Outcomes In Atrial Fibrillation Patients Research Articles

Risk of death, thrombotic and hemorrhagic events in patients with atrial fibrillation and systemic autoimmune diseases

Abstract Background Growing evidence showing that systemic autoimmune diseases (SAD) are associated with a high risk of incident atrial fibrillation (AF). However, the impact of SAD on the clinical course of AF patients is largely unknown. Purpose To assess the risk of all-cause death, thrombotic events, and bleeding in AF patients with SAD. Methods Retrospective cohort study within a global health care network (TriNetx). Using ICD codes, AF patients were categorized into two groups: 1) AF patients with SAD (M32: Systemic Lupus Erythematosus; M33: Dermato-polymyositis; M34: Systemic Sclerosis; M35: Sjogren syndrome), and 2) AF controls (without systemic autoimmune, autoinflammatory, or rheumatic diseases). The primary outcomes were the 5-year risks of 1) all-cause death, 2) thrombotic events (ischemic stroke, transient ischemic attack, peripheral arterial thromboembolism, acute myocardial infarction, deep vein thrombosis, and pulmonary embolism), and 3) hemorrhagic outcome (intracranial hemorrhage and gastrointestinal bleeding). Secondary outcomes were each component of the composite primary outcomes. Cox regression analysis before and after propensity-score-matching (PSM) was used to estimate HR and 95% confidence interval (95%CI). Sensitivity analyses were done to investigate the risk of primary outcomes associated with each systemic autoimmune disease and with different types of oral anticoagulant (OAC). Results We identified 22,371 AF patients with SAD (67.7±13.7 years, 72.2% females), and 1,478,693 AF controls (69.7±14.0, 42.6% females). Before PSM, AF patients with SAD were younger, more often females, and with a higher prevalence of cardiovascular risk factors; no differences were found after PSM. After PSM, AF patients with SAD showed a higher risk of all-cause death (HR 1.21, 95% 1.17-1.25), thrombotic events (HR 1.55, 95%CI 1.49-1.61), and hemorrhagic events (HR 1.39, 95%CI 1.32-1.46) compared to AF controls (Table 1). On sensitivity analyses, we found that the risk of primary outcomes in AF patients with SAD was independent from the OAC type, but NOAC was more effective than warfarin in reducing the risk of thrombotic events. The highest risk of all-cause death was associated with Systemic Sclerosis, while the highest risk of composite thrombotic events was associated with Systemic Lupus Erythematosus, and Dermato-polymyositis. The highest risk of stroke was associated with Sjogren syndrome; and myocardial infarction and deep vein thrombosis with Dermato-polymyositis, Systemic Lupus Erythematosus was associated with the highest risk of Intracranial hemorrhage, while Systemic Sclerosis to the highest risk of gastrointestinal bleeding (Table 2). Conclusion In AF patients the coexistence of SAD is associated with a high risk of all-cause death, thrombotic events, and bleeding. A personalized approach aimed to minimize the impact of SAD on the clinical course of AF patients is needed.Figure 1Figure 2

Atrial functional mitral regurgitation as a marker of atrial remodeling and ablation outcomes in atrial fibrillation patients

Abstract Background Atrial fibrillation (AF) triggers a cascade of atrial remodeling processes, significantly impacting atrial function and the efficacy of ablation therapies. This remodeling fosters the development of atrial cardiomyopathy and atrial dilation, which is linked to the emergence of mitral regurgitation, paving the way for the concept of atrial functional mitral regurgitation (aFMR). Our study delves into the intricate relationship between aFMR and the electrical architecture of the atrium, specifically focusing on left atrial bipolar voltage and the prevalence and extent of low-voltage areas (LVAs) in AF patients. By exploring these associations, this research aims to deepen our understanding of the interplay between the atrial substrate alterations and the development of aFMR. Methods A total of 282 patients were enrolled, who had presented for a redo PVI procedure after experiencing AF recurrence following a previous PVI. All patients received echocardiography prior to the electrophysiological procedure. All procedures were performed using 3D mapping and radiofrequency ablation. Reconnected pulmonary veins were detected in all patients and were re-isolated. The voltage of the electroanatomical points was documented on each of the atrial walls. LVAs were calculated in selected HD maps. Patients were followed-up for one year after the blanking period. Results Our cohort comprised 282 patients, predominantly male (69.4%), with a mean age of 64 years. 56% of the patients presented with persistent AF. LA area was larger in patients with aFMR ≥ 1+ as compared to aFMR < 1+ (17.0 [14.6-19.7] vs 20.6 [16.6-24.7] cm2, p<0.001). We observed significant differences in left atrial voltage and LVA extent between patients with varying degrees of aFMR (Table 1). Upon further investigation Patients with aFMR = 1+ showed significantly lower atrial voltage compared with aFMR < 1+ yet no significant increase in LVAs area. Patients with aFMR = 2 exhibited lower average voltage amplitudes in all atrial regions and larger LVA in the posterior wall, atrial roof, and septum compared to their aFMR < 1+ counterparts. Notably, the recurrence of AF was significantly higher in the AFMR ≥ 1+ (59% vs 46% p=0.027) group within one year of follow-up. aFMR was associated with AF recurrence even after adjusting for sex, age and AF types (HR:1.517, 95% CI: 1.057-2.184, p=0.025). Conclusion The presence of aFMR in AF patients may serve as a marker of progressive atrial remodeling and the onset of left atrial cardiomyopathy, characterized by reduced atrial voltage and increased LVAs. Additionally, aFMR is linked to the outcomes of PVI, suggesting that aFMR should be considered in the decision-making process for AF therapy. Further research is needed to explore the potential reversibility of these changes.Left atrial voltage and low voltage area

Obesity paradox in atrial fibrillation patients on oral anticoagulation therapy: a Korean nationwide cohort study

Abstract Background The obesity paradox is a phenomenon that has been observed in specific pathological conditions, wherein individuals who are overweight or obese exhibit a survival advantage over those with a normal weight. This phenomenon has also been noted in patients diagnosed with atrial fibrillation (AF), although the impact of body mass index (BMI) on clinical outcomes in AF patients undergoing oral anticoagulant (OAC) therapy remains uncertain. Purpose The aim of this study was to investigate the potential relationship between obesity and cardiovascular outcomes in patients diagnosed with AF who were receiving OAC. Methods We utilized administrative claims data from the Korean National Health Insurance Service and the combined health check-up database of the National Health Insurance Corporation to conduct a retrospective national cohort study spanning from 2013 to 2020. The patients newly prescribed OAC for AF were included, between January 2015 and December 2019. We followed up with patients from their index date until each outcome event or the end of the study period. BMI was categorized into 5 groups based on the World Health Organization's recommended criteria for Asian populations. The predefined clinical outcomes included thromboembolism, major bleeding, all-cause death, and the composite outcome. Results A total of 35,333 patients were included in the study. The mean age was 69 ± 10 years, and 37.1% were female. During a median follow-up of 2.0 years (IQR, 0.4–3.3), there were 11,634 thromboembolic events, 1,521 major bleeding events, and 2,586 deaths. The adjusted hazard ratio (HR) for thromboembolism, major bleeding, all-cause death, and a composite outcome were lower in obese II group (HR 0.79, 95% CI 0.73–0.86; HR 0.99, 95% CI 0.79–1.24; HR 0.75, 95% CI 0.62–0.91; HR 0.81, 95% CI 0.75–0.88) compared to the normal range BMI group. Conclusions In AF patients undergoing OAC therapy, individuals classified as obese exhibited a reduced risk of thromboembolism, major bleeding, all-cause mortality, and composite outcome compared to patients with normal weight.Adjusted hazard ratio of outcomes by BMI

Exosomal miRNA Changes Associated with Restoration to Sinus Rhythm in Atrial Fibrillation Patients.

We aimed to identify serum exosomal microRNAs (miRNAs) associated with the transition from atrial fibrillation (AF) to sinus rhythm (SR) and investigate their potential as biomarkers for the early recurrence of AF within three months post-treatment. We collected blood samples from eight AF patients at Chang Gung Memorial Hospital in Taiwan both immediately before and within 14 days following rhythm control treatment. Exosomes were isolated from these samples, and small RNA sequencing was performed. Using DESeq2 analysis, we identified nine miRNAs (16-2-3p, 22-3p, 23a-3p, 23b-3p, 125a-5p, 328-3p, 423-5p, 504-5p, and 582-3p) associated with restoration to SR. Further analysis using the DIABLO model revealed a correlation between the decreased expression of miR-125a-5p and miR-328-3p and the early recurrence of AF. Furthermore, early recurrence is associated with a longer duration of AF, presumably indicating a more extensive state of underlying cardiac remodeling. In addition, the reads were mapped to mRNA sequences, leading to the identification of 14 mRNAs (AC005041.1, ARHGEF12, AMT, ANO8, BCL11A, DIO3OS, EIF4ENIF1, G2E3-AS1, HERC3, LARS, NT5E, PITX1, SLC16A12, and ZBTB21) associated with restoration to SR. Monitoring these serum exosomal miRNA and mRNA expression patterns may be beneficial for optimizing treatment outcomes in AF patients.

IMPACT OF THYROID DYSFUNCTION IN PATIENTS WITH ATRIAL FIBRILLATION

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

Catheter Ablation for Atrial Fibrillation in Patients with Left Ventricular Ejection Fraction ≤ 45%: A Meta-Analysis of Randomized Controlled Trials.

Atrial fibrillation (AF) and heart failure (HF) frequently coexist, resulting in adverse outcomes. However, controversies remain regarding the efficacy of catheter ablation (CA) in AF patients with severe left ventricular dysfunction. The purpose of this study was to perform a meta-analysis of prospective randomized controlled trials to evaluate the efficacy of CA versus medical therapy (MT) in AF patients with left ventricular ejection fraction (LVEF) ≤45%. We searched the literature for studies that compared CA to MT in AF patients with LVEF ≤45%. A meta-analysis of 7 clinical trials was performed, including 1163 patients with AF and HF. Subgroup analysis was performed based on baseline LVEF. All tests were 2-sided; only the p-value <0.05 was considered statistically significant. We found that CA was associated with lower all-cause mortality (risk ratio: 0.52, 95% CI: 0.37 to 0.72; p<0.01) and greater improvements in LVEF (mean difference: 4.80%, 95% CI: 2.29% to 7.31%; p<0.01) compared to MT. Patients in the CA group had a lower risk of HF hospitalization and AF recurrence and a significantly better quality of life than those in the MT group. The results of subgroup analysis indicated that patients with milder left ventricular dysfunction improved LVEF after AF ablation (mean difference: 6.53%, 95% CI: 6.18% to 6.88%; p<0.01) compared to patients with more severe disease (mean difference: 2.02%, 95% CI: 0.87% to 3.16%; p<0.01). Our meta-analysis demonstrated that CA was associated with significant improvements in outcomes of AF patients with LVEF ≤45%. Additionally, AF patients with milder left ventricular dysfunction could benefit more from CA.

Time in target range of systolic blood pressure and clinical outcomes in atrial fibrillation patients: results of the COOL-AF registry

We aimed to investigate the relationship between time in target range of systolic blood pressure (SBP-TTr) and clinical outcomes in patients with atrial fibrillation (AF). We analyzed the results from multicenter AF registry in Thailand. Blood pressure was recorded at baseline and at every 6 monthly follow-up visit. SBP-TTr were calculated using the Rosendaal method, based on a target SBP 120–140 mmHg. The outcomes were death, ischemic stroke/systemic embolism (SSE), major bleeding, and heart failure. A total of 3355 patients were studied (mean age 67.8 years; 41.9% female). Average follow-up time was 32.1 ± 8.3 months. SBP-TTr was classified into 3 groups according to the tertiles. The incidence rates of all-cause death, SSE, major bleeding, and heart failure were 3.90 (3.51–4.34), 1.52 (1.27–1.80), 2.2 (1.90–2.53), and 2.83 (2.49–3.21) per 100 person-years, respectively. Patients in the 3rd tertile of SBP-TTr had lower rates of death, major bleeding and heart failure with adjusted hazard ratios 0.62 (0.48–0.80), p < 0.001, 0.64 (0.44–0.92), p = 0.016, and 0.61 (0.44–0.84), p = 0.003, respectively, compared to 1st SBP-TTr tertile. In conclusion, high SBP-TTr was associated with better clinical outcomes compared to other groups with lower SBP-TTr. This underscores the importance of good blood pressure control in AF patients.

The predictive role of N-terminal pro-B-type natriuretic peptide in assessing outcomes for atrial fibrillation patients, with or without heart failure: a comprehensive systematic review and meta-analysis

Background and purpose: Brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are commonly used to predict clinical outcomes in patients with heart failure (HF). The prognostic role of BNP/NT-proBNP in patients with atrial fibrillation (AF) and comorbid HF is controversial. The current study aimed to understand the clinical importance of BNP/NT-proBNP measurement in predicting the outcomes of AF patients regardless of HF status. Methods: This is a systematic review and meta-analysis. A comprehensive literature search was conducted using PubMed, EBSCOHost, Cochrane, ScienceDirect, and ClinicalKey. Studies that reported all-cause mortality, stroke/systemic embolic events (SEE)/thromboembolic events (TE), major adverse cardiovascular events (MACE), and major bleeding were included in this study. All-cause mortality was the primary outcome. Studies that reported BNP data but not NT-proBNP were also included. BNP/NT-proBNP is categorized as high and low level based on the highest and lowest groups compared in the included studies. Results: Sixteen studies (n = 45,400) were included in data synthesis: six were post hoc analysis of randomized controlled trials and the remaining were prospective cohort studies. The included studies were published between 2011 and 2022. The follow-up duration ranged from 1.0 to 5.2 years. High level of BNP/NT-proBNP was associated with a significantly increased risk of all-cause mortality (pooled hazard ratio [HR]: 2.26, 95% confidence interval [95% CI]: 1.98–2.56), stroke/SEE/TE (pooled HR: 2.45, 95% CI: 2.07–2.90), and MACE (pooled HR: 2.38, 95% CI: 1.90–2.99) in patients with AF; the pooled HR of major bleeding was 1.17 (95% CI: 1.01–1.36). Sensitivity analysis in patients with AF and HF produced similar results. Conclusions: BNP and NT-proBNP are strong predictors of clinical outcomes in patients with AF regardless of HF.

Clinical outcomes of obese and nonobese patients with atrial fibrillation according to associated metabolic abnormalities: A report from the COOL‐AF registry

AbstractBackgroundThe primary objective was to determine the influence of obesity and associated metabolic status on clinical outcomes of Asian patients with atrial fibrillation (AF).MethodsThis study was based on a prospective multicenter of patients with nonvalvular AF. Patients were classified as obese and nonobese and being metabolic unhealthy was defined as having at least one of the three cardiovascular risk factors including dyslipidemia, hypertension, or diabetes mellitus. Outcomes were a primary composite outcome of all‐cause death, ischemic stroke/systemic embolism (SSE), acute myocardial infarction (MI), and heart failure (HF), as well as the individual end points.ResultsThere were a total of 3141 enrolled patients (mean age 67.4 ± 11.1 years; 41.0% female), of whom 1566 (49.9%) were obese and 2564 (81.6%) were metabolic unhealthy. During a mean follow‐up of 32.2 ± 8.3 months, the incidence rate of the composite outcome, all‐cause death, SSE, MI, and HF were 7.21 (6.63–7.82), 3.86 (3.45–4.30), 1.48 (1.23–1.77), 0.47 (0.33–0.64), and 2.84 (2.48–3.23) per 100 person‐years, respectively. Metabolic unhealthy nonobese subjects were at higher risk of the composite outcomes than metabolic unhealthy obese subjects with hazard ratio (HR) 1.39, 95% confidence interval (CI) 1.17–1.66, p &lt; .001. Metabolic unhealthy obese subjects tend to have an increased risk of the composite outcomes compared to those metabolic healthy obese (HR 1.36, 95% CI 0.91–2.02, p = .133). Metabolic healthy obese subjects were not associated with increased risk.ConclusionsMetabolic unhealthy obese subjects were associated with an increased risk of adverse outcomes in AF patients, whereas metabolically healthy obesity was not associated with an increased risk.

The effect of COVID-19 on the thromboembolic outcomes in atrial fibrillation patients in the long run

Background While there has been a wealth of reports concerning the acute effects of the coronavirus disease 2019 (COVID-19), further information is needed to see how things unfold in the long run. This research aimed to ascertain whether the COVID-19 pandemic has increased the probability of thromboembolic events in atrial fibrillation (AF) patients. Methods In this retrospective study, we scanned 952 AF patients and classified 643 eligible ones per their history of catching COVID-19. Two hundred thirty-nine of 643 patients had a history of COVID-19 (Group 1), and 404 did not (Group 2). We then compared two years of thromboembolic events between the groups. Results Composite thromboembolic outcomes were seen in 76 (11.8%) patients. Of those, 32 (13.4%) were in Group 1, and 44 (10.8%) were in Group 2 (p = .03). 10 of 32 patients (31%) in Group 1 and 11 of 44 (25%) in Group 2 died because of thromboembolic events (p = .02). Histories of diabetes mellitus, chronic obstructive pulmonary disease, and COVID-19 independently predicted thromboembolic events in AF patients. Conclusions Having caught COVID-19 is likely to be associated with increased long-term thromboembolic outcomes in AF patients. Albeit the study design does not permit us to infer causality, our results question the necessity of more intensive anticoagulant therapy and closer follow-up in AF patients with past COVID-19.

Comparison of very high-power short-duration, high-power short-duration, and low-power long-duration radiofrequency ablation for atrial fibrillation: A systematic review and network meta-analysis.

The optimal power and duration settings for radiofrequency (RF) atrial fibrillation (AF) ablation to improve efficacy and safety is unclear. We compared low-power long-duration (LPLD), high-power short-duration (HPSD), and very HPSD (vHPSD) RF settings for AF ablation. This network meta-analysis (NMA) was structured according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Observational and randomized studies were included. Eligible studies compared outcomes in AF patients who underwent first-time RF ablation with the following settings: vHPSD (70-90W, 3-10 s), HPSD (45-60W, 5-10 s), or LPLD (20-40W, 20-60 s). Thirty-six studies comprising 10,375 patients were included (33% female). Frequentist NMA showed LPLD tended toward a lower odds of freedom from arrhythmia (FFA) versus HPSD (OR 0.93, 95% CI 0.86-1.00). There was no difference in FFA between vHPSD versus HPSD. Splitwise interval estimates showed a lower odds of FFA in LPLD versus vHPSD on direct (OR 0.78, 95% CI 0.65-0.93) and network estimates (OR 0.85, 95% CI 0.73-0.98). Frequentist NMA showed less total procedural (TP) time with HPSD versus LPLD (generic variance 1.06, 95% CI 0.83 to 1.29) and no difference between HPSD versus vHPSD. This NMA shows improved procedural times in HPSD and vHPSD versus LPLD. Although HPSD tended toward improved odds of FFA compared to LPLD, the overall result was not statistically significant. The odds of FFA in LPLD was lower versus vHPSD on direct and network estimates on splitwise interval analysis. Large prospective head-to-head randomized trials are needed to validate HPSD and vHPSD settings.

Association of C-reactive protein level with adverse outcomes in patients with atrial fibrillation: A meta-analysis

BackgroundStudies on the association between C-reactive protein (CRP) level and poor outcomes have been yielded controversial results in patients with atrial fibrillation (AF). This meta-analysis sought to investigate the utility of elevated CRP level in predicting adverse outcomes in AF patients. MethodsTwo authors systematically searched PubMed and Embase databases (until December 10, 2022) for studies evaluating the value of elevated CRP level in predicting all-cause mortality, cardiovascular death, stroke, or major adverse cardiovascular events (MACEs) in AF patients. The predictive value of CRP was expressed by pooling adjusted hazard ratio (HR) with 95% confidence intervals (CI) for the highest versus the lowest level or per unit of log-transformed increase. ResultsTen studies including 30,345 AF patients satisfied our inclusion criteria. For the highest versus the lowest CRP level, the pooled adjusted HR was 1.57 (95% CI 1.34-1.85) for all-cause mortality, 1.18 (95% CI 0.92-1.50) for cardiovascular death, and 1.57 (95% CI 1.10-2.24) for stroke, respectively. When analyzed the CRP level as continuous data, per unit of log-transformed increase was associated with a 27% higher risk of all-cause mortality (HR 1.27; 95% CI 1.23-1.32) and 16% higher risk of MACEs (HR 1.16; 95% CI 1.05-1.28). ConclusionsElevated CRP level may be an independent predictor of all-cause mortality, stroke, and MACEs in patients with AF. CRP level at baseline can provide important prognostic information in risk classification of AF patients.

Mortality prediction in patient with atrial fibrillation and 0 or 1 nongender-related CHA2DS2-Vasc risk factor using machine learning: a French nationwide study

Abstract Background Atrial fibrillation is associated with important mortality included in patients with low or intermediate thromboembolic risk. Usual clinical risk scores are challenged in this specific population and predict only modestly mortality. Machine learning approach helps to identify new risk factors and outperform existing tools for the prediction of outcomes in atrial fibrillation patients. Purpose This study aimed to developpe a machine learning model for the prediction death occurrence within the year following atrial fibrillation diagnosis and to assess performances in patients with 0 or 1 nongender-related CHA2DS2-Vasc risk factor compared to previously described clinical scores. Methods We used for this purpose a nationwide cohort of 2,435,541 newly diagnosed atrial fibrillation patients seen in all the French hospitals from 2011 to 2019. Among 110 variables, the 18 most predictive variables were identified and selected using a Random Forest algorithm as adding any other variable did not improve prediction (Figure 1). Three machine learning models (logistic regression, random forests, deep neural networks) were trained to predict mortality within the first year on a train set (70% of the cohort). The best model was selected to be evaluate on the validation set (30% of the cohort). We finally compared our best model with previously published scores in patients with 0 or 1 nongender-related CHA2DS2-Vasc risk factor using the C index. Results Among atrial fibrillation patients, 373,155 (15.32%) had 0 or 1 nongender-related risk factor. Within the first year following AF diagnosis, 23,857 patients (6.39%) died after a mean time of 86 (SD 26) days. After training, the best machine learning model selected was a deep neural network with a C index of 0.915 (95% CI, 0.905- 0.925) on the validation set. Compared to traditional clinical risk scores, the deep neural network model was significantly superior to the CHA2DS2-VASc and HAS-BLED scores, and dedicated scores such as Charlson Comorbidity Index and Hospital Frailty Risk Score to predict death within the year following AF diagnosis (C indexes: 0.521; 0.633; 0.849; 0.800 respectively. P&amp;lt;0.0001) (Figure 2, Panel A). The ability to predict AF was improved as shown by the net reclassification index and integrated discriminatory improvement increase (P&amp;lt;0.0001, respectively) and decision curve analysis (Figure 2, Panel B). Conclusion Patients with atrial fibrillation and 0 or 1 nongender-related CHA2DS2-Vasc risk factor remain at risk of mortality within the first year of the diagnosis. A ML approach may help clinicians to better risk stratify AF patients with low or intermediate thromboembolic risk at high risk of mortality.Figure 1.Feature importanceFigure 2.ROC and decision curves

Impact of cardiorenal syndrome on clinical outcomes of atrial fibrillation patients undergoing catheter ablation

Abstract Background Heart failure (HF) coexists with both atrial fibrillation (AF) and chronic kidney disease (CKD) and exacerbate each other. All of them are increasing in the aging society all over the world. Little is known regarding the impact of cardiorenal syndrome (CRS) on clinical outcomes of patients with AF undergoing catheter ablation (AFCA) in the real-world setting. Purpose In the present study, we investigated clinical outcomes of CRS patients with de novo AFCA. Method: Consecutive 494 patients (68.1±11.1 yrs, male 68.0%) undergoing de novo AF catheter ablation in our hospital from April 2019 to March 2021 were enrolled. CRS was defined as having both HF and CKD. HF was defined as having a history of HF admission and/or BNP≥100 pg/mL. CKD was defined as eGFR&amp;lt; 60 ml/min/1.73m2. The primary outcome was composite outcomes of; all-cause death, redo ablation, thromboembolisms, atherosclerotic cardiovascular disease (ASCVD) events, major bleeding, HF admission, and dialysis initiation. Result The incidence of primary outcome in CRS patients during median follow-up periods of 739.5 days was significantly higher than the non-CRS patients (54.9% in CRS vs. 30.3% in non-CRS; P&amp;lt;0.01, Figure 1). In CRS patients, all-cause death, ASCVD events, and HF admission were significantly worse (7.7% in CRS vs. 0.3% in non-CRS; P&amp;lt;0.01, 10.3% in CRS vs. 1.8% in non-CRS; P&amp;lt;0.01, 11.5% in CRS vs. 0.9% in non-CRS; P&amp;lt;0.01, respectively, Table), however redo ablation, thromboembolism, major bleeding and dialysis initiation were similar compared with non-CRS patients (10.3% in CRS vs. 14.5% in non-CRS; P=0.25, 1.3% in CRS vs. 0.6% in non-CRS; P=0.59, 5.1% in CRS vs. 2.1% in non-CRS; P=0.09, 1.3% in CRS vs. 0.3% in non-CRS; P=0.24, respectively, Table). The incidence of primary outcome in CRS patients was similar in those with ejection fraction (EF)≤40% and in those with EF&amp;gt;40% (47.6% in EF≤40% vs. 54.7% in EF&amp;gt;40%; P=0.48, Figure 2), however it was significantly higher in those with eGFR&amp;lt;45 compared with those with eGFR≥45 (74.8% in eGFR&amp;lt;45 vs. 26.2% in eGFR≥45+ P&amp;lt;0.01, Figure 3). Conclusion CRS patients with AFCA had significantly worse outcomes with more all-cause death, ASCVD events and HF admission compared with non-CRS patients. In the CRS patients undergoing AFCA, worse kidney function, rather than the cardiac systolic function, had a significant prognostic impact on the over-all clinical outcomes.

Impact of proton pump inhibitor on quality of anticoagulant control and outcomes in atrial fibrillation patients treated with an oral anticoagulant in the COOL-AF registry

Abstract Introduction Proton pump inhibitor (PPI) is commonly prescribed in patients treated with antithrombotic therapy, assuming it will reduce bleeding risk irrespective of the risk of bleeding. Although PPI may reduce the risk of gastrointestinal bleeding in those treated with an oral anticoagulant, PPI may increase INR by accelerating warfarin absorption, thereby increasing the risk of bleeding. We aimed to assess the impact of PPI use on outcomes and quality of anticoagulant control in AF patients treated with OAC. Methods The COOL-AF registry was a nationwide prospective observational study enrolling AF patients from 27 hospitals in Thailand between 2014 and 2017. The registry aimed to evaluate antithrombotic patterns, quality of OAC control, and clinical outcomes. Clinical information of patients was collected every six months and until three years. Patients treated with oral anticoagulants (either warfarin or non-vitamin K antagonist OAC (NOAC)) were included in the present analysis. Patients receiving any PPI type and dosage at the registry entry were counted as PPI users. Poor anticoagulant control was defined as time to therapeutic range (TTR) less than 65%. The association between PPI use and outcomes, including GI bleeding, overall bleeding, all-cause mortality, and ischemic stroke or systemic embolization, were assessed in the Cox model adjusted for age, prior GI bleeding, chronic alcohol use, chronic kidney disease, liver disease, smoking, and baseline anemia. Subgroup analyses were performed in patients at high bleeding risk (HAS-BLED score ≥ 3), and in patients concomitantly treated with antiplatelet. Results Of 3,402 patients in the registry, 2568 (75.5%) were treated with OAC at baseline. The prevalence of females was 43.4%, with a mean age of 68.4 years. The majority of patients (91.1%) received warfarin. The incidence of major bleeding was 2.11 (1.79–2.48) per 100 person-years. PPI was used at baseline in 707 patients (20.8%). Compared with their counterpart, PPI was more frequently used in high-bleeding risk patients (27.3% vs. 18.1%, p &amp;lt; 0.001) and in those with concomitant antiplatelet therapy (37.5% vs. 17.1%, p &amp;lt; 0.001). The mean TTR was similar between PPI and non-PPI users (52.5% vs. 53.8%, p 0.37). PPI use was not associated with poor anticoagulant control (adjusted OR 1.12, 95% 0.89-1.40). The risk of GI bleeding in PPI users was similar to non-user (adjusted HR 1.01, 95%CI 0.59-1.75). The risk of all-cause mortality, ischemic stroke or systemic embolization, and overall bleeding was not different between PPI and non-PPI users. There was no significant interaction between PPI use and bleeding risk or concomitant antiplatelet therapy on adverse outcomes. Conclusion PPI use has no impact on major outcomes, including bleeding in AF patients treated with OAC. The practice of concomitant prescribing of PPI in patients treated with OAC is needed to be re-examined, given the potentially high impact of health care costs.PPI use and outcomes

Year-to-year change of antithrombotic strategy and clinical outcomes of atrial fibrillation patients with vascular disease in this decade: The Fushimi AF Registry

Abstract Background Many atrial fibrillation (AF) patients have concomitant vascular diseases, and therefore, antithrombotic therapy is crucial for prevention of cardiovascular events in AF patients. In the last decade, antithrombotic therapy of AF patients has undergone major change due to launch of direct oral anticoagulants (DOAC). After the release of DOAC, several national guidelines for the management of AF were updated. The Japanese Circulation Society published the new guideline for the management of AF incorporating the recommendation of DOAC in 2014, which made a great impact on clinical practice in Japan. Purpose In this study, we investigated the year-to-year change of antithrombotic therapy of AF patients with vascular disease from 2011 to 2021 and compared the clinical characteristics and outcomes of those patients enrolled before and after the guideline (2011-2013 vs. 2014-2021) by using data of the Fushimi AF Registry. Methods The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients who visited the participating medical institutions in Fushimi-ku, Kyoto, Japan. We started to enroll patients from March 2011 and follow up data including prescription status were available in 4,464 patients from March 2011 to August 2021. We defined vascular disease as coronary artery disease, peripheral artery disease, ischemic stroke or transient ischemic attack. Results In 2011, 61% of AF patients with vascular disease received OAC and 53% received antiplatelet drug (APD). Proportion of the patients receiving OAC increased year by year and that receiving APD decreased year by year. In 2021, 76% of the patients received OAC and 31% received APD. Proportion of the patients with combination of OAC and APD was 27% in 2011 and decreased year by year. In 2021, 18% received the combination therapy. In 2011, when the first DOAC was launched, 2% of the patients received DOAC and 59% received warfarin. After that, proportion of the patients receiving DOAC increased progressively. In 2021, 55% of patients received DOAC and 21% of patients received warfarin. Of 4,464 patients, 1,386 patients (31.0% of the entire cohort) had history of vascular disease at enrollment. Of 1,386 patients, 1,120 patients were enrolled before 2013 and 266 patients were enrolled after 2014. The incidence of composite of cardiac death, stroke or myocardial infarction was similar between the two groups (patients enrolled before 2013 vs. patients enrolled after 2014: 5.0 vs. 4.1 per 100 person-years; log-rank p=0.27). The incidence of major bleeding tended to be lower in patients enrolled after 2014 than those enrolled before 2013 although it was not statistically significant (2.8 vs. 2.0 per 100 person-years; log-rank p=0.15). Conclusion Antithrombotic strategy of AF patient with vascular disease has undergone major change in this decade, but the incidences of cardiovascular events of those patients have not significantly changed.

Patterns of comorbidities and influence on the natural history of patients with atrial fibrillation: a latent class analysis from a prospective observational european AF registry

Abstract Background Patients with Atrial Fibrillation (AF) usually present with multiple comorbidities at diagnosis, and their combinations heterogeneously influence management and outcomes. While the effect of multimorbidity on the natural history of AF is well-known, the influence of patterns of multimorbidity is far less understood. Purpose To identify and analyse subgroups of AF patients according to their comorbidities, through a latent class analysis of a contemporary cohort of AF patients. Methods We used data from a European-wide prospective observational AF registry, and performed a latent class analysis, according to the presence of chronic diseases (including cardiovascular, respiratory, metabolic and other conditions); class membership was assigned according to the modal posterior probability. Multivariable logistic regression models were used to analyse odds of receiving oral anticoagulant (OAC) prescription and type of OAC received; the risk of the primary outcome of all-cause death and MACE was assessed using multivariable Cox-regression model. Results 9,613 AF patients were included in this analysis (mean age 68.9 ± 11.4 years, 40.2% females), and were grouped in 5 classes, which were different according to the burden of comorbidities: low morbidity pattern (46.1%), cardiovascular pattern (25.0%), metabolic pattern (11.3%), heart failure pattern (9.7%) and multisystemic pattern (8.0%) (Figure 1). Patients in the multisystemic pattern were older and more frequently frail and with polypharmacy compared to other classes. Compared to the low morbidity pattern, odds of receiving OAC was lower in those with cardiovascular pattern (OR [95%CI]: 0.73 [0.62-0.86]), heart failure pattern (OR [95%CI]: 0.60 [0.48-0.75] and multisystemic pattern (OR [95%CI]: 0.28 [0.22-0.36]), while those with metabolic pattern were more likely prescribed OAC (OR [95%CI]: 1.55 [1.20-2.00]). All patterns were less likely treated with NOAC compared to VKA (Figure 2). When analysing the risk of the primary composite outcome, all patterns except for the metabolic pattern were associated with higher hazard of events, with highest magnitude observed for the heart failure pattern (HR 2.68 [95%CI: 2.22-3.25]) and the multisystemic pattern (HR 2.67 [2.13-3.35]) (Figure 2). Conclusions Comorbidities are heterogeneously distributed in the AF population, and different phenotypes of AF patients may be identified according to the combination of other chronic diseases, with different OAC use for stroke prevention and an unequal impact on long-term prognosis. These findings reinforce the need for tailored preventive strategies to improve outcomes in AF patients, especially those with multimorbidity.Figure 1Figure 2

Abstract 12802: Impact of Atrial Fibrillation on Percutaneous Coronary Intervention With Orbital Atherectomy

Introduction: Patients with atrial fibrillation risk various complications following cardiovascular procedures. As there is a lack of data on the disparities in outcomes in atrial fibrillation patients undergoing orbital atherectomy (followed by the percutaneous intervention (PCI)), we aim to bridge this knowledge gap via our study. Methods: We queried cases of PCI between 2016-2020 via the National Inpatient Sample. Patients with a code for orbital atherectomy (followed by PCI) were retained as per past studies. We compared patient characteristics between patients with and without atrial fibrillation, and the adjusted odds ratios (aOR) of various complications were studied via logistic regression analysis. Results: Our analysis found 20710 patients (ages 18 and more) who underwent orbital atherectomy between 2016-2020 in the United States, which included 5250(25.4%) of cases with atrial fibrillation. Compared to cases without atrial fibrillation, patients with atrial fibrillation undergoing orbital atherectomy showed higher odds of various complications such as acute ischemic stroke (AIS) (aOR 1.507, p&lt;0.01), sepsis (aOR 1.389, p&lt;0.01), pericardial effusion (aOR 1.931, p&lt;0.01), major bleeding (aOR 1.423, p&lt;0.01), cardiogenic shock (aOR 1.258, p&lt;0.01), acute kidney injury (AKI) (aOR 1.438, p&lt;0.01), and mortality (aOR 1.298, p&lt;0.01). While fewer cases of coronary artery dissections were noted among patients with atrial fibrillation (2.0% vs. 2.3%), the results were not statistically significant (aOR 0.862, p=0.256). Conclusions: Atrial fibrillation predisposed patients undergoing orbital atherectomy to poorer outcomes, including AKI, AIS, sepsis, pericardial effusion, major bleeding, cardiogenic shock, and death. Physicians must therefore address this issue via proper screening for cardiac arrhythmias pre- and post-procedure and maintain a close follow-up in at-risk individuals.

Abstract 12639: Comparison of Very High-Power Short-Duration, High-Power Short-Duration, and Low-Power Long-Duration Radiofrequency Ablation for Atrial Fibrillation: A Systematic Review and Network Meta-Analysis

Introduction: The optimal power and duration settings for radiofrequency (RF) atrial fibrillation (AF) ablation is unclear. We compared low-power long-duration (LPLD), high-power short-duration (HPSD), and very HPSD (vHPSD) settings for AF ablation. Hypothesis: Ablation utilizing HPSD and vHPSD are expected to have shorter procedural times than LPLD and may have improved arrhythmic outcomes. Aims: To compare LPLD, HPSD, and vHPSD ablation by network meta-analysis Methods: This network meta-analysis (NMA) was structured according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Observational and randomized studies were included. Eligible studies compared outcomes in AF patients who underwent first-time RF ablation with the following settings: vHPSD (70-90 Watts for 3-10 seconds), HPSD (45-60 W, 5-10 s), or LPLD (20-40 W, 20-60 s). Results: Thirty-six studies comprising 10375 patients were included (33% female). Frequentist NMA showed LPLD tended towards a lower odds of freedom from arrhythmia (FFA) vs. HPSD (OR 0.93, 95% CI 0.86-1.00). There was no difference in FFA between vHPSD vs. HPSD. Splitwise interval estimates showed a lower odds of FFA in LPLD vs. vHPSD on direct (OR 0.78, 95% CI 0.65-0.93) and network estimates (OR 0.85, 95% CI 0.73-0.98). Frequentist NMA showed less total procedural (TP) time with HPSD vs. LPLD (generic variance 1.06, 95% CI 0.83-1.29) and no difference between HPSD vs. vHPSD. Conclusion: This NMA shows improved procedural times in HPSD and vHPSD vs. LPLD. Although HPSD tended towards improved odds of FFA compared to LPLD, the result was not statistically significant. The odds of FFA in LPLD was lower vs. vHPSD on direct and network estimates on splitwise interval analysis. Randomized clinical trials are needed to validate HPSD and vHPSD settings.

Impact of Unhealthy Lifestyles on Patients with Atrial Fibrillation at Low Risk of Stroke: A Nationwide Cohort Study

BackgroundThe impact of unhealthy lifestyles on clinical outcomes among patients with atrial fibrillation (AF) who are at low risk of stroke remains uncertain. The study objective was to evaluate the association between unhealthy lifestyles and clinical outcomes among low-risk AF patients with 0-1 non-sex risk factor of the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack [TIA], Vascular disease, Age 65-74 years, female Sex;) score. MethodsA total of 52,451 low-risk AF patients (mean age 51.6 ± 10.4 years) were evaluated with the National Health Insurance Service of the Republic of Korea database between 2009 and 2016. Using the survey on health habits, an unhealthy lifestyle score (ULS) was calculated by adding one point each if a respondent had a sedentary lifestyle, drinking, or smoking. The primary outcome was the composite of myocardial infarction, ischemic stroke, heart failure, and all-cause death. Multivariable Cox regression analysis was used to estimate the risk of the study outcome according to the ULS. ResultsThere was a total of 12,792 (24.4%), 24,785 (47.3%), 11,602 (22.1%), and 3272 (6.2%) low-risk AF patients with 0 to 3 points of the ULS, respectively. The median follow-up period was 4.1 (2.1-6.1) years. Compared with the healthiest-lifestyle group (ULS 0), the other groups were associated with significantly higher risks of the primary outcome, with a gradually increasing trend according to the ULS (adjusted hazard ratio [95% confidence interval] =1.17 [1.05-1.31], 1.37 [1.21-1.56], 1.82 [1.53-2.17], for the groups with ULS 1, 2, and 3, respectively). ConclusionUnhealthy lifestyles, including a sedentary lifestyle, drinking, and smoking, may synergistically impact poor clinical outcomes in AF patients who are deemed to be at low risk of stroke.