Recurrent Atrial Fibrillation Episodes Research Articles

Effects of mineralocorticoid receptor antagonists on new-onset or recurrent atrial fibrillation: a Bayesian and frequentist network meta-analysis of randomized trials

Abstract Aims Clinical and translational research suggests that mineralocorticoid receptor antagonists (MRAs) may prevent atrial fibrosis and electrical remodeling associated with atrial fibrillation (AF). This study aimed to consolidate existing evidence from randomized controlled trials (RCTs) evaluating the effect of MRAs on incident or recurrent AF. Methods Medline, Cochrane Library and Scopus were searched until February 12, 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using both pairwise and Bayesian and frequentist network meta-analyses. Results Twenty-three RCTs (13,358 participants) were identified. Based on the pairwise random effects meta-analysis, MRAs were associated with a significant reduction in AF events compared to placebo or usual care (risk ratio {RR}= 0.75; 95% confidence interval {CI}= [0.66, 0.87]; P< 0.001; I2= 3%). This protective effect was robust both for new-onset and recurrent AF episodes (subgroup p-value= 0.69), while the baseline HF status was not a significant effect modifier (subgroup p-value= 0.58). MRAs demonstrated a significantly higher reduction in AF events for patients with chronic renal disease compared to placebo (RR= 0.78; 95% CI= [0.62, 0.98]; P= 0.03; I2= 0%). The network meta-analyses revealed that only spironolactone was associated with a significant reduction in AF events (Bayesian RR= 0.76; 95% CI= [0.65, 0.89]; P< 0.001; level of evidence moderate; SUCRA 0.731), while eplerenone and finerenone showed a neutral effect. Conclusion MRAs confer a significant benefit in terms of reducing incident or recurrent AF episodes, irrespective of HF status. In this context, spironolactone may be preferable compared to eplerenone or finerenone.

Temporal relationship between high-intensity training sessions and episodes of atrial fibrillation among previously inactive patients with paroxysmal or persistent AF

Abstract Background Exercise is considered beneficial for managing comorbidities in atrial fibrillation (AF) patients in the long term, and emerging evidence also indicate that high-intensity interval training (HIIT) may reduce AF burden and symptoms. However, more data on the impact of individual training sessions on recurrence of AF is needed to understand mechanisms and tailor exercise recommendations. Purpose To assess the temporal relationship between training sessions and recurrent AF episodes among previously inactive patients with paroxysmal or persistent AF being introduced to HIIT. Methods The Norwegian Exercise in Atrial Fibrillation Trial is a multi centre randomized controlled trial including inactive patients with paroxysmal or persistent AF, who are randomly assigned to either a structured exercise intervention or control for 12 months. We analysed AF episodes and training data from the initial weeks with introduction to structured exercise in the intervention group (8 supervised sessions of HIIT at 85-95% of maximal heart rate). AF episodes lasting ≥30 seconds were registered using implantable cardiac monitors (ICM). Training sessions were registered using sports watches and manual logs. We report event rates and rate ratios for recurrent AF episodes during HIIT compared to episodes occurring outside HIIT. Due to non-normal data distribution statistical comparisons were performed using the Wilcoxon sign-ranked test. Results 81 patients (24 female, 57 male), mean age of 64.2 years (range 35-78), were included. 57 patients had paroxysmal and 24 had persistent AF. The combined duration of monitoring was 5272 days (median 53, range 30 – 163). The participants performed a total of 418 hours of HIIT (median 5.3 hours, range 0.67 – 6.58) during 615 training sessions (median 8, range 1 – 8). In total 4528 AF episodes (median 4, range 0 – 1693) were registered, of which 18 occurred during HIIT. The mean AF rate per 24 hours was 0.69 outside HIIT, 1.20 during HIIT, 0.92 for the periods 1 – 3 hours and 4-6 hours after HIIT (Figure 1). The rate ratio for AF during HIIT compared to outside HIIT was 1.73 (p=0.002). In the 52 participants with at least one episode of AF during follow-up, the rate ratio for AF during HIIT compared to outside HIIT was 10.4 (bootstrapped 95% CI 0.2 to 30.3). Conclusion Among previously inactive patients with paroxysmal or persistent AF, the rate of recurrent AF episodes was significantly higher during high-intensity exercise than outside exercise. Given the few AF episodes, this mechanism of trigging AF by high-intensity exercise needs further investigation.Mean AF per 24 hours

Impact of catheter ablation on erectile dysfunction in atrial fibrillation patients

Abstract Background Previous studies suggested a consequential link between impaired diastolic function, which could be related to atrial fibrillation (AF), and a heightened susceptibility to erectile dysfunction (ED). No data exists regarding the correlation between restoration of sinus rhythm and ED. Objective This study investigates the influence of cardiac ablation on the need for phosphodiesterase-5 inhibitors (PDEF5i) medications in patients with atrial fibrillation. Methods We retrospectively investigated by chart review 220 consecutive male patients with erectile dysfunction who underwent AF catheter ablation and performed at least one follow-up visit afterward between 2019 and 2022. Exclusion criteria were considered patients older than 85 years old and those assuming non-selective beta-blockers or antidepressant medications. Patients were monitored for arrhythmia at quarterly office visits, ECGs, 7-day Holter monitoring, and event recorders during the first year. The Chi-Square test was utilized to statistically analyze the correlation between the achievement of sinus rhythm post-ablation and the discontinuation of ED medications. Results During follow-up 182 (82.7%) pts remained in sinus rhythm after one year (Group 1). Among these, 141 (77.4%) reported withdrawal of ED medication and a marked improvement in their overall sexual health and satisfaction. Whereas among the 38 (17.3%) who did not maintain stable sinus rhythm during follow-up (Group 2), only 2 (5.2%) reported a reduction in ED medication. A statistically significant difference was observed when comparing the two groups (p<0.001, OR 0,016, 95%, 0,003 - 0,061). Moreover, patients maintaining sinus rhythm for more than six months exhibited a higher tendency to stop ED medications compared to those with shorter periods of sinus rhythm or with recurrent AF episodes. Conclusion Our findings suggest a strong association between the achievement of sinus rhythm through cardiac ablation and a reduction PDEF5i in patients affected by ED medications in AF patients. This highlights the potential dual benefits of cardiac ablation in improving quality of life and in improving sexual health.

Identification of Plasmatic MicroRNA-206 as New Predictor of Early Recurrence of Atrial Fibrillation After Catheter Ablation Using Next-generation Sequencing.

Catheter ablation (CA) of atrial fibrillation (AF) is indicated in patients with recurrent and symptomatic AF episodes. Despite the strict inclusion/exclusion criteria, AF recurrence after CA remains high. Identification of a novel biomarker that would predict AF recurrence would help to stratify the patients. The aim of the study was to seek novel biomarkers among the plasmatic microRNAs (miRNAs, miRs). A prospective monocentric study was conducted. A total of 49 consecutive AF patients indicated for CA were included. Blood sampling was performed prior to CA. RNA was isolated from plasma using commercial kits. In the exploration phase, small RNA sequencing was performed in ten AF patients (five with and five without AF recurrence) using Illumina instrument. In the validation phase, levels of selected miRNAs were determined using quantitative reverse transcription polymerase chain reaction (qRT-PCR) in all participants. Altogether, 22 miRNAs were identified as altered between the groups by next-generation sequencing (using the DESeq2 algorithm). Using qRT-PCR, levels of the five most altered miRNAs (miR-190b/206/326/505-5p/1296-5p) were verified in the whole cohort. Plasma levels of hsa-miR-206 were significantly higher in patients with early (within 6 months) AF recurrence and showed an increase of risk recurrence,2.65 times by every increase in its level by 1 unit in the binary logistic regression. We have identified a set of 22 plasmatic miRNAs that differ between the patients with and without AF recurrence after CA and confirmed hsa-miR-206 as a novel miRNA associated with early AF recurrence. Results shall be verified in a larger independent cohort.

Temporal relationship between training and episodes of atrial fibrillation in endurance athletes

Abstract Background Prolonged endurance training promotes exercise-induced cardiac remodeling and atrial fibrillation (AF), the most common arrhythmia among middle-aged endurance athletes. However, there is a lack of data on the impact of training sessions on the recurrence of AF episodes and current guidelines do not provide specific training recommendations for athletes diagnosed with AF. Both sympathetic stimulation during exercise and parasympathetic activity after exercise are possible mechanisms for recurrent episodes of AF. Purpose To assess the temporal relationship of training sessions with recurrent AF episodes among endurance athletes with paroxysmal AF. Methods The Effects of Detraining in Endurance Athletes with Atrial Fibrillation Trial is an international multicenter randomized controlled trial that includes athletes engaged in regular endurance sports ≥five hours per week, diagnosed with paroxysmal AF. AF episodes lasting ≥30 seconds were registered using wireless insertable cardiac monitors (ICM) and reviewed by an experienced cardiologist. Training sessions were registered using sports watches. We analyzed AF episodes and training data for the period from ICM implantation to randomization, and report event rates and rate ratios with 95% confidence intervals (CIs) for recurrent AF episodes during or within 3 hours after training sessions, compared to >3 hours after training. Results Eighteen athletes (1 female, 17 male) with a median age of 55 years (range 44-74) were included. The combined duration of monitoring was 845 days/20,280 hours (median 38.5, range 12-97 days). The athletes performed a total of 619 hours of training during 559 training sessions. In total, 66 AF episodes (median 1, range 0-15) were registered, of which 37 (56%) occurred within 24 hours after the start of a training sessions. Ten AF episodes (15%) occurred during a training session, 12 (18%) occurred within 3 hours after a training session and 44 (67%) occurred >3 hours after training. Figure 1 shows recurrent AF episodes during training (red bars) and within 24 hours from the start of a training session (blue bars) and smoothed density estimates. The event rate per 24 hours was 0.39 for AF during training, 0.17 the first 3 hours after training and 0.06 >3 hours after training. As compared to >3 hours after training, the rate ratio was 6.6 (95% CI 3.8 to 11.6) for recurrent AF episodes during training sessions and 3.9 (95% CI 2.2 to 6.9) for AF episodes during or within 3 hours after training. Conclusion Among middle-aged endurance athletes with paroxysmal AF, the rate of recurrent AF episodes was highest during and within 3 hours after training sessions. The impact of training and the pathophysiology of exercise-induced AF should be investigated further, with the aim of developing preventive strategies specific to athletic populations.Figure 1

Association between atrial fibrillation reoccurrence and new-onset ischemic stroke among patients with nonvalvular atrial fibrillation

Objective: Explore the association between atrial fibrillation (AF) reoccurrence and new-onset ischemic stroke (IS) in patients with nonvalvular AF, and explore whether there is a high-risk period of IS after recurrent episodes of AF. Methods: A nested case-control study design was used. A total of 565 nonvalvular AF patients with new-onset IS after a follow-up of at least 2 years in the China-AF cohort were enrolled as the case group, and 1 693 nonvalvular AF patients without new-onset IS were matched as the control group at a ratio of 1∶3. Frequency and types of recurrent AF in the previous 1 or 2 years were compared between two groups, and the adjusted associations of AF reoccurrence with new onset IS were explored using conditional logistic regression analysis. The proportion of recurrent AF was compared between the case period and control period, and conditional logistic regression analysis was performed to calculate adjusted associations of case-period AF with IS. Results: The nested case-control study design results showed that the proportion of at least one record of recurrent AF in the previous 1 year was higher in the case group than in the control group (72.0% vs. 60.8%, P<0.05), and the recurrent AF was positively correlated with new-onset IS (adjusted OR=1.80, P<0.001). Similar results were also observed in the previous 2 years period. The case-crossover study design analysis showed that among 565 patients with new-onset IS, recurrent AF in the case period was positively correlated with IS (adjusted OR=1.61, P=0.003). Conclusion: Recurrent AF is associated with IS, and there may be a high-risk period of IS after recurrent episodes of AF.

Recurrent atrial fibrillation episodes related to monosodium glutamate (MSG) - a case report

Cardiac disease is largely believed to be a gift of modern sedentary life style and junk foods. Yet often the clinicians fail to find the etiologic factors in many of the patients. This case report is about recurrent episodes of atrial fibrillation in a physician. Careful history revealed the relationship of having ingested Chinese food before every episode of the atrial fibrillation. Aspartame and flavor enhancer monosodium glutamate have been considered as the food ingredients that may cause such arrythmias. The patient had to be treated aggressively with drugs and even cardiac cryoablation of four pulmonary veins and radiofrequency ablation of right atrium.&#x0D; Key words: Monosodium glutamate (MSG); Exocitotoxins; Cardiac arrhythmias; Atrial fibrillation&#x0D; Citation: Purvez A, Valentine CM, Monfredi OJ, Engel GD. Recurrent atrial fibrillation episodes related to monosodium glutamate (MSG) - a case report. Anaesth. pain intensive care 2023;27(4):613−615.&#x0D; DOI: 10.35975/apic.v27i4.2273&#x0D; Received: June 29, 2023; Reviewed: July 4, 2023; Accepted: July 4, 2023

Wide antral circumferential vs. ostial pulmonary vein isolation using pulsed field ablation-the butterfly effect.

Wide antral circumferential ablation (WACA) in comparison to ostial pulmonary vein (PV) isolation (PVI) has been attributed with improved rhythm outcome. We investigated the feasibility, lesion formation, and rhythm outcome of WACA-PVI in comparison to ostial-PVI using pulsed field ablation (PFA). Symptomatic atrial fibrillation (AF) patients (69 years, 67% male; 67% paroxysmal AF) were prospectively enrolled into our single-center registry and underwent first-time ostial-PFA or WACA-PFA, N = 15 each. In all patients, eight pulse trains (2 kV/2.5 s, bipolar, biphasic, 4× basket/flower configuration each) were delivered to each PV. In WACA-PFA, two extra pulse trains in a flower configuration were added to the anterior and posterior antrum of the PVs. For comparison of PFA lesion size, pre- and post-ablation left atrial (LA) voltage maps were acquired using a multipolar spiral catheter together with a three-dimensional electroanatomic mapping system. WACA-PFA resulted in a significant larger lesion formation than ostial-PFA (45.5 vs. 35.1 cm2, p = 0.001) with bilateral overlapping butterfly shape-like lesions and concomitant posterior LA wall isolation in 73% of patients. This was not associated with increased procedure time, sedation dosage, or exposure to radiation. One-year freedom from AF recurrence was numerically higher after WACA-PFA than ostial-PFA (94% vs. 87%) but not statistically significant (p = 0.68). No organized atrial tachycardias (ATs) were observed. Ostial-PFA patients more often underwent re-ablation due to recurrent AF episodes. WACA-PFA is feasible and resulted in significantly wider lesion sets than ostial-PFA. Concomitant posterior LA wall isolation occurred as an epiphenomenon in the majority of patients. The WACA approach was associated with neither increased procedure and fluoroscopy times nor statistically significant differences in 1-year rhythm outcome. ATs were absent.

PO-02-157 IMPACT OF ATRIAL FIBRILLATION ON QUALITY OF LIFE IN HYPERTROPHIC CARDIOMYOPATHY

In hypertrophic cardiomyopathy (HCM) atrial fibrillation (AF) has been historically described as unrelenting, a driver for heart failure, with a decisive impact on quality of life. AF treatment has been deemed less effective in HCM due to high rates of AF recurrence. However, AF has predominantly been characterized from physicians perspective and there is no data on impact on patient reported outcome measures (PROMs). To evaluate the impact of AF on PROMs in HCM. PROMs were collected using the Atrial Fibrillation Severity Scale (AFSS) and Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ-OS) reflecting symptom burden and quality of life in 250 consecutive HCM patients. Among the 250 patients, 51 (20%) were diagnosed with AF at 56±10 years of age, 6.5±5.5 years prior to evaluation and reported health status. At evaluation, 45 of the 51 AF patients (88%) were in sinus rhythm, and 6 in AF (12%) including 5 in permanent AF. Each of the 51 patients required AF treatment for symptoms: 27 (53%) solely with medications (17 with AV nodal medications and 10 on antiarrhythmic drugs); and 24 (47%) with AF ablation (16 with catheter ablation and 8 surgical Cox-Maze IV at time of myectomy). Of the 24 AF ablation patients, 15 (63%) had recurrent AF including 6 (25%) requiring multiple ablation procedures. After most recent ablation, AF burden was reported as infrequent ≤1 episode per month in 17 (71%), including 10 with ≤1 episode/year. 75% had AFSS symptom score consistent with mild symptoms, and 91% had KCCQ-OS with mild or no disability. There was no difference in either KCCQ-OS or AFSS in patients with and without AF recurrence after ablation (p=0.68). The 27 patients treated solely with medications each had recurrent AF episodes on current therapy, but 15 (56%) reported infrequent AF burden ≤1 per month including 11 with ≤1 episode/year. With treatment, 67% had AFSS symptom score consistent with mild symptoms and 82% had KCCQ-OS with mild or no disability. There was no difference in KCCQ-OS in the 51 HCM patients with AF compared to 199 patients without AF (p=0.2). Recurrent AF in HCM is common despite treatment, however episodes tend to be infrequent. With treatment, the majority of patients with AF have no or mild symptom burden. These data support that despite recurrent AF episodes after treatment, quality of life metrics are not significantly impaired for most HCM patients.

Abstract 11497: Mineralocorticoid Receptor Antagonists and Atrial Fibrillation: A Systematic Review and Meta-Analysis

Introduction: Medical therapies to prevent atrial fibrillation (AF) episodes and to reduce heart failure (HF) or cardiovascular (CV) death in patients with AF are limited. The role of mineralocorticoid receptor antagonists (MRAs) in this population is unclear. Objectives: We aimed to assess whether the effect of MRAs (e.g. spironolactone, eplerenone, finerenone) in reducing cardiovascular events differs in patients with and without AF, and to evaluate the efficacy of MRAs in reducing AF events. Methods: We searched MEDLINE, Embase, and CENTRAL to March 2022 for randomized controlled trials (RCT) comparing an MRA to placebo or usual care in patients with established cardiovascular disease or risk factors. Pairs of reviewers systematically screened the eligible studies and used random-effects models to combine data. Results: We identified 6 RCTs including 7,245 participants (1,791 with AF and 5,454 without AF) that assessed the effect of MRAs on a composite of HF hospitalization or CV death (Figure). MRAs had similar efficacy for reducing HF hospitalization/CV death in patients with a history of AF (HR 0.86, 95% CI: 0.52-1.42; I 2 =71%) as compared to those without a history of AF (HR 0.77, 95% CI: 0.62-0.96; I 2 =58%) - P for subgroup differences=0.69. There was no evidence of difference in the efficacy of MRAs in reducing HF hospitalization (P for subgroup differences=0.93) and CV death (P for subgroup differences=0.41) in patients with and without AF. We identified 21 RCTs including 22,126 participants that reported on the occurrence of AF events. MRAs significantly reduced AF events (RR 0.78, 95% CI: 0.71-0.87; I 2 =0%). This effect was similar for reducing both new-onset AF (RR 0.81, 95% CI: 0.64-1.01; I 2 =32%) and recurrent AF episodes (RR 0.77, 95% CI: 0.67-0.88; I 2 =0%) - P for subgroup differences=0.71. Conclusions: MRAs reduce HF hospitalization or CV death to a similar extent in patients with and without AF. In addition, MRAs may prevent new-onset and recurrent AF events.

A palpable depression

Several studies have shown that patients with depression, anxiety and stress have a higher ratio in developing atrial fibrillation (AF), with higher proportion occurring in patients with recurrent episodes of AF which are related to severity of disease and increased mortality ratio. We aim to discuss the case of AF caused by mental disorder to examine its relationship and impact in patient’s clinical outcomes. A 70 years-old-man came to clinic with palpitation five days before admission. He often cries and has not been able to sleep since his wife died three months prior. He admits to have neither hope nor desire to do his usual activities or even start new activities. Vital signs show BP 140/90 mmHg, pulse 150x/m, RR 20x/m, SpO2 98%. Cardiopulmonary examination revealed irregular S1-S2. ECG shows premature atrial contraction which evolved to asinus rhythm with HR 150x/minute, AF and incomplete right bundle branch block a months after the first ECG was examined. Depression-Anxiety-stress scoring-42 (DASS-42) was conducted in this patient. Results shows the patient has very severe depression, intermediate anxiety and severe stress. Mental disorders lead to increased etiology of cardiac remodeling factors due to degeneration and sympathetic stimulation, which then induced the AF. Further research is needed to examine whether psychiatric treatment can prevent AF in improving quality of life, healthy behavior and awareness for managing mental health.

Predictors of atrial fibrillation recurrence in patients with metabolic syndrome after pulmonary vein isolation

Aim. To determine the role of biomarkers in predicting atrial fibrillation (AF) recurrence within 12 months after radiofrequency ablation (RFA) in patients with metabolic syndrome (MS).Material and methods. The study included 245 patients with AF aged 35 to 65 years: patients without MS components (n=32), with 1-2 MS components (n=62) and patients with 3 or more MS components (n=153). All patients underwent a comprehensive clinical and anamnestic, anthropometric, laboratory and echocardiographic examinations. The prospective follow-up for 12 months included 135 patients with AF who underwent RFA.Results. It was found that the presence of 3 or more MS components increased the risk of AF recurrence by 4,1 times within 12 months after RFA (relative risk (RR) =4,1, 95% CI 2,19-7,65, p&lt;0,0001). According to binomial logistic regression, epicardial fat thickness (EFT) (OR =3,71, 95% CI 2,12-6,73, p=0,00001), the severity of left atrial fibrosis (OR =1,48, 95% CI 1,03-1,78, p=0,0006), concentrations of galectin-3 (OR =1,31, 95% CI 1,12-1,51, p=0,0001) and GDF-15 (OR =1,11, 95% CI 1,02-1,18, p=0,0002) in patients with AF and MS increase the risk of AF recurrence after RFA. For galectin-3, GDF-15, and EFT, using ROC analysis, the following threshold values were established, the excess of which had the greatest effect on the risk of AF recurrence after RFA in patients with MS: galectin-3 &gt;11,0 ng/ml (RR =3,43, 95% CI 1,79-6,58, p=0,0001), GDF-15 &gt;1380,7 pg/ml (RR =2,84, 95% CI 1,81-4,46, p&lt;0,0001) and EFT &gt;6,4 mm (RR =4,50, 95% CI 2,32-8,71, p&lt;0,0001). In patients with excess of all three biomarker thresholds, the total risk of AF recurrence in patients with MS within 12 months after RFA increases by 3,2 times (RR =3,16, 95% CI 1,97-5,11, p&lt;0,00001).Conclusion. The risk of AF recurrence within 12 months after RFA in patients with three or more MS components is higher than in patients with 1-2 MS components. An increase in the blood concentration of profibrogenic biomarkers galectin-3, GDF-15 and an increase in the thickness of epicardial adipose tissue is associated with an increased risk of AF recurrence in patients with MS, and these biomarkers are likely to play a significant role in predicting recurrent episodes of AF after RFA.

Markers of Inflammation, Oxidative Stress, and Fibrosis in Patients with Atrial Fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice. The pathogenesis of AF is linked to inflammatory reaction and oxidative stress, which leads to fibrosis of the atria and progression of the disease. The purpose of this study was to define the role of several biomarkers of inflammation, fibrosis, and oxidative stress (OxS). We included 75 patients with paroxysmal/persistent AF, who were admitted for electrical cardioversion or pulmonary vein isolation (PVI). High-sensitivity C-reactive protein (hsCRP), galectin-3 (Gal-3), myeloperoxidase (MPO), oxidized low-density lipoprotein (oxLDL), and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured before the procedures. We compared the results with those of 75 healthy age-, sex-, and blood pressure-matched individuals. The patients were followed up for 1 year after the intervention to establish the recurrence of AF and its association with the measured markers. Patients with AF had higher MPO (52.6 vs. 36.2 ng/ml, p < 0.001) and NT-proBNP (209.0 vs. 28.0 pg/ml, p < 0.001) compared to healthy subjects. Also, they showed significantly higher levels of hsCRP (1.5 vs. 1.1 mg/l, p = 0.001) and Gal-3 (11.4 vs. 9.7 mg/l, p = 0.003), while there was no difference found in oxLDL (71.5 vs. 71.7 U/l, p = 0.449). MPO (OR = 1.012, p = 0.014), hsCRP (OR = 1.265, p = 0.026), and weight (OR = 1.029, p = 0.013) were independently associated with AF in a multivariable logistic regression analysis. Patients with successful maintenance of sinus rhythm (SR) for one year had lower baseline MPO (40.5 vs. 84.3 ng/ml, p = 0.005) and NT-proBNP (127.5 vs. 694.0 pg/ml, p < 0.001) compared to patients with recurrent AF episodes, but there was no difference in hsCRP, Gal-3, or oxLDL between them. MPO (OR = 0.985, p = 0.010) was independently associated with AF recurrence during the follow-up period when adjusted for cofounders. Patients with AF had increased markers of inflammation and fibrosis, while there was no increase detected in the OxS marker oxLDL. MPO was independently associated with AF in a multivariate model. Inflammatory and fibrotic mechanisms are important factors in electrical and structural remodelling progress in the atria of patients with AF.

Detection of atrial fibrillation in patients with cryptogenic stroke: The Nordic Atrial Fibrillation and Stroke (NOR-FIB) study - topline results

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): NOR-FIB is an investigator driven academic study. 100 of 259 devices are supported by Medtronic. BRT and ATL are recipients of a PhD grants from the South-Eastern Norway Regional Health Authority. The study is supported by the research infrastructure of the European Cerebrovascular Research Infrastructure (ECRI). Background Cardioembolism due to occult atrial fibrillation (AF) is one of the common causes often identified by additional investigations in patients with cryptogenic stroke (CS). A large proportion of recurrent cerebral infarctions caused by AF can probably be prevented if more patients receive optimal cardiac monitoring after CS and TIA. Purpose The aim of the prospective observational multi-center NOR-FIB study was to detect and quantify AF in patients with cryptogenic stroke or TIA under continuous 12 months cardiac rhythm monitoring with an implantable cardiac monitor (ICM) and to possibly identify biomarkers predicting incident AF. Methods Patients with cryptogenic stroke and TIA diagnosed after state-of-the-art work-up had their ICM implanted by a stroke physician within 14 days after symptom onset. All patients were followed clinically and by rhythm monitoring for 12 months. AF was defined by detected atrial arrhythmia episodes ≥ 2 min, and these patients were considered for a change of their secondary prevention from antiplatelet drugs to oral anticoagulants (OAC). Results A total of 259 patients with cryptogenic stroke or TIA from 18 hospitals in Norway, Sweden and Denmark were included. After 12 months follow-up 74 (28.6 %) patients were diagnosed with paroxysmal AF, of which 91.9% were asymptomatic. Patients with AF had significantly higher mean age (72.6 vs 62.2, p&amp;lt;0.001), more severe stroke (median National Institute Stroke Scale Score on admission 2 vs 1, p 0.002) and higher pre-stroke median CHA2DS2-VASc score (3 vs 2, p&amp;lt;0.001) than patients without AF. Both hypertension and hyperlipidemia was more common in patients with AF. In 64 (86.5%) cases AF was detected early after index stroke, i.e., within the first two months of monitoring (mean 47.7 days + 52,1). Recurrent AF episodes were detected in 68 (91.9%) cases. Of the 74 AF patients, 72 (97.3%) were switched to OAC. Recurrent strokes during follow-up occurred in 2 AF patients (2.7 %) and in 9 non-AF patients (4.9 %). Conclusion AF was detected in 29% of all cryptogenic stroke/TIA patients. Most of the patients were asymptomatic for their arrhythmia, and would have gone undiagnosed without a continuous monitoring approach. Since most of the patients with detected AF were switched to OAC, the 12 months risk of recurrent stroke in this group was low. Prolonged cardiac rhythm monitoring with ICMs is an effective tool for diagnosing underlying asymptomatic AF in a patient population typically confined to a stroke unit.

PO-711-04 CONTRASTLESS VERIFICATION OF PULMONARY VEIN OCCLUSION WITH A DEDICATED SOFTWARE IN ATRIAL FIBRILLATION CRYOBALOON ABLATION

In atrial fibrillation (AF) cryobaloon ablation, optimal pulmonary vein (PV) occlusion is mandatory to obtain effective and long-lasting pulmonary vein isolation (PVI). The purpose of this study was to assess the success rate of cryobaloon PVI in AF patients by verifying circumferential PV occlusion with a dielectric sensing occlusion tool. 21 consecutive patients undergoing cryobaloon ablation for paroxysmal AF at our centre were included in the analysis. The electroanatomical map of the left atrium was reconstructed with an octapolar mapping catheter (Achieve Advance 20 mm catheter, Medtronic Inc.), using the KODEX-EPD system. Proper circumferential occlusion of the PV antra with the inflated cryobaloon (Arctic Front Advance) was verified with the dedicated dielectric sensing occlusion tool, without using iodinated dye injections. The primary outcome was AF recurrence, and was assessed with periodical Holter monitors at 3-month intervals or continuous rhythm monitoring, when available. Intra- or peri-procedural complications were secondary outcomes. Of the 21 patients enrolled, n=17 were female (81%), the mean age was 59±11 years, and the mean volume of the left atrium was 31±11 ml/m2. To obtain PVI, 125 cryobaloon applications were required (6 per patient). Five patients (24%) received an implantable loop recorder for continuous rhythm monitoring. After a median follow-up of 5 months (interquartile range, 2-7), 20 patients (95%) were free from recurrent AF episodes. There were no intra- or peri-procedural complications, and no iodinated dye injections were required to verify PV occlusion. Our study confirms that a dedicated dielectric sensing occlusion tool may avoid the need to perform PV venography during cryobaloon ablation, with optimal survival free from recurrences at short-term follow-up.

Amiodarone with or without N-Acetylcysteine for the Prevention of Atrial Fibrillation after Thoracic Surgery: A Double-blind, Randomized Trial.

Postoperative atrial fibrillation may identify patients at risk of subsequent atrial fibrillation, with its greater risk of stroke. This study hypothesized that N-acetylcysteine mitigates inflammation and oxidative stress to reduce the incidence of postoperative atrial fibrillation. In this double-blind, placebo-controlled trial, patients at high risk of postoperative atrial fibrillation scheduled to undergo major thoracic surgery were randomized to N-acetylcysteine plus amiodarone or placebo plus amiodarone. On arrival to the postanesthesia care unit, N-acetylcysteine or placebo intravenous bolus (50 mg/kg) and then continuous infusion (100 mg/kg over the course of 48 h) was administered plus intravenous amiodarone (bolus of 150 mg and then continuous infusion of 2 g over the course of 48 h). The primary outcome was sustained atrial fibrillation longer than 30 s by telemetry (first 72 h) or symptoms requiring intervention and confirmed by electrocardiography within 7 days of surgery. Systemic markers of inflammation (interleukin-6, interleukin-8, tumor necrosis factor α, C-reactive protein) and oxidative stress (F2-isoprostane prostaglandin F2α; isofuran) were assessed immediately after surgery and on postoperative day 2. Patients were telephoned monthly to assess the occurrence of atrial fibrillation in the first year. Among 154 patients included, postoperative atrial fibrillation occurred in 15 of 78 who received N-acetylcysteine (19%) and 13 of 76 who received placebo (17%; odds ratio, 1.24; 95.1% CI, 0.53 to 2.88; P = 0.615). The trial was stopped at the interim analysis because of futility. Of the 28 patients with postoperative atrial fibrillation, 3 (11%) were discharged in atrial fibrillation. Regardless of treatment at 1 yr, 7 of 28 patients with postoperative atrial fibrillation (25%) had recurrent episodes of atrial fibrillation. Inflammatory and oxidative stress markers were similar between groups. Dual therapy comprising N-acetylcysteine plus amiodarone did not reduce the incidence of postoperative atrial fibrillation or markers of inflammation and oxidative stress early after major thoracic surgery, compared with amiodarone alone. Recurrent atrial fibrillation episodes are common among patients with postoperative atrial fibrillation within 1 yr of major thoracic surgery.

Abstract 11258: Engaging Diverse Patients, Caregivers, and Clinicians as Partners to Identify Disease Management Related Challenges in Atrial Fibrillation: A Qualitative Study Utilizing Human-Centered Design Methodology

Introduction: Despite advances in atrial fibrillation (AF) management, patients with AF continue to experience poor quality of life and adverse outcomes. Engagement of patients, caregivers, and clinicians to identify challenges in AF management can inform strategies to improve quality of life and improve AF related outcomes. Methods: We conducted virtual Human Centered Design (HCD) sessions with a) patients with AF and their caregivers to understand challenges in living with AF, and b) clinicians caring for patients with AF to identify difficulties encountered in AF management. During HCD sessions, we engaged participants to answer open-ended questions. Transcripts of audio recorded sessions were coded and emerging themes were identified. Results: 8 patients (25% African American, 13% Asian), 3 caregivers, and 7 clinicians participated in HCD sessions. Median (interquartile range) patient age was 69 years (58 - 78). Major themes from the patient and caregiver perspective included inadequate education on AF, lack of guidance on AF risk factor modification, lack of support networks, and absence of systems to guide patients when experiencing recurrent AF episodes. Major themes from the clinician perspective were complementary to patient and caregiver input. Themes included inadequate patient education due to limited time clinicians can spend with patients, lack of AF risk factor modification programs, and lack of streamlined services to allow timely communication with patients without increasing the administrative burden for physicians (Figure 1). Conclusions: A diverse group of patients, their caregivers, and clinicians identified lack of adequate education, guidance on AF risk factor modification as well as poorly structured patient-clinician communication as major challenges in AF care. Our findings are informing development of mobile health application addressing identified challenges with a goal to improve quality of life and adverse AF outcomes.

Dynamic changes of cardiovascular biomarkers after ablation for atrial fibrillation: observations from AXAFA-AFNET5

Abstract Background The dynamic changes and stability of blood biomarkers over time and after treatment are not well known. In this study, we describe changes in 12 centrally quantified known and novel cardiovascular biomarkers, prior to and 3 months after ablation for atrial fibrillation (AF). Purpose In patients enrolled in the AXAFA-AFNET5 trial, we 1) characterised changes in 12 biomarker levels pre and post-ablation, 2) ascertained if biomarker changes are consistent between males and females, and 3) identified biomarkers which predict recurrent AF post-ablation. Methods and results Of the 674 patients who were recruited and randomised, 633 received the study drug and underwent ablation. Peripheral blood samples were available for 488 patients at baseline and 434 at 3 months follow-up (median age [Q1, Q3] 64 [58, 70] years; 34% female). Between baseline (BL) and follow-up (FU), paired comparisons revealed that 3 biomarkers decreased, ANG2 (median [Q1, Q3] BL 2.185 [1.711, 3.115], FU 1.827 [1.457, 2.297] ng/mL, p&amp;lt;0.001), BMP10 (BL 2.056 [1.810, 2.380], FU 1.986 [1.757, 2.260] ng/mL, p&amp;lt;0.001), and NTproBNP (BL 2.219 [0.858, 5.731] per 100pg/mL, p&amp;lt;0.001), while 1 biomarker increased, FABP3 (BL 2.911 [2.425, 3.508], FU 2.911 [2.462, 3.521], p=0.005). The remaining 8 biomarkers remained unchanged. Significant differences in ANG2, BMP10, NTproBNP and FABP3 were driven by patients who remained arrhythmia free at follow-up whereas biomarker levels remained unchanged in 121 patients who experienced recurrent AF (39%; Figure). Change scores were mainly consistent between males and females, however, CRP decreased significantly more in females. Recurrent AF episodes were not different between males and females (p=0.319). Cox proportional hazards model assessed the relationship of individual biomarkers at baseline for predicting recurrent AF. Elevated ANG2 (hazard ratio, HR per ng/mL [95% confidence interval] 1.214 [1.113, 1.325]), BMP10 (HR per ng/mL 1.516 [1.039, 2.214]), and NTproBNP (HR per 100 pg/mL 1.050 [1.025, 1.076]) significantly predicted increased risk for recurrent AF, after adjustment for age, sex, body mass index, hypertension, diabetes, chronic obstructive pulmonary disease, stroke, heart failure, ablation type (PVI, PVI and other, other), ablation energy (radiofrequency, cryoablation, other), and treatment arm. Conclusion In this study, most cardiovascular biomarkers are unchanged after ablation for AF, however, ANG2, BMP10, and NTproBNP decreased at follow-up. These effects are driven by patients who remained arrhythmia free and could potentially reflect improvement in vascular (ANG2), endothelial (BMP10), and myocardial load (NTproBNP) parameters post-ablation. This outcome corresponds with the observation that elevated levels of these biomarkers at baseline predict recurrent AF at 3 months. Both males and females demonstrate similar changes in biomarker profiles and benefit equally from ablation for AF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DZHK (German Centre for Cardiovascular Research) and BMBF (German Ministry of Education and Research) to AFNET.Additional support from European Union [grant agreement No. 633196 (CATCH ME)]. Biomarker changes

Influence of frailty syndrome on anxiety and depression of patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background. Atrial fibrillation (AF) is a chronic disease whose somatic symptoms cause patients to feel anxiety. Anxiety and depression are associated with recurrent episodes of AF and may exacerbate the symptoms of arrhythmia, increasing the risk of sudden complications and death. The evidence suggests that frailty leads to cognitive decline and increased prevalence of anxiety and depression. However, there is little information on what increases the risk of frailty syndrome in atrial fibrillation. The aim of the study was to determine the impact of frailty syndrome on anxiety and depression in patients with AF. Material and methods. The study was conducted on 158 patients with AF (including 78 women) aged 70.4 ± 7.6 years. Standardized tools were used: the Edmonton frailty scale (EFS) and the hospital anxiety and depression scale (HADS-M) to assess and compare anxiety, depression, and frail and non-frail patients with AF. Results. The average ESF score was 8.555.0. 53.2% had frailty syndrome, 10.1% were vulnerable and 36.7% had no frailty syndrome. Mean level of anxiety was 10.253.0 and depression was 9.83.85. In comparative analysis patients with frailty syndrome had more often high level of anxiety (73.8% vs. 18.9%, p &amp;lt; 0.001) and high level of depression (72.6% vs. 2.7%; p &amp;lt; 0.001) in comparison to patients without frailty syndrome. In multivariate analysis the independent determinants of frailty syndrome were longer duration of AF (β=4.649, p = 0.001), anxiety (β=2.4727, p = 0.036) and depression (β=5.5712, p &amp;lt; 0.001). Conclusions. Patients with AF have high level of FS and anxiety and depression, and FS exacerbates the symptoms of anxiety and depression. Independent determinants of frailty syndrome are longer duration of AF, anxiety and depression.

Abstract 14775: Barriers to Anticoagulation Treatment in Atrial Fibrillation: A Survey of Providers in a Large Rural Healthcare System

Introduction: Atrial fibrillation (AF) is common and oral anticoagulants are recommended to reduce risk of thromboembolism for patients with elevated risk. Barriers to anticoagulation are not well described. Objectives: We aim to evaluate gaps in provider knowledge and barriers to anticoagulation management in AF. Methods: A REDCap survey was sent to providers at Essentia Health (N=894), a large rural healthcare system in MN, WI, and ND. Providers were grouped into 3 categories: cardiology, primary care, and other. Providers were asked how they would manage a hypothetical patient with AF: 67-year-old female with hypertension, recurrent episodes of paroxysmal AF, no other medical history. Answer options included aspirin, warfarin, or novel oral anticoagulant (NOAC). Demographic data were obtained along with answers to questions assessing barriers to anticoagulation use and patient education. Providers who reported they do not see AF patients were excluded (N=23). Results: A total of 220 providers started the survey (75.5% completion rate). Of 157 providers who completed the case study, 74.5% correctly recommended treatment with a NOAC. Providers in cardiology were more likely than those in primary care and other specialties to select NOAC (96.4% vs. 68.5% vs. 76.2%, respectively; p=0.01). Most (92%) providers stated they personally discuss the need for anticoagulation with their patients. Providers noted the primary barrier to educating patients about their increased risk of stroke was: “They have trouble understanding what I am trying to explain to them” (24%), “They think that once their symptoms are being treated, the risk of AF-related stroke goes away” (17%), and “They don't really believe their condition is serious” (13%). Providers cited the top barrier to patient compliance with anticoagulation was patients concern of cost with no difference between specialty (cardiology 40.7% vs. primary care 46.7% vs. other 34.8%; p=0.53). Conclusion: Cardiology providers are more likely to correctly recommend a NOAC, compared to primary care or other specialties, for AF. Primary barriers to patient education and compliance include inadequate patient understanding and medication cost.