). Sensitivity analyses were performed with the leave-one-out method and by including risk-adjusted populations. Results: Sixteen studies were included in both the qualitative and quantitative syntheses. After pooling data from 6335 patients, both groups demonstrated similar outcomes on all primary and secondary endpoints in the non-adjusted and adjusted total cohort analyses. These outcomes were further validated by the leave-one-out sensitivity analysis. In addition, the aortic cannulation EABO was associated with a lower cross-clamp time, followed by TTC and the femoral cannulation EABO approach. Furthermore, in the video-assisted subgroup analysis, the EABO approach was associated with a higher incidence of CVA, conversion to sternotomy, and longer ICU stay compared to the TTC group. Conclusions: The present meta-analysis indicates that both aortic occlusion techniques are safe and feasible in the context of MIMVS. A future well-designed randomized-control trial should further validate the current outcomes.

Emergence of Atrial Fibrillation and Flutter in COVID-19 Patients: A Retrospective Cohort Study.

COVID-19 is associated with various cardiovascular complications, including arrhythmias. This study investigated the incidence of new-onset atrial fibrillation (AFB) and atrial flutter (AFL) in COVID-19 patients and identified potential risk factors. We conducted a retrospective cohort study at a tertiary-care safety-net community hospital including 647 patients diagnosed with COVID-19 from March 2020 to March 2021. Patients with a prior history of AFB or AFL were excluded. Data on demographics, clinical characteristics, and outcomes were collected and analyzed using chi-square tests, t-tests, and binary logistic regression. We found that 69 patients (10.66%) developed AFB or AFL, with 41 patients (6.34%) experiencing new-onset arrhythmias. The incidence rates for new-onset AFB and AFL were 5.4% and 0.9%, respectively. Older age (≥65 years) was significantly associated with new-onset AFB/AFL (OR: 5.43; 95% CI: 2.31-12.77; p < 0.001), as was the development of sepsis (OR: 2.73; 95% CI: 1.31-5.70; p = 0.008). No significant association was found with patient sex. Our findings indicate that new-onset atrial arrhythmias are a significant complication in COVID-19 patients, particularly among the elderly and those with sepsis. This highlights the need for targeted monitoring and management strategies to mitigate the burden of atrial arrhythmias in high-risk populations during COVID-19 infection.

Long-Term Results Following Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients With Severe Aortic Stenosis: A Systematic Review and Meta-Analysis of Randomized Trials

Transcatheter aortic valve replacement (TAVR) is a safe and effective treatment option for patients with severe aortic stenosis at intermediate or high surgical risk. Results after TAVR in low-risk patients are very encouraging at midterm follow-up, whereas limited long-term (≥3 year) data are available in this subset of patients. This meta-analysis aims to compare the long-term follow-up after TAVR versus surgical aortic valve replacement (SAVR) in low-risk patients. We searched databases up to July 7, 2024 for randomized clinical trials comparing TAVR versus SAVR in low-risk patients (defined as Society of Thoracic Surgeons Predicted Risk of Mortality score <4%) (PROSPERO ID: CRD42023480495). Primary outcome analyzed was all-cause death at a minimum of 3 years of follow-up. The secondary outcomes were cardiovascular death, disabling stroke, myocardial infarction, aortic valve reintervention, endocarditis, new-onset atrial fibrillation, permanent pacemaker implantation, and bioprosthetic valve failure. A total of 3 randomized clinical trials with 2,644 patients (TAVR n = 1,371 patients; SAVR n = 1,273 patients) were included. The follow-up time was 6 ± 2.9 years. TAVR resulted noninferior to SAVR for all-cause death (risk ratio [RR] 0.99, 95% confidence interval [CI] 0.84 to 1.17, p = 0.89, I2 = 28%), cardiovascular death (RR 0.94, 95% CI 0.76 to 1.15, p = 0.54, I2 = 0%), myocardial infarction (RR 1.06, 95% CI 0.71 to 1.57, p = 0.79, I2 = 61%), aortic valve reintervention, endocarditis, and bioprosthetic valve failure. New-onset atrial fibrillation was more common in the SAVR group, whereas permanent pacemaker implantation was more common in the TAVR group. In conclusion, our meta-analysis showed that TAVR is associated with similar long-term outcomes compared with SAVR in selected low-risk patients.

A Systematic Review of Ongoing Registered Research Studies on Post-Operative Atrial Fibrillation after Cardiac Surgery.

Background/Objectives: New-onset atrial fibrillation (AF) after cardiac surgery is associated with patient-important outcomes. Uncertainty persists regarding its prevention, detection, and management. This review seeks to identify, compile, and describe ongoing registered research studies involving patients with or at risk for post-operative AF (POAF) after cardiac surgery. Methods: We searched clinical trial registries in January 2023 for studies focusing on POAF prediction, prevention, detection, or management. We extracted data from each record and performed descriptive analyses. Results: In total, 121 studies met the eligibility criteria, including 82 randomized trials. Prevention studies are the most common (n = 77, 63.6%), followed by prediction (n = 21, 17.4%), management (n = 16, 13.2%), and detection studies (n = 7, 5.8%). POAF after cardiac surgery is an area of active research. Conclusions: There are many ongoing randomized prevention studies. However, two major clinical gaps persist; future randomized trials should compare rate and rhythm control in patients who develop POAF, and long-term follow-up studies should investigate strategies to monitor for AF recurrence in patients with POAF.

Sweetened beverages and atrial fibrillation in people with prediabetes or diabetes.

To assess the association of intake of sugar-sweetened beverages (SSBs), artificially sweetened beverages (ASBs) and natural juices (NJs) with new-onset atrial fibrillation (AF) in people with prediabetes or diabetes. A total of 31 433 participants with prediabetes and diabetes from the UK Biobank were included. Information on the intake of SSBs, ASBs and NJs was accessed by 24-hour dietary recalls from 2009 to 2012. The study outcome was new-onset AF. During a median follow-up of 12.0 years, 2470 (7.9%) AF cases were documented. Both the intake of SSBs (per 1 unit/day increment; adjusted hazard ratio [HR] = 1.11; 95% confidence interval [CI]: 1.04-1.18) and ASBs (per 1 unit/day increment; adjusted HR = 1.08; 95% CI: 1.02-1.14) were linearly and positively associated with new-onset AF, while NJ intake was not significantly associated with new-onset AF (per 1 unit/day increment; adjusted HR = 1.00; 95% CI: 0.93-1.08). Accordingly, compared with non-consumers, participants who consumed more than one unit per day of SSBs (adjusted HR = 1.30; 95% CI: 1.11-1.53) or ASBs (adjusted HR = 1.21; 95% CI:1.05-1.40) had an increased risk of AF. Substituting 1 unit/day of NJs for SSBs was associated with a 9% (adjusted HR = 0.91; 95% CI: 0.83-0.99) lower risk of new-onset AF, while replacing SSBs with ASBs was not significantly associated with new-onset AF (adjusted HR = 0.97; 95% CI: 0.89-1.06). Both the intake of SSBs and ASBs were linearly and positively associated with new-onset AF, while NJ intake did not show a significant association with AF in people with prediabetes or diabetes. Replacing an equivalent amount of SSB intake with NJs, but not ASBs, was associated with a lower risk of AF.

Sutureless Aortic Valve Replacement with Perceval Bioprosthesis Superior to Transcatheter Aortic Valve Implantation: A Promising Option for the Gray-Zone of Aortic Valve Replacement Procedures-A State-of-the-Art Systematic Review, Meta-Analysis, and Future Directions.

Background: The management of patients with aortic valve pathologies can sometimes fall into a "gray zone", where the optimal treatment approach is not straightforward. The comparative benefits of sutureless aortic valve replacement (SUAVR) using the Perceval bioprosthesis versus transcatheter aortic valve implantation (TAVI) for the "gray zone" of aortic valve replacement procedures remain a topic of debate. To further explore this issue, we conducted a study with pairwise, single-arm, and Kaplan-Meier-based meta-analyses to compare the outcomes of SUAVR with the Perceval bioprosthesis versus TAVI, as well as to evaluate the efficacy, safety, and durability of SUAVR with the Perceval bioprosthesis over mid-term and long-term follow-up periods. Methods: The PubMed, PubMed Central, OVID Medline, Cochrane Library, Embase, and Web of Science databases were systematically searched. All study types were included, except study protocols and animal studies, without time restrictions. The final search was carried out in May 2024. Results: No statistically significant differences were observed in permanent pacemaker implantation (PPI) rates between the two groups. SUAVR showed a lower incidence of new-onset myocardial infarction but was associated with higher rates of new-onset atrial fibrillation and major bleeding. TAVI had higher rates of left bundle branch block and major vascular complications. Conclusions: Our findings show that SUAVR has a lower incidence of complications and a favorable mid-term overall survival compared to TAVI. SUAVR has more advantages compared to TAVI and can be considered a valuable and promising option for the "grey zone" of aortic valve pathologies.

Predicting New-Onset Atrial Fibrillation in Patients with Coronary Artery Bypass Graft: the Precise-Dapt Score

&lt;b&gt;Aim:&lt;/b&gt;&amp;nbsp;Postoperative new-onset atrial fibrillation (POAF) after isolated coronary artery bypass graft surgery (CABG) is associated with adverse events. The Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score is used to predict the bleeding risk after dual antiplatelet therapy and has been associated with arrhythmias in recent years. Therefore, the present study sought to investigate the association between the PRECISE-DAPT score and POAF after coronary artery bypass graft surgery.&lt;br /&gt; &lt;b&gt;Materials and Methods:&lt;/b&gt;&amp;nbsp;350 patients who underwent CABG were retrospectively screened. After exclusion criteria, 135 patients were included in the study. A total of 135 patients who underwent on-pump CABG were divided into two groups: patients with POAF and those without POAF. The PRECISE-DAPT score was calculated for each patient, and intergroup comparisons of the calculated scores were performed.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt;&amp;nbsp;POAF was detected in 66 patients out of 135. Patients with POAF had longer hospital stays. PRECISE-DAPT score was higher in the patients with POAF compared to the patients without POAF (p&amp;lt;0.001). PRECISE-DAPT score was determined to be a predictor of POAF after CABG (odds ratio [OR]: 1.305; 95% confidence interval [CI]: 1.268–2.030; p&amp;lt;0.001).&amp;nbsp;The PRECISE-DAPT score for POAF risk had a sensitivity of 60% and a specificity of 79% at cut-off values of 14.5 and above.&lt;br /&gt; &lt;b&gt;Conclusion:&lt;/b&gt;&amp;nbsp;An increased PRECISE-DAPT score may be used as a predictive score for POAF that may develop during hospital stay after on-pump CABG.

Hypertension and atrial fibrillation: the clinical impact of hypertension on perioperative outcomes of atrial fibrillation ablation and its optimal control for the prevention of recurrence.

Hypertension (HTN) is one of the major risk factors for developing atrial fibrillation (AF), and it has been estimated that approximately 70% of hypertensive patients are at risk of developing AF. On the other hand, 60-80% of AF patients have HTN. These two diseases share many risk factors such as diabetes mellitus, obesity, alcohol consumption, and sleep apnea syndrome during their onset and disease progression. The mutual presence of these diseases has the potential to create a negative spiral, exacerbating each other's impact and ultimately leading to cardiovascular events such as heart failure and cerebrovascular disorders, thereby increasing mortality rates. With regard to the treatment of HTN, the variety of antihypertensive drugs and treatment options have significantly increased. Alongside the widespread adoption of antihypertensive therapy, a certain level of efficacy has been recognized in suppressing the incidence of new-onset AF. Catheter ablation is an established and effective treatment for AF. However, a notable recurrence rate persists. In recent years, management of these multiple risk factors has been recognized to be essential for suppressing AF recurrence, and recent guidelines for AF underscore the significance of proactively managing these risks before treatment. Notably, effective HTN management assumes paramount importance given its impact on the morbidity of AF patients. This review summarizes the correlation between HTN control before and after ablation and the risk of AF recurrence. The focus is on elucidating the pathophysiological background and its impact on clinical outcomes.

CHA2DS2-VASc Score as Predictor of New-Onset Atrial Fibrillation and Mortality in Critical COVID-19 Patients.

Pre-existing and new-onset atrial fibrillation (NOAF) is a common arrhythmia in COVID-19 patients and is related to increased mortality. CHA2DS2-VASc score was initially developed to evaluate thromboembolic risk in patients with AF. Moreover, it predicted adverse outcomes in other clinical conditions, including SARS-CoV-2 infection. We aimed to evaluate the association of CHA2DS2-VASc with NOAF, ICU length of stay (LOS) and mortality in critically ill COVID-19 patients. We also examined the relationship of NOAF with mortality. We reviewed the literature to describe the link between cardiovascular risk factors and inflammatory response of severe COVID-19. We retrospectively studied 163 COVID-19 patients admitted to a level 3 general ICU from March 2020 to April 2022. Patients were of advanced age (median 64 years, IQR 56.5-71) and the majority of them were male (67.5%). Regarding NOAF, we excluded 12 patients with AF history. In this group, CHA2DS2VASc score was significantly elevated (3 IQR (1-4) versus 1 IQR (1-2.75), p = 0.003). Specifically, three components of CHA2DS2VASc were notably increased: age (p < 0.001), arterial hypertension (p = 0.042) and stroke (p = 0.047). ICU mortality was raised in the NOAF group [75.8% versus 34.8%, p < 0.001 OR 5.87, 95% CI (2.43, 14.17)]. This was significant even after adjusting for ICU clinical scores (APACHE II and SOFA). About mortality in the entire sample, survivors were younger (p = 0.001). Non-survivors had greater APACHE II (p = 0.04) and SOFA (p = 0.033) scores. CHA2DS2VASc score was positively associated with mortality [p = 0.031, OR 1.28, 95% CI (1.03, 1.6)]. ICU length of stay was associated with mortality (p = 0.016) but not with CHA2DS2VASc score (p = 0.842). NOAF and CHA2DS2VASc score were associated with higher mortality in COVID-19 ICU patients. CHA2DS2VASc score was also associated with NOAF but not with ICU LOS.

Dosing and Safety Profile of Aficamten in Symptomatic Obstructive Hypertrophic Cardiomyopathy: Results From SEQUOIA-HCM.

Aficamten, a novel cardiac myosin inhibitor, reversibly reduces cardiac hypercontractility in obstructive hypertrophic cardiomyopathy. We present a prespecified analysis of the pharmacokinetics, pharmacodynamics, and safety of aficamten in SEQUOIA-HCM (Safety, Efficacy, and Quantitative Understanding of Obstruction Impact of Aficamten in HCM). A total of 282 patients with obstructive hypertrophic cardiomyopathy were randomized 1:1 to daily aficamten (5-20 mg) or placebo between February 1, 2022, and May 15, 2023. Aficamten dosing targeted the lowest effective dose for achieving site-interpreted Valsalva left ventricular outflow tract gradient <30 mm Hg with left ventricular ejection fraction (LVEF) ≥50%. End points were evaluated during titration (day 1 to week 8), maintenance (weeks 8-24), and washout (weeks 24-28), and included major adverse cardiac events, new-onset atrial fibrillation, implantable cardioverter-defibrillator discharges, LVEF <50%, and treatment-emergent adverse events. At week 8, 3.6%, 12.9%, 35%, and 48.6% of patients achieved 5-, 10-, 15-, and 20-mg doses, respectively. Baseline characteristics were similar across groups. Aficamten concentration increased by dose and remained stable during maintenance. During the treatment period, LVEF decreased by -0.9% (95% CI, -1.3 to -0.6) per 100 ng/mL aficamten exposure. Seven (4.9%) patients taking aficamten underwent per-protocol dose reduction for site-interpreted LVEF <50%. There were no treatment interruptions or heart failure worsening for LVEF <50%. No major adverse cardiovascular events were associated with aficamten, and treatment-emergent adverse events were similar between treatment groups, including atrial fibrillation. A site-based dosing algorithm targeting the lowest effective aficamten dose reduced left ventricular outflow tract gradient with a favorable safety profile throughout SEQUOIA-HCM. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT05186818.

Complications of new-onset atrial fibrillation in critically ill COVID-19 patients admitted to the intensive care unit (ICU): a meta-analysis

BackgroundCOVID-19 infections can result in severe acute respiratory distress syndrome (ARDS) requiring admission to the intensive care unit (ICU). Cardiovascular manifestation or exacerbation of cardiovascular diseases could be another complication. Cardiac arrhythmias including New-Onset Atrial Fibrillation (NOAF), have been observed in hospitalized patients with COVID-19 infections. In this analysis, we aimed to systematically compare the complications associated with NOAF in critically ill COVID-19 patients admitted to the ICU.MethodsMEDLINE, EMBASE, Web of Science, the Cochrane database, http://www.ClinicalTrials.gov, Google Scholar and Mendeley were searched for relevant publications based on COVID-19 patients with NOAF admitted to the ICU. Complications including in-hospital mortality, ICU mortality, patients requiring mechanical ventilation, acute myocardial infarction, acute kidney injury, renal replacement therapy and pulmonary embolism were assessed. This is a meta-analysis and the analytical tool which was used was the RevMan software version 5.4. Risk ratios (RR) and 95% confidence intervals (CIs) were used to represent the data post analysis.ResultsIn critically ill COVID-19 patients with NOAF admitted to the ICU, the risks of ICU mortality (RR: 1.39, 95% CI: 1.07 – 1.80; P = 0.01), in-hospital mortality (RR: 1.56, 95% CI: 1.20 – 2.04; P = 0.001), patients requiring mechanical ventilation (RR: 1.32, 95% CI: 1.04 – 1.66; P = 0.02) were significantly higher when compared to the control group without AF. Acute myocardial infarction (RR: 1.54, 95% CI: 1.31 – 1.81; P = 0.00001), the risk for acute kidney injury (RR: 1.31, 95% CI: 1.11 – 1.55; P = 0.002) and patients requiring renal replacement therapy (RR: 1.83, 95% CI: 1.60 – 2.09; P = 0.00001) were also significantly higher in patients with NOAF.ConclusionsCritically ill COVID-19 patients with NOAF admitted to the ICU were at significantly higher risks of developing complications and death compared to similar patients without AF.

Early anti-coagulation therapy in new-onset atrial fibrillation after coronary artery bypass grafting: a randomized trial pilot study

BackgroundNew-onset postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG) surgery, increasing the risk of embolism and stroke. There is a lack of information on the use of anticoagulants in this context. The choice between Warfarin and Direct oral anticoagulants (DOACs) also is not well-established. This randomized study aimed to compare the feasibility and safety of Warfarin and Rivaroxaban in preventing thrombotic events in POAF patients after isolated CABG.MethodsA total of 66 patients were randomized parallelly with 1:1 allocation to receive either Rivaroxaban (n = 34) or Warfarin (n = 32). Major bleeding events within 30 days after discharge were the primary outcome. Secondary outcomes included minor bleeding events and thrombotic episodes. Clinical characteristics, medication regimens, and left atrial diameter were assessed. Statistical analyses were performed using appropriate tests.ResultsNo thrombotic episodes were observed in either treatment arm. No major bleeding events occurred in either group. Four minor bleeding events were reported, with no significant difference between the treatment groups (P = 0.6). Patients with atrial fibrillation had significantly larger left atrial diameters compared to those with normal sinus rhythm (40.5 vs. 37.8 mm, P = 0.01).ConclusionsThis pilot study suggests that Warfarin and Rivaroxaban are both safe and effective for preventing thrombotic episodes in POAF patients after isolated CABG. No significant differences in major bleeding events were observed between the two anticoagulants. These findings may support the preference for DOACs like Rivaroxaban due to their convenience and easier maintenance.Trial registrationNumber IRCT20200304046696N1, Date 18/03/2020 https//irct.behdasht.gov.ir/.

Incidence, Correlates, and Prognostic Implications of New-Onset Atrial Fibrillation in Adults With Repaired Coarctation of Aorta

BackgroundThere are limited data about the incidence and outcomes of atrial fibrillation (AF) in adults with coarctation of aorta (COA). The purpose of this study was to determine the incidence, correlates, and prognostic implications of new-onset AF in adults with repaired COA. MethodsA retrospective cohort study of adults with repaired COA without a prior history of atrial arrhythmias was performed. We reviewed rhythm data (electrocardiogram, Holter, and rhythm strip) obtained from baseline to the last clinical encounter. The correlates of AF and the relationship between AF and cardiovascular adverse events (heart failure hospitalization and/or all-cause mortality) were assessed using Cox regression. ResultsOf 782 patients (aged 32 [interquartile range: 21-43] years; 462 [59%] men), 42 (5.4%) developed new-onset AF. The incidence of new-onset AF was 9 per 1000 patient-years (0.9% per year), and the median age at onset of AF was 36 (interquartile range: 24-49) years. The correlates of new-onset AF were older age, hypertension, left atrial dysfunction, and left ventricular hypertrophy. Of 782 patients, 92 (12%) had cardiovascular adverse events. On multivariable analysis, new-onset AF was associated with cardiovascular adverse events (hazard ratio: 1.09, 95% confidence interval: 1.03-1.15), after adjustment for age, hypertension, and right and left ventricular structure and function. ConclusionsPatients with COA were at risk for developing AF at a relatively young age (median age: 36 years), and AF was associated with cardiovascular adverse outcomes. There is a need to target the modifiable risk factors for AF to reduce the adverse outcomes associated with AF.

Treatment of subclinical hyperthyroidism in patients older than 50 years: A randomized controlled study.

Subclinical hyperthyroidism (SCH) is common and associated with atrial fibrillation (AF) risk in the elderly. Current guidelines rely on a low level of evidence. Randomized clinical trial including patients 50 years and older, with TSH <0.4 mU/L and normal thyroid hormone concentrations. All patients showed autonomy on thyroid scan. They were randomized either to receive radioiodine (I131) or to be monitored and treated only if they underwent AF or evolved towards overt hyperthyroidism. Primary outcome was the onset of new AF. Secondary outcomes were treatment-induced hypothyroidism rate and health-related quality of life. 144 patients (mean age 65.3±8.9y, 76% female) were randomized, 74 to surveillance and 70 to treatment. Four patients in the surveillance group and one in the treatment group developed AF (p=0.238). However, the patient who developed AF in the treatment group maintained TSH <0.4 mU/L at AF onset. A post-hoc analysis was carried out and showed that when normalization of TSH was considered, the risk of AF was significantly reduced (p=0.0003). In the surveillance group, several patients showed no classical characteristics associated with AF risk, including age>65y or TSH<0.1mU/L. Of 94 patients treated using radioiodine, 25% developed hypothyroidism during follow-up. Due to recruitment difficulties this study failed to demonstrate that SCH treatment can reduce significantly the incidence of AF in patients older than 50 years with thyroid autonomy even if all the patients who developed AF maintained TSH <0.4 mU/L. This result must be balanced with the increased risk of radioiodine-induced hypothyroidism.

Usefulness of exercise stress echocardiography for predicting cardiovascular events and atrial fibrillation in hypertrophic cardiomyopathy

BackgroundIn hypertrophic cardiomyopathy (HCM), the determinants of exercise tolerance and the usefulness of exercise stress echocardiography (ESE) for predicting hard endpoints have not been fully investigated. We aimed to assess the key parameters of ESE for exercise tolerance and the factors predictive of cardiovascular events and new-onset atrial fibrillation (AF) in patients with HCM. MethodsSeventy-four consecutive patients with HCM who underwent ESE and with an ejection fraction ≥50 % were enrolled. The primary endpoint was a composite of cardiovascular death, heart failure hospitalization, ventricular fibrillation or tachycardia, and ventricular assist device implantation. The secondary endpoint was new-onset AF. ResultsThe primary endpoint occurred in 13 patients. The left and right ventricular functions during exercise were responsible for decreased exercise tolerance. Peak exercise e′ and tricuspid annular plane systolic excursion (TAPSE) significantly predicted increased primary outcome risk (hazard ratio 1.35, 95 % confidence interval 1.10–1.76, p = 0.003; hazard ratio 1.19, 95 % confidence interval 1.07–1.32, p = 0.002, respectively), and the results were consistent even after adjustment by maximum workload. These ESE parameters improved the prognostic model containing estimated glomerular filtration rate (eGFR) and left atrial (LA) volume index. In AF-naive patients (n = 58), LA volume, peak exercise LA reservoir strain, and left ventricular outflow tract (LVOT) pressure gradient predicted new-onset AF. ConclusionsIn patients with HCM, ESE parameters related to left and right ventricular function were responsible for low exercise tolerance. Furthermore, e′ and TAPSE at peak workload could be useful for predicting cardiovascular events in addition to eGFR and LA volume index. LVOT pressure gradient and LA function during exercise predicted new-onset AF.

Determinants of adverse outcomes following patent foramen ovale closure in elderly patients.

Limited data are available on transcatheter patent foramen ovale (PFO) closure outcomes in the elderly. Through this study, we aimed to determine the incidence and predictors of adverse events (recurrent cerebrovascular events [CVE] and atrial fibrillation [AF]) post-PFO closure in older patients with cryptogenic events. This multicentre international study included patients over 60 years undergoing PFO closure for cryptogenic thromboembolic events. A dedicated database compiled baseline, procedural, and follow-up data. Competing risk and adjusted outcome predictor analyses were conducted. A total of 689 patients were included (median age 65 years, 41.2% female, mean Risk of Paradoxical Embolism [RoPE] score 4.5). The procedural success rate was 99.4%. After a median follow-up of 2 (interquartile range 1-5) years, 66 patients (9.6%) had died. CVE and stroke rates were 1.21 and 0.55 per 100 patient-years, respectively. Diabetes (hazard ratio [HR] 3.89, 95% confidence interval [CI]: 1.67-9.07; p=0.002) and atrial septal aneurysm (ASA; HR 5.25, 95% CI: 1.56-17.62; p=0.007) increased the CVE risk. New-onset AF occurred at a rate of 3.30 per 100 patient-years, with 51.3% within one month post-procedure. Older age (HR 1.05 per year, 95% CI: 1.00-1.09; p=0.023) and the absence of hypertension (HR 2.04, 95% CI: 1.19-3.57; p=0.010) were associated with an increased risk of AF. Older patients undergoing PFO closure had a relatively low rate of CVE and new-onset AF after a median follow-up of 2 years. The presence of diabetes, ASA, and a more advanced age determined an increased risk of adverse clinical events. These factors may be considered in the clinical decision-making process regarding PFO closure in this challenging population.

Novel insight into neurofilament light chain and rhythm outcomes after catheter ablation of new-onset atrial fibrillation: A prospective cohort study

BackgroundAtrial fibrillation (AF) is an age-related disorder closely linked to autonomic nervous system dysfunction. Neurofilament light chain (NFL) protein is a biomarker for neurodegenerative diseases. ObjectiveThe purpose of this study was to evaluate the predictive value of NFL in forecasting AF recurrence after ablation. MethodsPatients newly diagnosed with AF who underwent catheter ablation were included. Serum NFL levels were measured using enzyme-linked immunosorbent assay. The primary outcome was AF recurrence during follow-up. ResultsA total of 215 consecutive patients were enrolled, with average follow-up period of 10.69 months. During this period, 29 patients experienced AF recurrence. Multivariate Cox regression analysis revealed that high NFL levels (≥300 pg/mL) were an independent predictor of recurrence risk (adjusted hazard ratio [HR] 3.756; 95% confidence interval [CI] 1.392–10.136). The associations between NFL levels and AF recurrence were consistent across subgroups defined by age (>65 years), gender, hypertension, and paroxysmal AF. Restricted cubic spline analysis showed a consistent linear relationship across the entire range of NFL levels. Furthermore, incorporating NFL into the CHA2DS2-VASc score model significantly improved the prediction of recurrent AF risk, as demonstrated by time-dependent area under the curve and decision curve analysis. Notable enhancements were also observed in terms of net reclassification improvement (HR 0.464; 95% CI 0.226–0.675; P <.05) and integrated discrimination improvement (HR 0.087; 95% CI 0.017–0.183; P = .08). ConclusionNFL may serve as an effective biomarker for risk stratification and therapeutic decision-making in patients with new-onset AF who have undergone catheter ablation.

Atrial Fibrillation Occurring After Smoking Marijuana: A Case Report and Review of the Literature.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, occurring primarily in individuals with known risk factors such as advanced age, heart failure, and coronary artery disease. Cannabis use produces several cardiovascular changes resulting in proarrhythmic effects on the heart. A 38-year-old woman with no significant past medical history presented to the emergency department (ED) complaining of palpitations with associated shortness of breath occurring after smoking marijuana. She was found to be in AF. Evaluation in the ED and during hospitalization found no cardiac or metabolic conditions that predisposed to AF. The AF resolved within three hours of onset without intervention. Cannabis use should be considered as a possible etiology of new-onset AF, especially in relatively young patients with no other predisposing risk factors.