Pre-existing Atrial Fibrillation Research Articles

Long-term heart failure risk after atrial septal defect closure in elderly

Abstract Background There is concern that atrial septal defect (ASD) closure will unmask underlying diastolic dysfunction or left heart disease in elderly causing heart failure. It is controversial whether fenestrated devices should be used in elderly patients. Purpose To assess the long-term heart failure risk after ASD closure in elderly and risk factors associated with heart failure hospitalization in a single centre. Method From 2003-2023, all elderly patients aged more that 60 years old who had ASD closure performed successfully in this centre were retrospectively studied. Baseline demographics, underlying risk factors and survival without heart failure hospitalization were analyzed. Result From 2003-2023, 73 patients aged more than 60 years old underwent successful ASD closure in our centre. None of these patients had balloon occlusion test for assessment of left atrial pressure. Median age was 66 years old (60-84) at operation and 27 (37.0%) of them were male. Common risk factors included diabetes (n=9, 12.3%), hypertension (n=31, 42.5%) and ischaemic heart disease (n=8, 11%). Thirty-nine (53.4%) patients had pre-existing atrial fibrillation and 17 (23.3%) of them had moderate to severe left sided valvular lesions. Heart failure symptoms were present in 31 (42.5%) of them (Figure 1). During a median follow-up time of 4 years (1-15 years), 80.8% of patients did not experience heart failure hospitalization (Figure 2). Pre-existing atrial fibrillation and left-sided valvular lesions were associated with higher risk of heart failure hospitalization (OR 4.06, 95% CI 1.03-16.06 p=0.036 and OR 4.9, 95% CI 1.41-17.09 p=0.009). Conclusion In a median follow-up time of 4 years, patients aged more than 60 years old had low rate of heart failure hospitalization after ASD closure. Pre-existing atrial fibrillation and left-sided moderate to severe valvular lesions were associated with higher risk of heart failure admission. Further studies should be conducted on ASD closure in these group of patients.Figure 1Figure 2

Impact of rhythm control strategy on outcomes in patients with first diagnosed atrial fibrillation in an 11-year real-world registry

Abstract Background Atrial fibrillation (AF) is a highly prevalent arrhythmia with a high burden of disease. This sub-study of the Heidelberg Registry of Atrial Fibrillation (HERA-FIB) sought to evaluate clinical characteristics, treatment strategies and outcomes in patients with first diagnosed AF (FDAF). Methods Patients with AF presenting to the emergency department (ED) of an University Hospital between June 2009 and March 2020 were consecutively enrolled. Follow-up was performed for all-cause mortality, stroke, major bleeding and myocardial infarction (MI). Outcomes were were related to patients with FDAF or pre-existing AF, as well as assigned treatement strategy (rhythm vs. rate control). The trial was registered at ClinicalTrials.gov Identifier: NCT05995561. Results Overall 2,758 (27%) of all patients presented with FDAF. Compared to FDAF, patients with pre-existing AF showed higher all-cause mortality HR 1.41 (95%CI 1.28-1.55, p<0.0001) and major bleeding events 1.29 (95% CI 1.06-1.56, p=0.0098). Non-implementation of rhythm control in FDAF was seen in 2,079 cases (75.4%) and was associated with an excess of all-cause mortality HR 1.66 (95%CI 1.30-1.99, p<0.0001) and incident MI HR 1.79 (95% CI 1.03-3.09, p=0.0385). A non-implementation of rhythm control remained an independent predictor for all-cause mortality and MI even after adjustment for significant univariate variables aHR: 1.34 (95%CI: 1.04-1.72, p=0.0234) and aHR: 1.79 (95%CI: 1.03-3.09, p=0.0385). Conclusion Real-world data from FDAF patients presenting in the setting of an ED showed a potential benefit regarding mortality and MI for rhythm control strategy. Further research is needed to validate this hypothesis.

Risk of atrial fibrillation recurrence after new-onset transient episode during ST-elevation myocardial infarction

Abstract Background Atrial fibrillation (AF) often complicates ST-elevation myocardial infarction (STEMI) and is associated with major in-hospital complications and increased mortality. The data on AF recurrence after new-onset transient STEMI-associated AF is scarce, and electrocardiographic (ECG) predictors of AF recurrence are unknown. Purpose Our aim was to assess the risk of AF recurrence and to find out the predictors of AF recurrence after transient STEMI-associated AF. Methods STEMI patients admitted during 2007-2010 for primary percutaneous coronary interventions (PCI) were followed up until 2018. All ECGs ever recorded before, during or after STEMI (n=58907) were exported from regional database in digital format and processed using Glasgow algorithm. Clinical characteristics and mortality status were retrieved from the Swedish national registries. Information regarding AF was obtained from the national registries and the regional ECG database. STEMI-associated AF was defined as first-ever AF episode occurring between symptom onset and hospital discharge. Patients with pre-existing AF, AF after acute coronary artery bypass surgery and patients discharged with ongoing AF were excluded from analysis. P-wave indexes were assessed from the latest sinus rhythm ECG before discharge. The primary endpoint was the first documented AF episode after discharge. The secondary endpoints were total mortality and ischemic stroke. Cox regression analysis was adjusted for relevant clinical covariates. Results 1) 1956 patients who were discharged alive on sinus rhythm were included in the analysis (age 65±12, 70% males), 127(6.5%) of them had transient STEMI-associated AF. 2) Patients with STEMI-associated AF were more likely to develop AF during follow-up (n=74 [58.3%]) than patients without AF before or during STEMI (No AF) (n=56 [3.1%], HR=4.80 95%CI 3.93-5.97) (Figure 1). 3) None of the clinical and demographic characteristics was associated with AF recurrence. P-wave duration, P-terminal force in V1 and P-voltage in lead I were associated with AF recurrence, however only reduced P-wave voltage in lead I <93 µV (75th percentile) (HR=2.29 95% CI 1.21-4.35, p=0.011) remained independently associated with AF recurrence in adjusted analysis (Figure 2). 4) During follow-up, 134 patients had an ischemic stroke and 522 died. STEMI-associated AF was associated with higher long-term mortality risk comparing to No AF (HR=1.18 95%CI 1.02-1.36). The risk of stroke was not associated with STEMI-associated AF (HR=1.08 95%CI 0.79-1.49). In patients with STEMI-associated AF, occurrence of stroke did not differ between patients with and without AF recurrence (5[7%] vs 8 [15%] respectively, p=0.147). Conclusion STEMI-associated transient AF is associated with a 4.8-fold increased risk of AF after discharge, reaching 28% by 1 year after discharge. ECG-based P-wave indexes reflecting atrial remodeling can be used for the prediction of AF recurrence after discharge.

Echocardiographic signs of atrial cardiopathy and MRI-detected silent brain infarcts in a middle-aged cohort: the Akershus Cardiac Examination 1950 Study

Abstract Background Atrial fibrillation (AF) is linked to clinical stroke and silent brain infarction (SBI). In the majority of AF patients, there exists a recognized form of atrial cardiopathy, and it is suggested that atrial cardiopathy, even in the absence of AF, may serve as a risk factor for stroke. However, existing evidence is limited, and it remains unclear whether atrial cardiopathy indeed poses a risk for stroke and SBI. Purpose We aimed to investigate the association between echocardiographic signs of atrial cardiopathy and the detection of SBI through magnetic resonance imaging (MRI) in a middle-aged cohort from the general population. Methods In the prospective Akershus Cardiac Examination (ACE) 1950 Study conducted within the general population in Norway, cardiovascular risk assessment including transthoracic echocardiography, was undertaken at study inclusion between 2012 and 2015. We assessed body surface area-indexed left atrial (LA) maximum and minimum volume, as well as LA reservoir and contractile strain. Subsequently, brain MRI was conducted in a subset of the cohort between 2017 and 2023. SBI was defined as presence of neuroimaging sign of infarcts, including lacunes, in individuals without a history of stroke. Logistic regression analyses were performed to explore the associations between echocardiographic measures of atrial cardiopathy and SBI on MRI, adjusting for sex, age, hypertension, and diabetes. Results A total of 397 out of 3706 (10.7%) participants in the ACE 1950 study underwent MRI examination and were included in this analysis. At the time of MRI, the mean age was 70.0±2.2 years, with 157 (40%) women, 248 (62%) with hypertension, and 36 (9%) with diabetes at study inclusion. SBI was present in 51 (13%), of which only 1 (2%) had known AF. After excluding 18 participants with pre-existing AF, no significant difference were observed in LA volumes or LA strain between participants with or without SBI (Figure 1). In unadjusted and adjusted logistic regression analyses, neither LA volume nor LA strain were associated with SBI (Table 1). Conclusion Echocardiographic signs of atrial cardiopathy were not associated with silent brain infarcts in a middle-aged cohort from the general population.

Sex-specific prognostic implications of new-onset atrial fibrillation in patients treated with dual chamber pacemakers

Abstract Background Right ventricular pacing induces ventricular dyssynchrony, which over time may result in left ventricular dysfunction, increased left ventricular filling pressures, and ensuing left atrial dilatation, with increased risk of atrial arrhythmias. Atrial fibrillation (AF) prior to device implant is associated with worse prognosis, but the prognostic effects of new-onset AF during pacemaker treatment are less well described. Purpose To describe risk factors, incidence, and prognostic effects of new-onset AF after treatment is initiated with a dual chamber pacemaker. To evaluate mortality and risk of heart failure diagnosis or hospitalisation for heart failure in patients who develop AF, compared to those who do not develop AF. Methods All patients without pre-existing heart failure or atrial fibrillation, who received a dual chamber pacemaker at a large-volume tertiary care center during the period 2005–2020 were included. Data was crossmatched between the national pacemaker registry, the population registry and national disease registries. The primary outcome was 10-year mortality, and the secondary outcome was new-onset heart failure. Results 37127 patients were included in the study, of which 14760 (30%) were female. Median age was 76.4 years [interquartile range, IQR, 68.0–83.1] and the most common indication for pacemaker implant was AV block (57.7%), see Table 1. Overall, 10-year survival was higher for female patients, compared to male patients, p<0.0001 (see Kaplan-Meier curve in Figure 1A). Patients who developed new-onset AF had more comorbidities, were slightly older and a higher percentage were men. During follow-up 3661 (9.9%) developed atrial fibrillation within two years (9.1% of female and 10.3% of male patients, p<0.001), at a median of 291 [88–461] days after implant. In multivariable Cox regression analysis with new-onset AF as time dependent covariable and adjusted for clinically relevant covariables, AF was an independent predictor of higher all-cause mortality (HR 1.43 [1.37–1.49], p<0.0001). Risk factors for new-onset AF included increasing age, male sex, hypertension, malignancy, diabetes, chronic obstructive lung disease, chronic renal disease, and sick sinus syndrome indication (all p<0.01). In separate analyses for men and women, the risk factors and magnitude of odds ratios were the same. Conclusion In patients treated with dual chamber pacemakers due to bradycardia or AV block, development of new-onset AF within two years was associated with a higher 10-year mortality. The risk of developing AF was higher for men, but the negative prognostic effect was more pronounced for women.Figure 1A.-B. K-M survival curves

Temporal and age-related trends in risk factors for development of atrial fibrillation in peripartum patients

Abstract Background Incidence of atrial fibrillation (AF) in pregnancy has steadily increased over the past two decades and may be related to changes in rates of AF risk factors. Objective To characterize trends in the prevalence of AF risk factors among patients with peripartum AF. Methods TrinetX, a large national healthcare database, was used to identify patients with peripartum AF from 2017-2022. Inclusion criteria were female patients aged >18 years old who received a diagnosis of AF within one month prior to and one year after a diagnosis of pregnancy. Annual prevalence of pre-existing AF risk factors, including diabetes, chronic kidney disease (CKD), obesity, and hypertension, were obtained, normalized to the annual number of peripartum AF cases, and followed. In a second analysis, student’s t-test and standardized mean difference were used to compare the rates of AF risk factors between patients with peripartum AF and pregnant patients with no history of AF within the same time frame. Comparisons were performed across age ranges. Results From 2017-2022, there were 6,465 patients with peripartum AF and 2,852,348 pregnant patients with no AF. There was an increase in the proportion of peripartum AF patients with pre-existing obesity (16.7% to 18.5%) and hypertension (28.9% to 33.7%). In comparing pregnant patients with no AF history with peripartum AF patients, the standardized mean difference for rates of all risk factors increased with age group. The peripartum AF group had significantly higher rates of all risk factors across all age groups (p < 0.0001 for all groups). Conclusion Rates of pre-existing obesity and hypertension increased among patients with peripartum AF, which could be a factor in increasing rates of peripartum AF. Differences in rates of AF risk factors between peripartum AF patients and pregnant patients with no AF were more pronounced at older age groups.

A pooled analysis of the incidence and mortality risk of atrial fibrillation in patients with COVID-19.

There exist serious cardiovascular complications subsequent to SARS-Cov2 infection (COVID-19); however, the association between COVID-19 and atrial fibrillation (AF) remains to be elucidated. We aimed to assess the prevalence of AF among COVID-19 patients and its associated risk of death. The present systematic review was performed in accordance with the PRISMA guidelines. The protocol was registered with CRD42022306523. A comprehensive literature search was performed across PubMed, Embase, and Cochrane databases to identify studies reporting on the prevalence of pre-existing or new-onset fibrillation (AF), and/or the associated clinical outcomes in patients with COVID-19 from January 2020 to December 2023. The random-effect model was used to estimate the prevalence of AF and its related mortality. A total of 80 studies, including 39,062,868 COVID-19 patients, were identified in the present investigation. The prevalence rates of pre-existing AF or new-onset AF were 10.5% (95% CI [9.3-11.7%]) or 10.3% (95% CI [6.2-14.5%]), respectively. Subgroup analysis revealed a two fold higher incidence of AF in older patients (≥65 years) compared to younger patients (<65 years) (14.4% vs. 6.4%). The highest rate of AF was observed in Europeans (10.7%, 95% CI [10.2-11.2%]), followed by Northern Americans (10.0%, 95% CI [8.2-11.7%]), while Asians demonstrated a lower prevalence (2.7%, 95% CI [2.2-3.3%]). Notably, severe COVID-19 patients displayed a significantly elevated prevalence of AF at 14.l% (95% CI [13.3-14.9%]), which was approximately 2.5-fold higher than that in non-severe patients (5.2%, 95% CI [4.8-5.5%]). Both pre-existing (HR: 1.83, 95% CI [1.49-2.17]) and new-onset AF (HR: 3.47, 95% CI [2.26-5.33]) were associated with an increased mortality risk among COVID-19 patients. Furthermore, the effect on mortality risk was more significant in Asians (HR: 5.33, 95% CI [1.62-9.04]), compared to Europeans (HR: 1.68, 95% CI [1.24-2.13]) and North Americans (HR: 2.01, 95% CI [1.18-2.83]). This study comprehensively investigated the association between AF and COVID-19 in a real-world setting. Notably, a high prevalence of AF was observed among older individuals, severe COVID-19 patients, and in Europe and Northern America. Moreover, co-existing AF was found to be associated with an increased risk for mortality. Further investigations are warranted to improve the management and outcomes of COVID-19 patients with AF.

The left atrial appendage exclusion for prophylactic stroke reduction (leaaps) trial: rationale and design

IntroductionLeft atrial appendage exclusion (LAAE) has been shown in randomized trials to reduce ischemic stroke risk in patients undergoing cardiac surgery with known atrial fibrillation (AF). Many patients undergoing cardiac surgery without pre-existing AF are at risk of stroke and may benefit from LAAE. MethodsLeft Atrial Appendage Exclusion for Prophylactic Stroke Reduction (LeAAPS) is an international, prospective, randomized, multicenter, blinded trial evaluating the effectiveness of LAAE in preventing ischemic stroke or systemic embolism in patients undergoing cardiac surgery at increased risk of AF and ischemic stroke. The trial will enroll 6500 patients at increased risk of stroke in whom a cardiac surgery is planned at 250 sites worldwide. Eligible patients are ≥18 years old, have no pre-existing AF but are at increased risk for AF and stroke (based on age, CHA2DS2-VASc score, left atrium size or brain natriuretic peptide). Patients are randomized 1:1 to receive either LAAE with AtriClip or no LAAE during cardiac surgery. Healthcare providers outside of the operating room and the patient will be blinded to allocation. The primary effectiveness endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or surgical or endovascular LAA closure. The powered secondary effectiveness endpoint is ischemic stroke or systemic arterial embolism. The primary safety endpoint is the occurrence of one of the following events (through 30 days): pericardial effusion requiring percutaneous or surgical treatment, peri-operative major bleeding, deep sternal wound infection, or myocardial infarction. Other endpoints include mortality, rehospitalizations, clinically diagnosed AF, transient ischemic attack, and cognitive and quality of life assessments. Follow-up is every 6 months for a minimum of 5 years; primary analysis occurs when 469 patients have had an ischemic stroke or systemic embolism. ConclusionThe results of the LeAAPS trial will demonstrate whether LAAE with AtriClip at the time of other routine cardiac surgery reduces stroke or systemic arterial embolism during long-term follow-up in patients at high risk of stroke without pre-existing AF. Trial RegistrationClinicalTrials.gov, Identifier: NCT05478304, https://clinicaltrials.gov/study/NCT05478304?term=%20NCT05478304&rank=1

Atrial Fibrillation Prevalence In Ischemic Strokes In An Irish Hospital. Spotlight On Anticoagulation Failure In Patients On Direct Oral Anticoagulants

Abstract Background Global atrial fibrillation (AF) burden in acute ischemic stroke patients approximates at 30%. An Audit in 2022, in the concerned hospital identified lack of compliance and under-dosing as major causes of ischemic strokes whilst on direct acting anticoagulants (DOACs). This year, we sought repeat the audit of process with focus on ischemic strokes with pre-existing AF patients established on DOACs, to study trends related to anticoagulation failure. Methods The study was a retrospective observational audit study of all patients admitted with a diagnosis of acute ischemic stroke to the concerned hospital from January 2023 to December 2023 who had known diagnosis of atrial fibrillation and were prescribed a DOAC prior to their admission in the concerned hospital with an ischemic stroke. Patients were identified via HIPE coding and in-hospital stroke registry. Data was collected via charts review, compiled via flow charts, graphs and excel sheets, and studied. Results 143 patients were admitted to the hospital’s stroke service with ischemic stroke in the set time frame. 46 (32%) had Atrial Fibrillation (AF) which was deemed to be the cause of their stroke. 29 (20.2%) had pre-existing diagnosed AF, and 22 of those patients were prescribed DOACs. In all patients already on DOACs, compliance was found questionable or lack of in 11 (50%). 8 (36.3%) patients were on low dose (adjusted dose DOACs). 3 patients were diagnosed with DOAC failure without cause. All new and existing AF patients not anticoagulated, were commenced on anticoagulation. Conclusion The audit showed under dosage and poor compliance were major causes of anticoagulation failure in stroke patients who were anticoagulated with DOACs. Similar results were noted as secondary results in last year’s audit in the concerned hospital. As part of quality improvement process, a specialist DOAC clinic was being set up with further audit process planned for the coming year.

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.

Cardio-cerebrovascular adverse outcomes in patients with influenza with and without preexisting cardiovascular disease: Oral antiviral agents impact.

This study aimed to compare the 2-year cardio-cerebrovascular adverse outcomes of patients with influenza with and without preexisting cardiovascular disease (preCVD) treated with oral antiviral agents in the outpatient clinic. Oral antiviral agents are routinely prescribed to treat influenza infection with a positive rapid-antigen test in the outpatient clinic; however, influenza-associated cardio-cerebrovascular outcomes have not yet been characterized in patients with preCVD treated with oral antiviral agents. Data between 2006 and 2016 were extracted from the National Health Database of South Korea. A total of 865,522 patients with influenza treated with oral antiviral agents were selected in South Korea and classified as preexisting ischemic heart disease (IHD), heart failure (HF), or atrial fibrillation (AF), and 2-year cardio-cerebrovascular outcomes were analyzed using a Cox proportional hazard regression model. Among the participants, 96,433 had preCVD (11.1%; mean age, 46 years) including IHD (86.4%), HF (23.1%), and AF (12.5%). The incidence of new-onset IHD, AF, HF, and death was similar between patients with influenza with and without preCVD. The incidences of IHD and stroke were 0.489 and 0.047 per 100-person year in the preCVD group, respectively. The incidence of cardiovascular mortality was 0.489 per 100-person year in the preCVD group, and the hazard ratio for cardiovascular mortality in the preCVD group was not significantly different from that in patients without preCVD. Based on the national health data, 2-year cardio-cerebrovascular adverse outcomes were not significantly different between patients with and without preCVD treated with oral antiviral agents.

Pre-Existing Atrial Fibrillation in Hospitalized Patients with COVID-19: Insights from the CARDIO COVID 19-20 Registry.

Pre-existing (chronic) atrial fibrillation (AF) has been identified as a risk factor for cardiovascular complications and mortality in patients with COVID-19; however, evidence in Latin America (LATAM) is scarce. This prospective and multicenter study from the CARDIO COVID 19-20 database includes hospitalized adults with COVID-19 from 14 countries in LATAM. A parsimonious logistic regression model was used to identify the main factors associated with mortality in a simulated case-control setting comparing patients with a history of AF to those without. In total, 3260 patients were included, of which 115 had AF. The AF group was older, had a higher prevalence of comorbidities, and had greater use of cardiovascular medications. In the model, AF, chronic kidney disease, and a respiratory rate > 25 at admission were associated with higher in-hospital mortality. The use of corticosteroids did not reach statistical significance; however, an effect was seen through the confidence interval. Thus, pre-existing AF increases mortality risk irrespective of other concomitant factors. Chronic kidney disease and a high respiratory rate at admission are also key factors for in-hospital mortality. These findings highlight the importance of comorbidities and regional characteristics in COVID-19 outcomes, in this instance, enhancing the evidence for patients from LATAM.

Prediction of New-Onset Atrial Fibrillation in Transcatheter Aortic Valve Implantation.

This study investigates the association between prolonged total atrial conduction time and the development of new-onset atrial fibrillation (AF) following transcatheter aortic valve implantation (TAVI). We enrolled 307 patients who underwent TAVI. Total atrial conduction time was calculated as the time between the onset of the P wave on the electrocardiography and the peak of the a' wave velocity (PA-TDI duration) on tissue Doppler imaging echocardiography. A total of 263 patients were analyzed after excluding 44 with pre-existing AF. Of these 263 patients, 47 (17.8%) experienced new-onset AF after the TAVI procedure. The new-onset AF group had an older median age (80.6 vs. 77.5 years) and a higher incidence of paravalvular aortic regurgitation than those without AF (none 29.8%, mild 46.8%, moderate 23.4%). The new-onset AF group had increased end-systolic diameter (35.0 vs. 31.7 mm, p = 0.03), left atrial diameter (44.7 vs. 41.9 mm, p = 0.049), and PA-TDI duration (137.0 vs. 125.4 ms, p = 0.009). Older age, the presence of paravalvular aortic regurgitation, and prolonged PA-TDI duration were independently associated with new-onset AF in multivariate analysis. The optimal cut-off value for PA-TDI duration was 123.5 ms. AF in patients treated with TAVI may pose significant risks for morbidity and mortality. PA-TDI duration, a readily available echocardiographic parameter, can detect patients with a high risk of new-onset AF.

Racial and Gender Differences in Cardiorespiratory Fitness and Atrial Fibrillation.

The expanding field of cardiorespiratory fitness (CRF) in individuals with and without atrial fibrillation (AF) presents a complex landscape, demanding careful interpretation of the existing research. AF, characterized by significant mortality and morbidity, prompts the exploration of strategies to mitigate its impact. Increasing physical activity (PA) levels emerges as a promising avenue to address AF risk factors, such as obesity, hypertension, and diabetes mellitus, through mechanisms of reduced vasoconstriction, endothelin-1 modulation, and improved insulin sensitivity. However, caution is warranted, as recent investigations suggest a heightened incidence of AF, particularly in athletes engaged in high-intensity exercise, due to the formation of ectopic foci and changes in cardiac anatomy. Accordingly, patients should adhere to guideline-recommended amounts of low-to-moderate PA to balance benefits and minimize adverse effects. When looking closer at the current evidence, gender-specific differences have been observed and challenged conventional understanding, with women demonstrating decreased AF risk even at extreme exercise levels. This phenomenon may be rooted in divergent hemodynamic and structural responses to exercise between men and women. Existing research is predominantly observational and limited to racially homogenous populations, which underscores the need for comprehensive studies encompassing diverse, non-White ethnic groups in athlete and non-athlete populations. These individuals exhibit a disproportionately high burden of AF risk factors that could be addressed through improved CRF. Despite the limitations, randomized control trials offer promising evidence for the efficacy of CRF interventions in patients with preexisting AF, showcasing improvements in clinically significant AF outcomes and patient quality of life. The potential of CRF as a countermeasure to the consequences of AF remains an area of great promise, urging future research to delve deeper to explore its role within specific racial and gender contexts. This comprehensive understanding will contribute to the development of tailored strategies for optimizing cardiovascular health and AF prevention in all those who are affected.

Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year, and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation

Previous reports on the impact of preexisting atrial fibrillation (AF) on clinical outcomes after transcatheter aortic valve implantation (TAVI) have presented limited data on the relative impact of paroxysmal versus persistent AF subtypes. We compared in-hospital, 1-year, and late clinical outcomes in 1,098 patients who underwent TAVI with preoperative AF (556 paroxysmal, 542 persistent) versus 1,787 patients without AF. The propensity-matched cohorts with AF (n = 643) and without AF (n = 686) did not differ with respect to baseline clinical characteristics, operative technique, or in-hospital TAVI complications. At 1-year, patients with AF had higher all-cause mortality (9.0% vs 6.1%, p = 0.046) and readmission rates (13.1 vs 8.8%, p = 0.014), with lower Kansas City cardiomyopathy questionnaire scores (77.8 ± 21.8 vs 84.3 ± 17.1, p <0.001). Echocardiographic follow-up (mean time 455 ± 285 days) demonstrated no significant intergroup differences in hemodynamic findings other than a progressive increase in left atrial volume index in patient subgroups (without AF: 37.4 ± 14.7 ml/m2 vs paroxysmal AF: 46.4 ± 21.4 ml/m2 vs persistent AF: 60.5 ± 26.3 ml/m2, p <0.001). On late follow-up (mean time 49.0 [45.1 to 52.9] months), patients with persistent AF had worse all-cause mortality than patients without AF (hazard ratio 1.55, 95% confidence interval 1.17 to 2.06, p = 0.003), with no significant survival differences between the paroxysmal AF and without AF subgroups. In conclusion, patients with preexisting AF and patients without AF who underwent TAVI had similar in-hospital outcomes but worse 1-year mortality, hospital readmission, and quality of life outcomes. Compared with patients without AF, patients with persistent but not paroxysmal preexisting AF have higher late all-cause mortality at a mean follow-up of 49 months. Patients with persistent AF have higher levels of left atrial volume index than patients with paroxysmal AF and patients without AF on intermediate echocardiographic follow-up.

The Role of 24-Hour Holter Electrocardiogram in the Early Detection of Atrial Fibrillation in Newly Diagnosed Acute Ischemic Stroke Patients.

Introduction Stroke is a leading cause of death and disability globally, with atrial fibrillation (AF) recognized as a significant risk factor due to its association with increased stroke recurrence and mortality. Timely detection of AF is crucial to prevent recurrent strokes and improve outcomes. This study primarily aimed to evaluate the utility of 24-hour Holter monitoring for AF detection in acute ischemic stroke patients. Methods This retrospective observational study examined data from 207 patients admitted with acute ischemic stroke to a tertiary-care hospital over a two-year period. Patients with pre-existing AF, transient ischemic attacks, unconfirmed diagnoses, and missing Holter reports were excluded. A total of 140 patients were included in the analysis. The study investigated AF detection rates, the relationship between AF and stroke risk factors, other Holter findings, and the time delay in attaching Holter monitors. Results Of the 140 patients evaluated, AF was detected in nine (6.4%), exclusively in those aged ≥65 years. The most prevalent risk factors among the study participants were hypertension (74.3%) and diabetes (61.4%). No significant correlations were observed between AF and the analyzed stroke risk factors. The median delay for Holter device attachment was 3,503 minutes (approximately two days and 10 hours), with longer delays noted in males (4,084 mins (approximately two days and 20 hours) vs. 2,565 mins (approximately one day and 18 hours), p=0.005). Premature atrial complexes(PACs) were notably associated with the absence of AF, suggesting their potential role as markers for undiagnosed AF. Conclusion The study highlights the limited utility of 24-hour Holter monitoring in detecting AF in acute ischemic stroke patients, advocating for extended monitoring durations, especially in older patients. To improve AF detection, potential strategies include using longer monitoring periods and optimizing hospital workflows to reduce delays in attaching Holter devices. These approaches can minimize the risk of underdiagnosing paroxysmal AF, thereby preventing recurrent strokes and improving patient outcomes. Further investigation into PACs as potential predictive markers for AF is warranted.

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

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. We performed a retrospective analysis on a prospective register involving 4,184 patients admitted for STEMI to the intensive cardiac care unit of 2 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). 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, advanced atrioventricular block, heart failure, and cardiogenic shock. 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%). As a conclusion, patients with AF complicating STEMI have higher rates of heart failure, cardiogenic shock, and in-hospital mortality. After a 10-year follow-up, they exhibit a high risk of AF recurrence and mortality, with no significant differences in stroke incidence.

Machine Learning of Cardiac Anatomy and the Risk of New-Onset Atrial Fibrillation After TAVR

BackgroundNew-onset atrial fibrillation (NOAF) occurs in 5% to 15% of patients who undergo transfemoral transcatheter aortic valve replacement (TAVR). Cardiac imaging has been underutilized to predict NOAF following TAVR. ObjectivesThe objective of this analysis was to compare and assess standard, manual echocardiographic and cardiac computed tomography (cCT) measurements as well as machine learning–derived cCT measurements of left atrial volume index and epicardial adipose tissue as risk factors for NOAF following TAVR. MethodsThe study included 1,385 patients undergoing elective, transfemoral TAVR for severe, symptomatic aortic stenosis. Each patient had standard and machine learning–derived measurements of left atrial volume and epicardial adipose tissue from cardiac computed tomography. The outcome of interest was NOAF within 30 days following TAVR. We used a 2-step statistical model including random forest for variable importance ranking, followed by multivariable logistic regression for predictors of highest importance. Model discrimination was assessed by using the C-statistic to compare the performance of the models with and without imaging. ResultsForty-seven (5.0%) of 935 patients without pre-existing atrial fibrillation (AF) experienced NOAF. Patients with pre-existing AF had the largest left atrial volume index at 76.3 ± 28.6 cm3/m2 followed by NOAF at 68.1 ± 26.6 cm3/m2 and then no AF at 57.0 ± 21.7 cm3/m2 (P < 0.001). Multivariable regression identified the following risk factors in association with NOAF: left atrial volume index ≥76 cm2 (OR: 2.538 [95% CI: 1.165-5.531]; P = 0.0191), body mass index <22 kg/m2 (OR: 4.064 [95% CI: 1.500-11.008]; P = 0.0058), EATv (OR: 1.007 [95% CI: 1.000-1.014]; P = 0.043), aortic annulus area ≥659 mm2 (OR: 6.621 [95% CI: 1.849-23.708]; P = 0.004), and sinotubular junction diameter ≥35 mm (OR: 3.891 [95% CI: 1.040-14.552]; P = 0.0435). The C-statistic of the model was 0.737, compared with 0.646 in a model that excluded imaging variables. ConclusionsUnderlying cardiac structural differences derived from cardiac imaging may be useful in predicting NOAF following transfemoral TAVR, independent of other clinical risk factors.

Incidence and outcome of periinterventional atrial fibrillation in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention

Abstract Background Peri-interventional atrial fibrillation (AF) may be detected in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). Data on the thromboembolic risk and long-term clinical outcome in patients with AF limited to the peri-interventional period is scarce. Purpose To assess the incidence and impact on long-term clinical outcome of peri-interventional de-novo AF in STEMI patients. Methods and Results This retrospective single-center cohort study included all patients who underwent PCI between January 2016 and November 2020 (n=491) due to STEMI. Patients were stratified to three cohorts of AF status: Pre-existing AF: n=42 [8.6%], newly diagnosed peri-interventional AF: n=56 [11.4%] and no AF: n=393 [80.0%]. Patients with newly diagnosed peri-interventional AF as well as patients with pre-existing AF had in median a mild-moderately reduced left ventricular ejection fraction (LVEF), patients in sinus rhythm in median a normal LVEF. During the average follow-up time of 4.7 years (min. 2 years, max. 7 years) the rate for readmission for AF or occurrence of AF without hospital admission was increased in patients with peri-interventional de-novo AF or pre-existing AF (n=6 [10.7%], n=10 [23.8%]) compared to those in sinus rhythm n=22 [5.6%] (p&amp;lt;0,001) The occurrence of ischemic stroke was higher in patients with peri-interventional de-novo AF (n=2 [3.6%] or with pre-existing AF (n=2 [4.8%]) compared to those in sinus rhythm (n=6 [1.5%]. (p=0.256) The risk of cardiovascular death was significantly higher in patients with newly diagnosed peri- interventional AF compared to patients with pre-existing or no AF (n=13 [23.2%], n=5 [11.9%], n= 37 [9.4%]) (p=0.009). In the patient group with peri-interventional de-novo AF, only 25.0% (n=13) received long-term oral anticoagulation therapy (OAK). The rate of stroke in patients who received OAK after peri- interventional de-novo AF was 7.7% (n=1) compared to those without OAK 2.6% (n=1). Conclusion Peri-interventional AF is a frequent finding in STEMI patients undergoing primary PCI. Patients with peri-interventional AF had a significantly increased risk for an adverse cardiovascular outcome. Optimal secondary prophylactic measures appear mandatory in this patient population. The significance of long-term OAK therapy is to be determined.

Cardiovascular crossroads - exploring the impact of atrial fibrillation on mitral valve regurgitation and MitraClip treatment

Abstract Introduction The use of the MitraClip technique is becoming increasingly popular as a treatment option for patients suffering from mitral valve regurgitation who are not suitable for surgery. It is unclear how pre-existing atrial fibrillation impacts patients during the procedure. Purpose The question arises: What is the underlying cause of atrial fibrillation in patients with significant mitral valve involvement and why do some patients remain unaffected? This study aims to compare and identify differences in cohorts of patients with and without atrial fibrillation before the MitraClip procedure. Methods We analyzed a register of 279 patients who underwent MitraClip treatment. The study classified the patients according to the presence (n=140, 50%) or absence (n=139, 50%) of atrial fibrillation prior to the procedure. We utilized univariate analysis to compare demographic, clinical, and echocardiographic parameters. Multivariate logistic regression was also performed to determine significant predictors. Results Both cohorts were of similar size, but there were significant differences in certain parameters. Women were more frequent in the group without atrial fibrillation (45% compared to 34%, p=0.045). The group with atrial fibrillation was slightly older (73 years compared to 70 years, p&amp;lt;0.001) and had a lager body surface area (1.95 compared to 1.87, p=0.005). Parameters such as Euroscore II, NT-proBNP and creatinine levels were not significantly different. Nevertheless, it is important to note that the group with atrial fibrillation had a greater transverse dimension of the left atrium (55 compared to 50, p&amp;lt;0.001). Additionally, the atrial fibrillation group exhibited a higher degree of tricuspid regurgitation (2.9 vs 2.0, p=0.007) and a slightly lower baseline VO2 max (11.63 vs 12.59, p&amp;lt;0.001). Multivariate logistic regression revealed that baseline tricuspid regurgitation is a significant predictor of atrial fibrillation, with and odds ratio of 2.066 (95% CI: 1.041-4.097, p=0.038). Conclusion During the MitraClip procedure, patients with atrial fibrillation demonstrate certain specific characteristics, including older age, increased body surface area, larger left atrial size, and higher grade of tricuspid regurgitation. The significant association of tricuspid regurgitation with atrial fibrillation emphasizes its potential role in clinical evaluation and subsequent treatment.