Permanent Atrial Fibrillation Research Articles

Ten-year prognosis of acute atrial fibrillation in ST-elevation myocardial infarction: recurrence and stroke risk

Abstract Funding Acknowledgements None. Background Atrial fibrillation (AF) often complicates ST elevation acute myocardial infarction (STEMI), with associated risks including stroke and mortality. Anticoagulation therapy for these patients and AF prognosis remains controversial. The aim was to evaluate long-term prognosis of STEMI patients complicated with AF in the acute phase. Methods We performed a prospective register involving 4,184 patients admitted for STEMI to the intensive cardiac care unit of two tertiary centres from 2007 to 2015. Patients with pre-existing permanent AF were excluded. Out of these, 269 (6.4%) patients developed AF within the first 48 hours after STEMI and were matched with a control group based on age and left ventricular ejection fraction (LVEF). Results After matching, a total of 470 patients were included (n=235, AF-STEMI; n=235, control group). Mean age 69.0 years, and 31.7% women. No differences were found in gender, cardiovascular risk factors or ischemic heart disease. AF-STEMI patients experienced more sustained ventricular tachycardia (12.8% vs. 4.7%; p=0.003), advanced atrioventricular block (13.2% vs. 6.0%; p=0.012), heart failure (28.5% vs. 18.7%; p=0.017), and cardiogenic shock (17.4% vs. 8.5%; p=0.006). In-hospital mortality was also higher in AF-STEMI patients (11.9% vs 7.2%, p=0.008). After 10-years follow-up, the AF-STEMI group had remained with higher mortality (50.5% vs. 36.2%; p=0.003) and a greater recurrence of AF (44.2% vs. 14.7%; p<0.001), without differences in stroke incidence (10.1% vs. 9.3%). Conclusion Patients with AF complicating STEMI have higher rates of heart failure, cardiogenic shock, and in-hospital mortality. After a 10-years follow up, they exhibit a high risk of AF recurrence, with no significant differences in stroke incidence.Kaplan Meier curves

Diltiazem reduces levels of NT-proBNP and improves symptoms compared with metoprolol in patients with permanent atrial fibrillation.

Short-term treatment with calcium channel blockers lowers levels of N-terminal pro B-type natriuretic peptide (NT-proBNP) and reduces rhythm-related symptoms compared to treatment with beta-blockers. The aim of this study was to compare the longer-term effects of metoprolol and diltiazem for rate control in patients with permanent atrial fibrillation after six months. Men and women with permanent atrial fibrillation and preserved left ventricular systolic function were randomised to receive either diltiazem 360 mg or metoprolol 100 mg once daily. The primary endpoint was the level of NT-proBNP after a six-month treatment period. Secondary endpoints included heart rate, rhythm-related symptoms and exercise capacity. A total of 93 patients (mean age 71 ±7 years, 28 women) were randomised. After six months' treatment, mean levels of NT-proBNP decreased in the diltiazem group and increased in the metoprolol group, with a significant between-group difference (409.8 pg/mL, 95% CI: 230.6 - 589.1, P<0.001). Treatment with diltiazem significantly reduced rhythm-related symptoms compared to baseline, but no change was observed in the metoprolol group. Diltiazem and metoprolol had similar effects on heart rate and exercise capacity. Diltiazem reduced NT-proBNP levels and improved rhythm-related symptoms. Metoprolol increased peptide levels but had no impact on symptoms despite similar heart rate reduction. Non-dihydropyridine calcium channel blockers should be considered more often for rate control in permanent atrial fibrillation.

Cost prediction for ischemic heart disease hospitalization: Interpretable feature extraction using network analysis

Objectives: Ischemic heart disease (IHD) is a significant contributor to global mortality and disability, imposing a substantial social and economic burden on individuals and healthcare systems. To enhance the efficient allocation of medical resources and ultimately benefit a larger population, accurate prediction of healthcare costs is crucial. Methods:We developed an interpretable IHD hospitalization cost prediction model that integrates network analysis with machine learning. Specifically, our network-enhanced model extracts explainable features by leveraging a diagnosis-procedure concurrence network and advanced graph kernel techniques, facilitating the capture of intricate relationships between medical codes. Results:The proposed model achieved an R2 of 0.804 ± 0.008 and a root mean square error (RMSE) of 17,076 ± 420 CNY on the temporal validation dataset, demonstrating comparable performance to the model employing less interpretable code embedding features (R2: 0.800 ± 0.008; RMSE: 17,279 ± 437 CNY) and the hybrid graph isomorphism network (R2: 0.802 ± 0.007; RMSE: 17,249 ± 387 CNY). The interpretation of the network-enhanced model assisted in pinpointing specific diagnoses and procedures associated with higher hospitalization costs, including acute kidney injury, permanent atrial fibrillation, intra-aortic balloon bump, and temporary pacemaker placement, among others. Conclusion:Our analysis results demonstrate that the proposed model strikes a balance between predictive accuracy and interpretability. It aids in identifying specific diagnoses and procedures associated with higher hospitalization costs, underscoring its potential to support intelligent management of IHD.

Guillain-Barre syndrome following COVID-19 vaccination: a study of 70 case reports.

Guillain-Barre syndrome (GBS) has been found to have some interesting association with vaccinations. This paper mainly focuses on exploring different associations between COVID-19 vaccination and GBS. Electronic databases such as PubMed, Google Scholar, Cochrane, and Embase were searched using MESH terms for case reports published till 1 August 2023 from which 70 case reports were documented involving 103 individuals from 23 different countries. The case reports were from a wide range of individuals aged from 13 to 87 years with an average age of 53±20 interquartile range years along with male predominance. The average time between receiving the vaccine and the onset of symptoms was 13.08±2.14 days. Prominent clinical features included back pain, facial diplegia, weakness, and paraesthesia whereas the main diagnostic studies were cerebrospinal fluid (CSF) analysis and electromagnetic studies. The principal diagnostic clue was albumin-cytological dissociation in CSF while being negative for anti-ganglioside antibodies or SARS-CoV-2. Available treatment options consisted of intravenous immunoglobulin and Plasmapheresis. Patients with comorbidities such as diabetes mellitus, hypertension, dyslipidemia, permanent atrial fibrillation, hypothyroidism, Hashimoto's thyroiditis, Chronic Obstructive Pulmonary Disease, asthma, osteoporosis, migraine, rheumatoid arthritis, osteoarthritis, ulcerative colitis, coeliac disease, seizures, bipolar disorder, endometriosis, multiple sclerosis, bell's palsy, squamous cell carcinoma, prostate cancer were included in our study. Overall, this review evaluated innovative and clinically relevant associations between COVID-19 vaccination and GBS. Understanding of this uncommon potential side effect of COVID-19 vaccination is crucial for prompt diagnosis and appropriate treatment. Importantly, GBS should not be considered a contraindication to vaccination. This underscores the importance of ongoing research to enhance the safety and efficacy of COVID-19 vaccination efforts.

La identificación subjetiva y ablación de impulsores auriculares mejora el control del ritmo en la fibrilación auricular persistente. Estudio CHAOS-AF

Introduction and objectivesThe optimal approach for persistent atrial fibrillation (AF) ablation remains unknown. In patients with persistent AF, we compared an ablation strategy based on pulmonary vein isolation (PVI) plus ablation of drivers (PVI+D), with a conventional PVI-only approach performed in a 1:1 propensity score-matched cohort. MethodsDrivers were subjectively identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid), without dedicated software, as fractionated continuous or quasicontinuous electrograms on 1 to 2 adjacent bipoles, which were ablated first; and as sites with spatiotemporal dispersion (the entire cycle length comprised within the mapping catheter) plus noncontinuous fractionation, which were only targeted in patients without fractionated continuous electrograms, or without AF conversion after ablation of fractionated continuous electrograms. Ablation included PVI plus focal or linear ablation targeting drivers. ResultsA total of 50 patients were included in each group (61±10 years, 25% women). Fractionated continuous electrograms were found and ablated in 21 patients from the PVI+D group (42%), leading to AF conversion in 7 patients. In the remaining 43 patients, 143 sites with spatiotemporal dispersion plus noncontinuous fractionation were targeted. Globally, AF conversion was achieved in 21 patients (42%). The PVI+D group showed lower atrial arrhythmia recurrences at 1 year of follow-up (30.6% vs 48%; P=.048) and at the last follow-up (46% vs 72%; P=.013), and less progression to permanent AF (10% vs 40%; P=.001). ConclusionsSubjective identification and ablation of drivers, added to PVI, increased 1-year freedom from atrial arrhythmia and decreased long-term recurrences and progression to permanent AF.

Left Atrium Volume Measured with Multislice Computed Tomography as a Prognostic Predictor for Atrial Fibrillation Catheter Ablation Outcomes.

Background: Current guidelines consider atrial fibrillation (AF) type as the prognostic factor for a recommendation of catheter ablation. We aimed to determine whether LA and LA appendage (LAA) volumes measured using multislice computed tomography (MSCT) were related to long-term outcomes in AF following radiofrequency catheter ablation (RFCA). Methods: We evaluated 152 consecutive patients with drug-refractory AF (median age, 55.8 ± 9.6 years), including 110 male patients, who underwent RFCA in a single center. All patients underwent MSCT imaging for anatomical assessment. The endpoint of this study was documented AF recurrence after RFCA. Results: The overall procedure success rate was 77.6% (n = 118) during a mean follow-up period of 12.6 months. The LA volume was significantly larger for those who experienced AF recurrence after RFCA than for the patients without recurrent AF after the procedure (153.8 ± 29.9 mL vs. 139.2 ± 34.1 mL, p = 0.025). However, LAA volumes were nearly equivalent between the patients with and without AF recurrence after RFCA (16.2 ± 6.3 mL and 14.7 ± 6.5 mL, respectively; p = 0.235). LA volume ≥ 153.2 mL was the optimal cutoff value for estimating AF recurrence after RFCA, with 94% sensitivity and 66% specificity. LA volume remained an independent predictor of both AF recurrence and permanent AF. Conclusions: LA volume as assessed by MSCT might be helpful for identifying patients likely to achieve successful AF ablation. LA volume ≥ 153.2 mL, but not LAA volume, showed good accuracy in predicting AF recurrence after RFCA.

Impact of preoperative persistent or permanent atrial fibrillation on inhospital mortality after coronary artery bypass graft surgery

Introduction: Atrial fibrillation (AF) is an arrhythmia that has a well-established impact on cardiovascular and cerebrovascular morbidity and mortality. However, the role of this arrhythmia plays on surgical risk remains uncertain. Objective: to evaluate the impact of preoperative persistent or permanent AF on in-hospital mortality after isolated coronary artery bypass graft surgery (CABG). Methods: prospective cohort with 2,377 patients submitted to isolated CABG between January 2014 and December 2021. Sixty-two variables, including baseline factors, operative characteristics, and outcomes, were analyzed. Patients were divided into two study groups: No preoperative AF (n=2,287) and preoperative persistent or permanent AF (N=90). The comparison between the groups was performed initially by descriptive and univariate analysis. Subsequently, the analysis of mortality predictors was performed using binary logistic regression - multivariate adjusted analysis. Results: patients with preoperative AF were older, had a higher prevalence of pulmonary hypertension and anemia, had lower ejection fraction and had higher surgical risk scores when compared with patients with no history of atrial fibrillation. The in-hospital death was more frequent in patients with a history of AF (3.2% vs 8.9%, P=0.010). Through the multivariate analysis, it was possible to verify that preoperative AF is independently associated with the occurrence of in-hospital mortality after CABG (OR 2.68; 95% CI 1.21-5.94, P=0.015). Conclusion: Preoperative persistent or permanent AF has been shown to have a significant impact on in-hospital mortality rates after CABG even after adjusted multivariate analysis, being an independent risk predictor for the occurrence of postoperative death.

NSAID-induced gastropathy in a comorbid patient in a multidisciplinary hospital

The purpose of this case report is to demonstrate the importance of outpatient management of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients, especially those at risk (elderly patients, alcohol abusers, patients with a history of peptic ulcer disease, patients taking glucocorticoids or anticoagulants) to avoid life-threatening complications. The following clinical case shows the association between gastric and duodenal mucosal barrier disruption and the use of nonsteroidal anti-inflammatory drugs. Methods: a complete blood count, blood biochemistry test, ultrasound, and abdominal radiography. Results. The clinical case describes a patient with coronary heart disease, ischemic cardiomyopathy, hypertension, permanent atrial fibrillation, impaired glucose tolerance, obesity, and a long history of smoking who had been taking 1–2 tablets of Nimesulide per day for a long time without doctor’s prescription; the intake of NSAIDs was not controlled on an outpatient basis. The reason for hospitalization was sharp pain in the epigastrium; the plain abdominal radiography in the emergency room revealed free gas below both domes of the diaphragm, and ultrasound examination of the abdominal cavity showed a level of inhomogeneous free fluid detected in all sloping areas and pneumatosis intestinalis. In this regard, the patient was urgently hospitalized to the department of surgery, where surgical intervention was performed, including upper-middle laparotomy, abdominoscopy, suture repair of the perforated gastric ulcer, and sanitation and drainage of the abdominal cavity. Conclusion. This clinical case draws attention to the problem of NSAID gastropathy in clinical practice. The task of a clinician is to prevent the development of NSAID-induced gastropathy, identify patients with risk factors for NSAID gastropathy at the earliest possible time, and carry out preventive and therapeutic measures. Patient management at the outpatient stage according to the clinical recommendations could have prevented the development of gastrointestinal bleeding associated with NSAID gastropathy.

Transcatheter Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: A Multicenter Propensity Score-Based Analysis

BackgroundThe prognostic impact of catheter ablation (CA) of atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients has not yet been satisfactorily elucidated. ObjectivesThe aim of the study was to assess the impact of CA of AF on clinical outcomes in a large cohort of HCM patients. MethodsIn this retrospective multicenter study, 555 HCM patients with AF were enrolled, 140 undergoing CA and 415 receiving medical therapy. 1:1 propensity score matching led to the inclusion of 226 patients (113 medical group, 113 intervention group) in the final analysis. The primary outcome was a composite of all-cause mortality, heart transplant and acute heart failure exacerbations. Secondary outcomes included AF recurrence and transition to permanent AF. Additionally, an inverse probability weighted (IPW) model was examined. ResultsAt propensity score matching analysis, after a median follow-up of 58.1 months, the primary endpoint occurred in 29 (25.7%) patients in intervention group vs 42 (37.2%) in medical group (P = 0.9). Thromboembolic strokes and major arrhythmic events in intervention vs medical group were 9.7% vs 7.1% (P = 0.144) and 4.4 vs 8.0% (P = 0.779), respectively. Fewer patients in intervention vs medical group experienced AF recurrences (63.7% vs 84.1%, P = 0.001) and transition to permanent AF pattern (20.4% vs 33.6%, P = 0.026). IPW analysis showed consistent results. Severe complications related to CA were uncommon (0.7%). ConclusionsAfter 5 years of follow-up, CA did not improve major adverse cardiac outcomes in a large cohort of patients with HCM and AF. Nevertheless, CA seems to facilitate the maintenance of sinus rhythm and slow the progression to permanent AF, without significant safety concerns.

Modern physiological approach to inappropriate ICD shocks due to atrial fibrillation with very fast ventricular response. A case report

BackgroundFast-conducting atrial fibrillation misinterpreted as ventricular tachycardia is the leading cause for inappropriate shocks in patients with implantable cardiac defibrillators (ICD). These inappropriate shocks are associated with significant morbidity and mortality and cause great discomfort and stress.Case presentationWe report the case of a patient with ischemic cardiomyopathy, permanent atrial fibrillation, and a single-chamber DF-1 ICD implanted for the primary prevention of sudden cardiac death, who presented for multiple inappropriate internal shocks due to very fast-conducting atrial fibrillation, which was mislabeled as ventricular fibrillation by the ICD. Since the patient was under maximal atrioventricular nodal blocking medical therapy (beta-blockers and digitalis) and we didn`t find any reversible causes for the heart rate acceleration, we opted for rate control with atrioventricular node ablation. To counteract the risk of pacing-induced cardiomyopathy in this patient who would become totally pacemaker-dependent, we successfully performed left bundle branch area pacing. Because the patient`s ICD had a DF-1 connection and the battery had a long life remaining, we connected the physiological pacing lead to the IS-1 sense-pace port of the ICD. The 6-month follow-up showed an improvement in left ventricular function with no more inappropriate shocks.ConclusionsLeft bundle branch area pacing and atrioventricular node ablation in patients with an implantable single-chamber DF-1 defibrillator and fast-conducting permanent atrial fibrillation is a cost-efficient and very effective method to prevent and treat inappropriate shocks, avoiding the use of an additional dual-chamber or CRT-D device.

Impact of Atrial Fibrillation Burden on Health Care Costs and Utilization

BackgroundIntegrating patient-specific cardiac implantable electronic device (CIED)-detected atrial fibrillation (AF) burden with measures of health care cost and utilization allows for an accurate assessment of the AF-related impact on health care use. ObjectivesThe goal of this study was to assess the incremental cost of device-recognized AF vs no AF; compare relative costs of paroxysmal atrial fibrillation (pAF), persistent atrial fibrillation (PeAF), and permanent atrial fibrillation (PermAF) AF; and evaluate rates and sources of health care utilization between cohorts. MethodsUsing the de-identified Optum Clinformatics U.S. claims database (2015-2020) linked with the Medtronic CareLink database, CIED patients were identified who transmitted data ≥6 months postimplantation. Annualized per-patient costs in follow-up were analyzed from insurance claims and adjusted to 2020 U.S. dollars. Costs and rates of health care utilization were compared between patients with no AF and those with device-recognized pAF, PeAF, and PermAF. Analyses were adjusted for geographical region, insurance type, CHA2DS2-VASc score, and implantation year. ResultsOf 21,391 patients (mean age 72.9 ± 10.9 years; 56.3% male) analyzed, 7,798 (36.5%) had device-recognized AF. The incremental annualized increased cost in those with AF was $12,789 ± $161,749 per patient, driven by increased rates of health care encounters, adverse clinical events associated with AF, and AF-specific interventions. Among those with AF, PeAF was associated with the highest cost, driven by increased rates of inpatient and outpatient hospitalization encounters, heart failure hospitalizations, and AF-specific interventions. ConclusionsPresence of device-recognized AF was associated with increased health care cost. Among those with AF, patients with PeAF had the highest health care costs. Mechanisms for cost differentials include both disease-specific consequences and physician-directed interventions.

Optimizing Atrial Fibrillation Care: Comparative Assessment of Anticoagulant Therapies and Risk Factors.

Atrial fibrillation (AF) is a common arrhythmia associated with various risk factors and significant morbidity and mortality. This article presents findings from a study involving 345 patients with permanent AF. This study examined demographics, risk factors, associated pathologies, complications, and anticoagulant therapy over the course of a year. The results showed a slight predominance of AF in males (55%), with the highest incidence in individuals aged 75 and older (49%). Common risk factors included arterial hypertension (54%), dyslipidemia, diabetes mellitus type 2 (19.13%), and obesity (15.65%). Comorbidities such as congestive heart failure (35.6%), mitral valve regurgitation (60%), and dilated cardiomyopathy (32%) were prevalent among the patients. Major complications included congestive heart failure (32%), stroke (17%), and myocardial infarction (5%). Thromboembolic and bleeding risk assessment using CHA2DS2-VASc and HAS-BLED scores demonstrated a high thromboembolic risk in all patients. The majority of patients were receiving novel oral anticoagulants (NOACs) before admission (73%), while NOACs were also the most prescribed antithrombotic therapy at discharge (61%). This study highlights the importance of risk factor management and appropriate anticoagulant therapy in patients with AF, to reduce complications and improve outcomes. The results support the importance of tailored therapeutic schemes, for optimal care of patients with AF.

Abstract TP21: Consequences of Atrial Fibrillation Burden on Deep Cerebral Hemodynamic Related Structural Brain Damage

Background: Recent data using ultrahigh-resolution brain MRI suggests that atrial fibrillation (AF) has adverse effects on wall shear stress and blood flow in lenticulostriate arteries (LSA). The structural consequences of such pathophysiological alterations and whether they contribute to cognitive impairment in AF are not known. We hypothesized that the AF burden is associated with the severity of MRI markers of ischemic and hemorrhagic injury related to LSA disease. Methods: We analyzed data from 560 patients with AF and no clinical history of stroke or neurodegenerative disease, who received brain MRIs at a tertiary referral center. Neuroimaging data were collected by a stroke neurologist who was blinded to the clinical data. The presence of paroxysmal/persistent vs permanent AF was the main measure of AF burden. The imaging outcome variables were counts of deep lacunes, deep cerebral microbleeds (dCMB), and presence of a peri-basal ganglia white matter hyperintensity pattern (peri-BG WMH). Results: The mean age of the 560 AF patients was 73 + 11 and 212 (38%) patients were female. Mean CHA 2 DS 2 -VASc was 3.4 + 1.5 and 86 (15.4%) had permanent atrial fibrillation. Deep lacunes were found in 26.6%, dCMBs in 6.3% and a peri-BG WMH pattern in 2.7% of patients. In univariate analyses, the presence of permanent AF was associated with higher mean deep lacune counts (0.84 vs 0.51, p=0.026), higher mean dCMB counts (0.25 vs 0.1, p=0.018), and peri-BG WMH pattern (7.1% vs 1.9%, p=0.016) when compared to paroxysmal/persistent AF. In separate multivariable analyses, permanent AF type remained an independent predictor of dCMBs (p=0.019) and peri-BG WMH pattern (p=0.028) after controlling for age, sex, and vascular risk factors. Permanent AF also showed a tendency for independent association with deep lacunes (p=0.06) in a similar model. Discussion: Our results show that AF burden independently correlates with parenchymal MRI markers of LSA disease in patients without history of stroke. Such deep brain damage might contribute to AF-induced cognitive changes. The effects of better rhythm control on visible brain damage and cognitive changes should be studied in randomized trials.

Characteristics and Outcomes of Atrial Fibrillation in Chronic Heart Failure Patients: A Comprehensive Analysis of the Colombian Heart Failure Registry.

Heart failure (HF) and atrial fibrillation (AF) represent conditions that commonly coexist. The impact of AF in HF has yet to be well studied in Latin America. This study aimed to characterize the sociodemographic and clinical features, along with patients' outcomes with AF and HF from the Colombian Heart Failure Registry (RECOLFACA). Patients with ambulatory HF and AF were included in RECOLFACA, mainly with persistent or permanent AF. A 6-month follow-up was performed. Primary outcome was all-cause mortality. To assess the impact of AF on mortality, we used a logistic regression model. A P value of < 0.05 was considered significant. All statistical tests were two-tailed. Of 2,528 patients with HF in the registry, 2,514 records included information regarding AF diagnosis. Five hundred sixty (22.3%) were in AF (mean age 73 ± 11, 56% men), while 1,954 had no AF (mean age 66 ± 14 years, 58% men). Patients with AF were significantly older and had a different profile of comorbidities and implanted devices compared to non-AF patients. Moreover, AF diagnosis was associated with lower quality of life score (EuroQol-5D), mainly in mobility, personal care, and daily activity. AF was prevalent in patients with preserved ejection fraction (EF), while no significant differences in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were observed. Although higher mortality was observed in the AF group compared to individuals without AF (8.9% vs. 6.1%, respectively; P = 0.016), this association lost statistical significance after adjusting by age in a multivariate regression model (odds ratio (OR): 1.35; 95% confidence interval (CI): 0.95 - 1.92). AF is more prevalent in HF patients with higher EF, lower quality of life and different clinical profiles. Similar HF severity and non-independent association with mortality were observed in our cohort. These results emphasize the need for an improved understanding of the AF and HF coexistence phenomenon.

Abstract 97: Acute Ischemic Stroke Despite Anticoagulant Use: The Neuro-AFib Study

Background: Acute ischemic stroke (AIS) admissions in patients with atrial fibrillation (AF) using anticoagulants (AIS-despite-AC) are commonly seen in stroke units but data on their frequency, causes, and outcomes are scarce. Methods: The Neuro-AFib study is a multicenter effort geared toward elucidating the causes and consequences of strokes in a contemporary AF cohort. Detailed clinical, laboratory and multimodal imaging data from known AF patients consecutively admitted to 20 stroke centers with an IS between 1/2018-12/2019 were used to define characteristics of AIS-despite-AC and compared to AIS-off-AC. Results: Out of 4456 patients with known AF prior to the AIS, 2051 (46%) were using anticoagulants. Patients who had AIS-despite-AC were younger (76.8 + 11 vs 77.8 + 12, p=0.007), had higher mean CHA 2 DS 2 -VASc scores (4.57 + 1.7 vs 4.21 + 1.7, p&lt;0.001), and they were more likely to have permanent AF (23.5% vs 19.6%, p=0.002) and a past-history of stroke/TIA (36% vs 25%, p&lt;0.001) when compared to non-AC group. Chronic embolic (non-lacunar) infarcts on imaging were more common among AIS-despite-AC (34.5% vs 26.7%, p&lt;0.001). Acute large vessel occlusion (LVO) was common among AIS-despite-AC (48%). The pattern of the acute infarcts (numbers, embolic features) was not different. The calculated acute infarct volume was large (34ml) and mean NIHSS was 10.4 for AIS-despite-AC. Intravenous thrombolysis was used much less commonly for AIS-despite-AC (10.5% vs 32.1%, p&lt;0.001). Symptomatic carotid disease was suspected in 2.4%, a hypercoagulable condition in 5.7%, whereas acute lacunar infarct was found in 6.5% of all patients. Death or significant disability (mRS 3-5) at hospital discharge were common in AIS on vs off AC (70.6% vs 75.2%, p&lt;0.001). Conclusions: Based on a large multicenter cohort, AF patients who have AIS-despite-AC have higher AF load and risk scores, most don't have a concurrent etiology and they are more likely to have recurrent embolic events. The stroke severity, common presence of LVO, infarct size, and poor outcomes are alarming features, and most patients are unable to receive thrombolysis because of AC use. Overall, detection of AF patients at risk of AIS-despite-AC and development of specific preventive modalities should be priorities.

Subjective identification and ablation of drivers improves rhythm control in patients with persistent atrial fibrillation. The CHAOS-AF study

Introduction and objectivesThe optimal approach for persistent atrial fibrillation (AF) ablation remains unknown. In patients with persistent AF, we compared an ablation strategy based on pulmonary vein isolation (PVI) plus ablation of drivers (PVI+D), with a conventional PVI-only approach performed in a 1:1 propensity score-matched cohort. MethodsDrivers were subjectively identified using conventional high-density mapping catheters (IntellaMap ORION, PentaRay NAV or Advisor HD Grid), without dedicated software, as fractionated continuous or quasicontinuous electrograms on 1 to 2 adjacent bipoles, which were ablated first; and as sites with spatiotemporal dispersion (the entire cycle length comprised within the mapping catheter) plus noncontinuous fractionation, which were only targeted in patients without fractionated continuous electrograms, or without AF conversion after ablation of fractionated continuous electrograms. Ablation included PVI plus focal or linear ablation targeting drivers. ResultsA total of 50 patients were included in each group (61±10 years, 25% women). Fractionated continuous electrograms were found and ablated in 21 patients from the PVI+D group (42%), leading to AF conversion in 7 patients. In the remaining 43 patients, 143 sites with spatiotemporal dispersion plus noncontinuous fractionation were targeted. Globally, AF conversion was achieved in 21 patients (42%). The PVI+D group showed lower atrial arrhythmia recurrences at 1 year of follow-up (30.6% vs 48%; P=.048) and at the last follow-up (46% vs 72%; P=.013), and less progression to permanent AF (10% vs 40%; P=.001). ConclusionsSubjective identification and ablation of drivers, added to PVI, increased 1-year freedom from atrial arrhythmia and decreased long-term recurrences and progression to permanent AF.

A pilot study of the quality of care of atrial fibrillation in Irish general practice.

Worldwide, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults and poses a significant burden to patients, physicians, and healthcare systems. We developed a quality of care score based on the Atrial Fibrillation Better Care pathway recommended by the European Society of Cardiology and the European Heart Rhythm Association guidelines. This is a 14-point score that we have termed the MAGIC score(Management of Atrial Fibrillation in Integrated Care and General Practice). The objective of this pilot study was to develop and test a quality of care score for patients with permanent AF in general practice. An observational cross-sectional pilot study was undertaken. Proportionate sampling was used across 11 practices from the Ireland East practice-based research network. The GPs completed a report form on each patient by undertaking a retrospective chart review. Eleven practices participated with a total of 1855 patients with AF. We received data on 153 patients. The main findings were that no patient met all 14 guideline based recommendations. The mean MAGIC score was 11.3. Points were most commonly deducted because the creatinine clearance and HAS-BLED score were not recorded, and the patient was not on the correct dose of oral anti-coagulation. This study demonstrates the feasibility of using a quality of care score to measure the quality of AF management in general practice. This scoring system, which is based on internationally recognized quality of care markers, highlights key areas that can be targeted with quality improvement intervention.

Serum levels of neuregulin-1 in patients with coronary artery disease: clinical and pathogenetic aspects

Aim. To determine the relationship between the serum level of neu-regulin-1 (NRG-1) and the severity of coronary artery (CA) atherosclerosis and clinical and paraclinical characteristics of patients with coronary artery disease (CAD).Material and methods. The study included 264 people, of which 220 were patients diagnosed with coronary CAD. The patients underwent coronary angiography using the Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score and echocardiography. The patients were divided into groups according to SYNTAX score: group 1 — with moderate CA atherosclerosis (≤22 (n=124); group 2 — with severe CA atherosclerosis (23-32) (n=53); group 3 — with extremely severe CA atherosclerosis (≥33) (n=43). Group 4 was represented by healthy volunteers (n=44). All subjects underwent a study of the serum NRG-1 (ng/ml) level. Statistical processing of the results was carried out using Statistica 10.0 software. Differences were considered significant at p&lt;0,05.Results. Significantly higher NRG-1 values were obtained in the control group compared to patients with CAD (p&lt;0,001). An inverse correlation was found between the NRG-1 concentration and the severity of CA atherosclerosis (p&lt;0,001). A decrease in NRG-1 concentration is associated with a high functional class of = heart failure (p&lt;0,01) and low left ventricular ejection fraction (p&lt;0,001). The significance of NRG-1 differences between groups of patients with a history of myocardial infarction (p&lt;0,001), angina pectoris (p&lt;0,01), permanent atrial fibrillation (p&lt;0,01), chronic left ventricular aneurysm (p&lt;0,01) and repeated myocardial infarction (p&lt;0,05) in comparison with patients without these pathologies.Conclusion. The identified correlations between the NRG-1 concentration and CAD, as well as the clinical and paraclinical characteristics of patients, makes it possible to consider NRG-1 as a reliable biomarker of CA and heart failure severity and may form the basis for the development of novel diagnostic approaches.

Atrial fibrillation type and long-term clinical outcomes in hospitalized patients with heart failure: insight from JROADHF.

Atrial fibrillation (AF) type (paroxysmal, persistent, or permanent) is important in determining therapeutic management; however, clinical outcomes by AF type are largely unknown for hospitalized patients with heart failure (HF). The JROADHF is a retrospective, multicenter, nationwide registry of patients hospitalized for acute HF in Japan. Follow-up data were collected up to 5 years after hospitalization. Patients were divided based on diagnosis and AF type into 3 groups (without AF, paroxysmal AF, and sustained AF [defined as a composite of persistent and permanent AF]), and compared the backgrounds and outcomes between the groups. Of 12895 hospitalized HF patients (mean age: 78±13 years, female: 6077 [47%], and mean left ventricular ejection fraction: 47±17%), 1725 had paroxysmal AF, and 3672 had sustained AF. Compared with patients without AF, sustained AF had a higher risk of the primary composite endpoint of cardiovascular death or HF hospitalization (hazard ratio [HR]: 1.09, 95% confidence interval [CI]: 1.01-1.17; P=0.03), mainly driven by HF hospitalization (HR: 1.16, 95% CI: 1.06-1.26; P<0.001), whereas the corresponding risk for the primary endpoint in patients with paroxysmal AF was not elevated (HR: 1.03, 95% CI: 0.94-1.13; P=0.53) after adjustment by multivariable Cox regression analysis. These results were consistent among the subgroups of patients with reduced or preserved ejection fraction (interaction P=0.74). Among hospitalized patients with HF, sustained AF, but not paroxysmal AF, was significantly associated with a higher risk for cardiovascular death or HF hospitalization, indicating the importance of accounting for AF type in HF patients.

Current management of atrial fibrillation in routine practice according to the last ESC guidelines: an EHRA physician survey-how are we dealing with controversial approaches?

Although guidelines for the management of atrial fibrillation (AF) are regularly published, many controversial issues remain, limiting their implementation. We aim to describe current clinical practice among European Heart Rhythm Association (EHRA) community according to last guidelines. A 30 multiple-choice questionnaire covering the most controversial topics related to AF management was distributed through the EHRA Research Network, National Societies, and social media between January and February 2023. One hundred and eighty-one physicians responded the survey, 61% from university hospitals. Atrial fibrillation screening in high-risk patients is regularly performed by 57%. Only 42% has access to at least one programme aiming at diagnosing/managing comorbidities and lifestyle modifications, with marked heterogeneity between countries. Direct oral anticoagulants are the preferred antithrombotic (97%). Rhythm control is the preferred strategy in most AF phenotypes: symptomatic vs. asymptomatic paroxysmal AF (97% vs. 77%), low vs. high risk for recurrence persistent AF (90% vs. 72%), and permanent AF (20%). I-C drugs and amiodarone are preferred while dronedarone and sotalol barely used. Ablation is the first-line therapy for symptomatic paroxysmal AF (69%) and persistent AF with markers of atrial disease (57%) and is performed independently of symptoms by 15%. In persistent AF, 68% performs only pulmonary vein isolation and 32% also additional lesions. There is marked heterogeneity in AF management and limited accordance to last guidelines in the EHRA community. Most of the discrepancies are related to the main controversial issues, such as those related to AF screening, management of comorbidities, pharmacological treatment, and ablation strategy.