Rhythm Control Of Atrial Fibrillation Research Articles

Inhibition of the KCa2 potassium channel in atrial fibrillation: a randomized phase 2 trial

Existing antiarrhythmic drugs to treat atrial fibrillation (AF) have incomplete efficacy, contraindications and adverse effects, including proarrhythmia. AP30663, an inhibitor of the KCa2 channel, has demonstrated AF efficacy in animals; however, its efficacy in humans with AF is unknown. Here we conducted a phase 2 trial in which patients with a current episode of AF lasting for 7 days or less were randomized to receive an intravenous infusion of 3 or 5 mg kg−1 AP30663 or placebo. The trial was prematurely discontinued because of slow enrollment during the coronavirus disease 2019 pandemic. The primary endpoint of the trial was cardioversion from AF to sinus rhythm within 90 min from the start of the infusion, analyzed with Bayesian statistics. Among 59 patients randomized and included in the efficacy analyses, the primary endpoint occurred in 42% (5 of 12), 55% (12 of 22) and 0% (0 of 25) of patients treated with 3 mg kg−1 AP30663, 5 mg kg−1 AP30663 or placebo, respectively. Both doses demonstrated more than 99.9% probability of superiority over placebo, surpassing the prespecified 95% threshold. The mean time to cardioversion, a secondary endpoint, was 47 (s.d. = 23) and 41 (s.d. = 24) minutes for 3 mg kg−1 and 5 mg kg−1 AP30663, respectively. AP30663 caused a transient increase in the QTcF interval, with a maximum mean effect of 37.7 ms for the 5 mg kg−1 dose. For both dose groups, no ventricular arrhythmias occurred and adverse event rates were comparable to the placebo group. AP30663 demonstrated AF cardioversion efficacy in patients with recent-onset AF episodes. KCa2 channel inhibition may be an attractive mechanism for rhythm control of AF that should be studied further in randomized trials. ClinicalTrials.gov registration: NCT04571385.

Rate Versus Rhythm Control for Atrial Fibrillation.

Atrial fibrillation (AF) is an arrhythmia characterized by disorganized atrial activity with an associated unevenly irregular ventricular response on an electrocardiogram. It is the most common sustained arrhythmia, with a lifetime risk of 25% in patients older than 40 years old. The incidence of AF increases with age and is associated with an increased risk for heart failure, stroke, adverse cardiac events, and dementia. The 2 main aims of AF treatment include anticoagulation for thromboembolism prophylaxis as well as rate vs rhythm control. The focus of this article will be on the treatment strategies in managing AF. Rate control refers to the use of atrioventricular nodal blocking medications, including beta blockers and calcium channel blockers, to maintain a goal heart rate. Rhythm control, on the other hand, refers to a treatment strategy focused on the use of antiarrhythmic drugs (AAD), cardioversion, and ablation to restore and to maintain a patient in sinus rhythm. Currently, the ideal treatment strategy remains greatly debated. Thus, we hope to compare the risks and benefits of rate to rhythm control to highlight how patients with AF are managed here at Kaiser Permanente Northern California.

Atrial Fibrillation Ablation: Current Practice and Future Perspectives.

Catheter ablation to perform pulmonary vein isolation (PVI) is established as a mainstay in rhythm control of atrial fibrillation (AF). The aim of this review is to provide an overview of current practice and future perspectives in AF ablation. The main clinical benefit of AF ablation is the reduction of arrhythmia-related symptoms and improvement of quality of life. Catheter ablation of AF is recommended, in general, as a second-line therapy for patients with symptomatic paroxysmal or persistent AF, who have failed or are intolerant to pharmacological therapy. In selected patients with heart failure and reduced left-ventricular fraction, catheter ablation was proven to reduce all-cause mortality. Also, optimal management of comorbidities can reduce AF recurrence after AF ablation; therefore, multimodal risk assessment and therapy are mandatory. To date, the primary ablation tool in widespread use is still single-tip catheter radiofrequency (RF) based ablation. Additionally, balloon-based pulmonary vein isolation (PVI) has gained prominence, especially due to its user-friendly nature and established safety and efficacy profile. So far, the cryoballoon (CB) is the most studied single-shot device. CB-based PVI is characterized by high efficiency, convincing success rates, and a beneficial safety profile. Recently, CB-PVI as a first-line therapy for AF was shown to be superior to pharmacological treatment in terms of efficacy and was shown to reduce progression from paroxysmal to persistent AF. In this context, CB-based PVI gains more and more importance as a first-line treatment choice. Non-thermal energy sources, namely pulsed-field ablation (PFA), have garnered attention due to their cardioselectivity. Although initially applied via a basket-like ablation tool, recent developments allow for point-by-point ablation, particularly with the advent of a novel lattice tip catheter.

Which Is Better? Rate Versus Rhythm Control in Atrial Fibrillation: A Systematic Review.

Atrial fibrillation (AF) is a common arrhythmia associated with significant morbidity and mortality. The optimal approach to managing AF, specifically rate control versus rhythm control, remains a topic of debate in clinical practice. This systematic review aims to compare the rate control and rhythm control strategies based on their clinical outcomes, quality of life, and adverse events associated with them. A comprehensive search was conducted using PubMed, Google Scholar, Science Direct, Research Gate, MEDLINE (Medical Literature Analysis and Retrieval System Online), Scopus, and Embase (Excerpta Medica dataBASE) databases. A total of 1657 research papers were identified through the search strategy, and after applying the eligibility criteria, 28 studies were selected for the analysis. The studies encompassed a range of methodologies, including randomized controlled trials, observational studies, and meta-analyses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for study selection, data extraction, and analysis. The outcomes of interest included all: cause mortality, stroke, bleeding events, cardiovascular hospitalizations, quality of life, and adverse effects of treatment. Data were synthesized and presented in tables, charts, and forest plots for meta-analysis where appropriate. The results indicate that both rate control and rhythm control strategies have their own merits and limitations, with the outcomes varying based on patient characteristics and comorbidities. While rhythm control strategies may lead to better symptom control and improved quality of life, rate control strategies maybe associated with lower risks of adverse events and complications. This systematic review provides a comprehensive overview of the current evidence regarding rate and rhythm control strategies in AF management, offering insights for clinical decision-making and highlighting the need for individualized treatment approaches.

Abstract 18056: Transhepatic and Trans-Patent Foramen Ovale Ablation of Atrial Fibrillation in the Setting of Chronic Inferior Vena Cava Occlusion: Addressing Complex Anatomic Hurdles and Achieving Therapeutic Success

Background: Rhythm control for atrial fibrillation (AF) is the preferred approach for symptomatic patients, particularly those with reduced ejection fraction. Catheter ablation primarily consists of pulmonary vein isolation via a transseptal approach. In patients with chronic occlusion of inferior vena cava (IVC), surgical ligation of IVC, or congenital venous system abnormalities, conventional femoral venous access may not feasible. Case Report: A 78-year-old male with history of Hypertension, diabetes, coronary artery disease, bilateral DVTs s/p thrombectomy, prior IVC stenting, presented with persistent, symptomatic AF on apixaban. Given a moderately reduced EF of 40-45%, amiodarone intolerance, and contraindication to other AADs, he was referred for catheter ablation. CT venogram showed chronically occluded IVC with patent hepatic veins, therefore transhepatic access to the right atrium was obtained. Transesophageal echocardiography (TEE) was planned for transseptal puncture; however, this showed an incidental PFO. This PFO was easily engaged using a manual modification of a VersaCross transseptal sheath and after entering the left atrium, the sheath was exchanged with a bi-directional sheath (Vizigo). Using this single left atrial access, pulmonary vein isolation and posterior wall isolation were performed. The transhepatic access site was closed with coil embolization to prevent track bleeding (figure 1). Conclusion: We present a case where successful AF ablation was achieved via percutaneous transhepatic approach, with improvised utilization of a conveniently located PFO. This was guided by pre-operative CT, and intra-operative TEE which allowed us to minimize any transseptal puncture related complications. The utilization of a multidisciplinary team comprising electrophysiologists, advanced imaging cardiologists and interventional radiologists is invaluable in executing complex procedures of this nature.

Abstract 12324: Current Trends in Anticoagulation, Referral and Utilization of Procedures for Rhythm Control for Atrial Fibrillation

Introduction: Atrial fibrillation (AF) can reduce quality of life and cause thromboembolic events, heart failure and death. Prior studies have identified disparities in the treatment of AF based on sex, race, and ethnicity. Hypothesis: There will be disparities in procedures for rhythm control (RC) based on sex, race and ethnicity. Methods: Cohorts of patients with new AF from 2016 to 2021 were identified with 1 year follow up to identify referrals, anticoagulant prescription, and procedures for RC. We calculated the proportion of patients with each outcome overall stratified by sex and race/ethnicity. We used logistic regression to compare outcomes across sex and race/ethnicity after adjustment for confounding variables. Results: We identified 2,919 patients with a new onset AF. The mean age: 68 years, 53% were male, 66% had Medicare, 69% self-identified as White, 23% as Black, and 3% as Hispanic. There was no difference in referral rates between men and women. Compared to White patients, Black and Hispanic patients were more likely to be referred to Cardiology and more likely to complete a visit. Prescription of anticoagulants was high (83%) and did not differ between men and women (84% vs. 82%, p = 0.65). Compared to White patients, Black and Hispanic patients were more likely to receive a prescription for anticoagulation (86% and 88% vs. 81%, p = 0.006). Women were significantly less likely to receive cardioversion or ablation compared to men (17% vs. 25%, p < 0.001). Similarly, Blacks and Hispanics were significantly less likely to receive procedures compared to Whites (17% vs. 23%, p = 0.01). Conclusions: Despite equal attendance at Cardiology visits, women and Black or Hispanic patients were significantly less likely to receive cardioversion or ablation compared to men and Whites respectively.

Abstract 14992: Impact of Coronary Artery Disease on Rate vs. Rhythm-Control of Atrial Fibrillation

Introduction: Atrial fibrillation (AF) is a common arrhythmia that can impair quality of life and increase cardiovascular mortality. Previous studies have shown potentially better outcomes with rate-control agents in patients with coronary artery disease (CAD). Yet, optimal treatment of AF is not yet known. Methods: Leveraging data from the AFFIRM trial, we performed a post-hoc analysis examining outcome differences in patients on rate vs. rhythm-control agents, based on CAD status. The primary outcome was defined as death from any cause; secondary outcomes included ischemic stroke, major bleeding, and hospitalization after baseline. Univariate and multivariate modeling were used to determine risk factors associated with designated outcomes. Results: Of 4060 patients enrolled, 1551 patients had CAD at baseline. There were no differences in treatment randomization based on CAD status; however, more patients with CAD had worse heart function and comorbid CHF. More patients with CAD ultimately used some form of rate-control compared to those without. Overall, CAD patients were more likely to experience death (HR 2.08 [1.79-2.42], P<0.001), specifically those on rhythm-control (HR 1.24 [1.01-1.52], P=0.04, Figure). CAD patients were also more likely to have ischemic stroke (HR 1.24 [1.00-1.53], P=0.05). When comparing CVD vs. non-CVD death, only CAD patients on rhythm-control exhibited a significantly higher rate of CVD death (HR 1.39 [1.03-1.89], P=0.03), while no differences in primary outcomes were noted for all other groups (P>0.05, Figure). In multivariate modeling, the effect of treatment arm on risk of CVD death in CAD patients diminished upon accounting for age, smoking, rhythm at randomization, first episode of AF, CHF, and LVEF<50% (HR 1.18 [0.93-1.50], P=0.17). Conclusions: AF patients with CAD on rhythm-control agents exhibited worse CVD outcomes, which may be more reflective of heart disease severity rather than treatment effects.

Abstract 17275: Clinical Outcomes Following Maze and Left Atrial Appendage Occlusion Procedures for Patients With Atrial Fibrillation Undergoing Mitral Valve Surgeries: Insights From the National Readmission Database

Background: Maze procedure and left atrial appendage occlusion (LAAO) are often done as adjunctive procedures during mitral valve surgery in patients with atrial fibrillation (AF). We examined the effect of the Maze procedure and LAAO on AF-related clinical outcomes. Methods: We identified patients with AF from the Nationwide Readmission Database who underwent mitral valve surgery in the years 2016-2019 using ICD 10 codes. Patients were grouped by procedure type (Maze+/LAAO+, Maze+/LAAO-, Maze-/LAAO+, Maze-/LAAO- (control)). Outcomes were in-hospital and 180-day readmission rate for stroke and mortality, and 180-day AF/atrial flutter readmission. Multivariate regression analysis was conducted adjusting for demographics, hospital characteristics, comorbidities, and cardiac surgery type. Results: Of 14,979 patients with AF who underwent mitral valve surgery, adjunctive procedures were performed as follows: 2427 Maze+/LAAO+, 997 Maze+/LAAO-, 4052 Maze-/LAAO+, and 7503 Maze-/LAAO-. Stroke during the index admission and within 180 days occurred less frequently in the adjunctive procedure groups than in control group (2.5%, 2.3%, 3.4%, and 4.9% respectively, P<0.001). Similar results were observed for in-hospital and 180-day mortality (3.9%, 7.6%, 4.8%, and 6.8% respectively, P<0.001). However, readmission within 180 days for AF/atrial flutter was higher in the adjunctive procedure groups than the control group (5.6% vs 4.2% vs 5.4% vs 3.8%, P<0.001). On multivariate analysis, patients who had either Maze or LAAO procedures (Maze+/LAAO+, Maze+/LAAO-, Maze-/LAAO+) had a lower 180-day stroke risk when compared to the control group (hazard ratio (HR) 0.7, P=0.01; HR 0.66, P=0.55; and HR 0.79, P=0.01 respectively). Similarly, 180-day mortality was lower in patients who underwent LAAO compared to the control group (HR 0.71, P=0.002; HR 1.27, P=0.05; and HR 0.78, P=0.004 respectively). Conclusion: Patients with AF who underwent Maze and/or LAAO procedures during mitral valve surgery had lower 180-day stroke and mortality rates. There was a higher rate of readmission for AF/atrial flutter, which may be a short-term proarrhythmic effect of these procedures or may reflect differences in AF type and rhythm control goals in the control group.

Angiographic assessment of vein of Marshall in atrial fibrillation: Implications for identification and cannulation

BackgroundThe vein of Marshall (VOM) ethanol infusion improves rhythm control in atrial fibrillation (AF). The identification and cannulation of the VOM can be technically challenging. This study aimed to assess the angiographic morphology of the VOM and investigate its value in the VOM ethanol infusion. MethodsPatients with AF (n = 162) scheduled for combined catheter ablation and VOM ethanol infusion were enrolled. The VOM morphologic features in the right anterior oblique (RAO), the left anterior oblique (LAO), and the LAO cranial views were analyzed. The impact of morphology on the identification and cannulation of the VOM was investigated. ResultsThe VOM was identified in 159 (98.1 %) and cannulated in 150 (92.6 %) patients. The VOM identification rate in the RAO and LAO/LAO cranial view was 97.3 % and 89.3 %, respectively. Of 134 patients with VOM identification in the LAO/LAO cranial view, 104 (77.6 %) had a VOM ostium clock location (VOMoClock) of ≤3 and 3–4 o'clock. The VOM cannulation success rate in the ≤3, 3–4, 4–5, and 5–6 o'clock groups was 100 %, 92.6 %, 88.5 %, and 77.8 %, respectively (p = 0.032). The median (interquartile range) cannulation time in the four groups was 10.5 (6.3), 12.0 (9.0), 13.0 (23.0), and 34.0 (30.0) minutes, respectively (p < 0.001). The diameter of the coronary sinus ostium in the RAO view and the VOMoClock were independent predictors for difficult cannulation. ConclusionsThe VOM morphologic features in different angiographic views provide valuable information which could facilitate the identification and cannulation of the VOM.

Effects of rhythm control on left atrial structure remodeling in atrial fibrillation and heart failure with preserved ejection fraction.

The benefits of rhythm control for atrial fibrillation (AF) in heart failure with preserved ejection fraction (HFpEF) have not been conclusively determined. We assessed the effects of rhythm control on left atrial (LA) structure remodeling and prognosis in patients with AF and HFpEF. This was a retrospective, real-world, observational study involving patients diagnosed with AF and HFpEF. The cohort was divided into rhythm-control and rate-control groups depending on their treatment strategies. The primary outcomes were all-cause mortality, rehospitalization for any cause, HF-related rehospitalization, and stroke. Differences in follow-up LA structure parameters were also analyzed. Compared to the rate-control group, patients in the rhythm-control group had a lower risk of HF-related rehospitalization even after adjusting for potential confounders (adjusted HR 0.605, 95% CI 0.413-0.887, p = 0.010). Moreover, rhythm-control therapy led to marked reductions in LA echocardiographic indicators and a higher proportion of LA reverse remodeling (LARR). Rhythm-control therapy reverses LA structure remodeling and is associated with improved clinical outcomes; therefore, it is an optimal treatment approach for AF in HFpEF patients.

Effects of Rhythm Control for Atrial Fibrillation on Cardiac Remodeling and Valvular Regurgitation in Patients with Heart Failure.

Previous studies investigating cardiac remodeling and functional regurgitation of rhythm control for atrial fibrillation (AF) in heart failure (HF) are limited. Therefore, this study aimed to evaluate the impact of rhythm control for AF on cardiac remodeling and functional regurgitation in the spectrum of HF. Its effect on prognosis was explored. According to the treatment strategies of AF, the cohort was classified into the rhythm control and rate control groups. To further detect the implications of rhythm control on cardiac remodeling, functional regurgitation, and outcomes in HF subtypes, patients were further divided into HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction, and HF with preserved ejection fraction (HFpEF) subgroups. A total of 828 patients were enrolled, with 307 patients in the rhythm control group and 521 patients in the rate control group. Over a median follow-up time of 3.8 years, patients with rhythm control treatments experienced improvements in biatrial structure parameters, left ventricular ejection fraction, and functional regurgitation (mitral and tricuspid regurgitation) compared with rate control treatment (p < 0.05). Cox regression analysis demonstrated that rhythm control reduced the risks of all-cause mortality (HR 0.436 [95% CI, 0.218-0.871], p = 0.019) in HFpEF and HF-related admissions in HFrEF (HR 0.500 [95% CI, 0.330-0.757], p = 0.001) and HFpEF (HR 0.541 [95% CI, 0.407-0.720], p < 0.001); these associations were similar after adjusting for multiple confounders. Rhythm control therapy can be considered an appropriate treatment strategy for the management of AF in HF to improve cardiac remodeling, functional regurgitation, and prognosis.

Mortality and ventricular arrhythmias in patients on d,l-sotalol for rhythm control of atrial fibrillation: A nationwide cohort study

Use of d,l-sotalol for rhythm control in patients with atrial fibrillation (AF) has raised safety concerns. Previous randomized studies are few and not designed for mortality outcome. The purpose of this study was to compare the incidences of mortality and ventricular arrhythmias in AF patients treated with d,l-sotalol for rhythm control vs matched control patients treated with cardioselective beta-blockers. This population-based cohort study included AF patients from the Swedish National Patient Registry (2006-2017) who underwent rhythm control after a second cardioversion. Incidence rates (IRs) and adjusted hazard ratios (aHRs) for mortality and a composite endpoint of cardiac arrest/death and ventricular arrhythmias were calculated for the overall cohort and a 1:1 propensity score matched cohort of d,l-sotalol vs beta-blocker treatment. Among patient treated with d,l-sotalol (n = 4987) and beta-blocker (n = 27,078) (mean follow-up 458 days), all-cause mortality was lower in patients treated with d,l-sotalol: IR 1.21; 95% confidence interval 0.95-1.52 vs 2.42 (2.26-2.60) deaths per 100 patient-years; aHR 0.66 (0.52-0.83). The difference in mortality persisted in the propensity score matched comparison (n = 4953 in each group): aHR 0.63 (0.48-0.86). No differences were observed in the composite outcome: IR in propensity cohorts 2.13 (1.78-2.52) vs 2.07 (1.73-2.53) events per 100 years; aHR 1.01 (0.78-1.29). There was no excess mortality with d,l-sotalol compared with cardioselective beta-blockers in patients undergoing rhythm control treatment for AF after a second cardioversion. Our results indicate that the risk associated with d,l-sotalol treatment for AF can be mitigated by careful patient selection and strict adherence to follow-up protocols.

Incidence, risk factors, and outcomes of atrial functional mitral regurgitation in patients with atrial fibrillation or sinus rhythm.

Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on incident AFMR are scarce. We aimed to study the incidence, risk factors, and clinical significance of AFMR in AF or sinus rhythm (SR). Adults with new diagnosis of AF and adults in SR were identified. Patients with >mild MR at baseline, primary mitral disease, cardiomyopathy, left-sided valve disease, previous cardiac surgery, or with no follow-up echocardiogram were excluded. Diastolic dysfunction (DD) was indicated by ≥2/4 abnormal diastolic function parameters [mitral medial e', mitral medial E/e', tricuspid regurgitation velocity, left atrial volume index (LAVI)]. Overall, 1747 patients with AF and 29 623 in SR were included. Incidence rate of >mild AFMR was 2.6 per 100 person-year in new-onset AF and 0.7 per 100 person-year in SR, P < 0.001. AF remained associated with AFMR in a propensity score-matched analysis based on age, sex, and comorbidities between AF and SR [hazard ratio: 3.80 (95% confidence interval 3.04-4.76)]. Independent risk factors associated with incident AFMR were age ≥65 years, female sex, LAVI, and DD in both AF and SR, in addition to rate (vs. rhythm) control in AF. Incident AFMR was independently associated with all-cause death in both groups (both P < 0.001). AF conferred a three-fold increase in the risk of incident AFMR. DD, older age, left atrial size, and female sex were independent risk factors in both SR and AF, while rhythm control was protective. AFMR was universally associated with worse mortality.

Strategies for rate and rhythm control of atrial fibrillation in the ED.

Atrial fibrillation (AF) is one of the most common dysrhythmias managed in the ED and accounts for more than half a million visits a year in the United States. More than 6 out of 10 of these visits result in admissions. As the prevalence of AF has continued to increase in recent years, so has the presentation of patients with AF to the ED. For these reasons, clinicians in emergency settings must be knowledgeable of evidence-based rate and rhythm control strategies for stabilizing patients and preventing complications. This article discusses options, indications, contraindications, and safe implementation of rate and rhythm control strategies for ED clinicians. Recent studies have suggested that early rhythm control may benefit newly diagnosed patients, reducing stroke risk, cardiovascular deaths, and disease progression.

Short-term and long-term effects of cryoballoon ablation versus antiarrhythmic drug therapy as first-line treatment for paroxysmal atrial fibrillation: A systematic review and meta-analysis.

Cryoballoon ablation (CBA) is an effective treatment for drug-refractory atrial fibrillation (AF) patients. Whether CBA as a first-line treatment is superior in the rhythm control of AF than antiarrhythmic drugs (AAD) remains unclear.CBA is superior to AAD as initial therapy for rhythm control of paroxysmal atrial fibrillation(PAF). A comprehensive database search was performed in PubMed, Embase, Cochrane, and Web of Science from inception to March 22, 2023. Treatment efficacy was pooled using risk ratio (RR) and standardized mean difference (SMD) with a 95% confidence interval (CI). This study was registered with Prospero (CRD42023401596).Five randomized-controlled trials involving 923 patients and an observational study were included in this study. The CBA group had a significantly lower overall recurrence rate than theAAD group (CBA vs.AAD: RR = 0.59, 95% CI = 0.49-0.71, p < .05, I2 = 0). The incidence of persistent AF could be better controlled in the CBA group than in the AAD (CBA vs.AAD: RR = 0.17, 95% CI = 0.06-0.49, p < .05, I2 = 0). CBA could improve the quality of life (QoL) of patients better than AAD (CBA vs.AAD: SMD = 0.40, 95% CI = 0.14-0.67, p < .05, I2 = 68.5%). CBA can reduce hospitalization rate significantly than AAD at 36-month follow-up (CBA vs.AAD: RR = 0.29, 95% CI = 0.15-0.58, p < .05, I2 = 0%). Compared to AAD, CBA as first-line therapy could reduce the recurrence rate of atrial arrhythmia and incidence of persistent AF and improve QoL in PAF patients with lower incidences of hospitalization.

Incident atrial functional mitral regurgitation in atrial fibrillation and sinus rhythm

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on its incidence, risk factors, and clinical outcomes are scarce. Objective We aimed to study the incidence, risk factors and clinical significance of AFMR, defined as &amp;gt;mild functional MR in the absence of more than mild left ventricle enlargement or dysfunction, in AF and sinus rhythm (SR). Methods Adults with a new diagnosis of AF between 2010–2021 who had a transthoracic echocardiogram (TTE) were identified (n=57,109). Similarly, adults with no diagnosis of AF who had a TTE between 2010–2021 were identified for comparison (n= 364,767). Patients with &amp;gt;mild MR at baseline, primary mitral valve disease, cardiomyopathy, ≥moderate aortic valve disease, current or previous low ejection fraction, enlarged left ventricle, cardiac devices, previous cardiac surgeries, or with no follow up TTE ≥6 months from baseline were excluded. Furthermore, patients with AF had to have a TTE within 1 month of AF diagnosis. The presence of ≥2 of 4 abnormal diastolic function parameters [mitral septal e’ &amp;lt;0.07 m/sec, mitral septal E/e’ &amp;gt;15 in SR and &amp;gt;11 in AF, TR velocity &amp;gt;2.80 m/sec, left atrial volume index &amp;gt;34 ml/m2] was determined. Cox proportional hazards regression was used to determine risk factors associated with incident AFMR and all-cause death. Patients without the event of interest were censored at last follow up. Patients who developed &amp;gt;mild MR of other types (primary or functional ventricular) were censored at that time. Results Overall, 1,747 (median age 67 years; 34% females) patients with AF and 29,623 (median age 59; 51% females) in SR were included. Incident AFMR occurred in 167 patients with AF over median 3.1 (IQR 1.6–5.1) years [incidence rate of 2.6 per 100-person year] and in 780 patients in SR over median 3.1 (IQR 1.5–5.8) years [incidence rate 0.7 per 100-person year] (Figure 1). AF remained associated with AFMR after adjusting to confounding factors [age ≥65, female sex, ≥2 abnormal diastolic function parameters, and low hemoglobin; adjusted HR 3.23 (2.71–3.85)]. Independent risk factors associated with incident AFMR in AF were age ≥65, female sex, persistent AF, and ≥2 abnormal diastolic function parameters, whereas successful rhythm control without recurrence was a protective factor (Figure 2a). Risk factors for AFMR in SR were age ≥65 years, female sex, presence of ≥2 abnormal diastolic function parameters, and low hemoglobin (Figure 2a). Incident AFMR was independently associated with all-cause death in both AF and SR (Figure 2b). Conclusions AF confers more than 3-fold increase in the risk of AFMR. Diastolic dysfunction, older age, and female sex were independent risk factors for incident AFMR in both SR and AF. Paroxysmal AF and successful rhythm control were protective factors against AFMR in AF. AFMR is universally associated with worse mortality.

Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Chronic obstructive pulmonary disease (COPD) is a well-recognized risk factor for atrial fibrillation (AF) and negatively impacts symptom burden and AF rhythm control treatment. Nevertheless, there are currently no guideline recommendations or practical guides about whether or not and how to screen for COPD. Purpose To describe the implementation of an integrated screening and management pathway for COPD in patients with diagnosed AF, into the existing pre-ablation work-up embedded in an AF outpatient clinic infrastructure. Methods Unselected consecutive AF patients scheduled for catheter ablation were prospectively screened for airflow limitation using handheld (micro)spirometry devices. Patients with a forced expiratory volume (FEV) in one second (FEV1)/FEV in six seconds ratio of ≤0.73 or a FEV1/forced vital capacity ratio of &amp;lt;0.70, depending on the device, were offered referral to a pulmonologist. The COPD assessment test (CAT) (eight items scoring symptoms such as dyspnoea and coughing on a scale of 0-5) was applied to evaluate perceived disease burden, whereas the Respiratory Health Screening Questionnaire (RHSQ) (ten items scoring age, smoking, body mass index and respiratory symptoms) was evaluated as an additional screening tool. The COPD screening and management pathway consisted of six steps: 1) patient education about COPD, 2) handheld (micro)spirometry under supervision of a specialized AF nurse, 3) review of diagnostic results, 4) telephone consultation with the patient in case of results suggestive of airflow limitation, 5) referral if opted by patient and 6) full pulmonary function testing and consultation with a pulmonologist (Figure 1). Results In total, 232 patients (median age 66 [59-71], 31.9% female, 33.6% self-reported dyspnoea) were included in this screening and management pathway. Screening (micro)spirometry yielded interpretable results in 88.8% of patients. Airflow limitation was observed in 47 patients (20.3%) of whom 29 (12.5%) opted for referral to the pulmonologist and 17 (7.3%) received a final diagnosis of chronic respiratory disease, either COPD or asthma (11 newly diagnosed). The majority of these 17 patients (70.6%) scored high on the CAT (score ≥10), whereas 14 (82.4%) had a moderate-to-highly increased risk of COPD based on the RHSQ (score ≥16.5). Conclusions A COPD care pathway can successfully be embedded in an existing AF patient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although all patients chose to perform handheld (micro)spirometry, only 60% of those in whom referral was advised opted for referral. Preselection of patients based on respiratory symptoms as well as increasing patient involvement might increase patient acceptance for respiratory analysis, and requires further research.

PO-02-098 CHARACTERISTICS OF PATIENTS CHOSEN FOR CATHETER ABLATION AS AN INITIAL RHYTHM CONTROL STRATEGY IN SYMPTOMATIC PERSISTENT ATRIAL FIBRILLATION: AN ANALYSIS OF THE REAL-AF REGISTRY

According to the 2017 HRS guidelines, catheter ablation (CA) for symptomatic persistent atrial fibrillation (PSAPF) is reasonable whether the patient is currently taking antiarrhythmic drugs (AADs) or has not started them. It is unclear what drives decision-making regarding CA versus AADs as first-line therapy for rhythm control in atrial fibrillation. We aimed to analyze differences in patients who are chosen for first-line CA compared with those who receive CA after a trial of AADs. To describe differential characteristics in patients undergoing first-line CA versus those who started AAD for symptomatic PsAF and ended up requiring ablation therapy. Based on The Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and PsAF Using Novel Contact Force Technologies (Real-AF) registry as a prospective, observational, multicenter registry of patients undergoing radiofrequency (RF) ablation. A total of 1,464 patients with symptomatic PsAF who underwent de novo ablation were identified and characterized, regardless of whether they had initiated AAD. First-line CA for rhythm control was defined as patients undergoing CA who had never been prescribed antiarrhythmic medication. First-line CA was performed on 593 patients (40.5%), while first-line AAD was used in 871 patients (59.5%). At the time of ablation, 76.2% of patients in the AAD arm were still taking them, specifically amiodarone was the most prescribed antiarrhythmic (39.8%), followed by flecainide (14.1%). Likewise, patients who received first-line CA were significantly more likely to be male, younger, have a lower BMI, minor CHADS2Vasc and HASBLED scores, reduced prevalence of renal disease or diabetes, and a higher baseline LVEF (Table 1). In addition, patients who received first-line CA were closer in time to their initial diagnosis, were much less likely to have undergone prior cardioversion, and had a lower incidence of recent PsAF related hospitalization (Table 1). There were no differences in baseline left atrial parameters on imaging or electroanatomic mapping. Patients offered first-line CA for rhythm control as opposed to AAD tended to be healthier and in an earlier course of PsAF disorder. Interestingly, despite these baseline differences , there were no significant divergences in left atrial size or voltage.

PO-01-133 REAL-WORLD COMPARISON OF DRONEDARONE VS. SOTALOL IN ANTI-ARRHYTHMIC DRUG NAÏVE PATIENTS WITH ATRIAL FIBRILLATION

Sotalol and dronedarone have class II/III anti-arrhythmic drug (AAD) properties and are used for rhythm control in atrial fibrillation (AF). While sotalol requires monitoring for proarrhythmia on initiation, dronedarone does not. These treatments have not been compared head-to-head. To compare the safety and clinical outcomes of dronedarone and sotalol in AAD naïve patients using real-world data. Using Veterans Affairs data, we identified 11296 AAD naïve patients with AF prescribed dronedarone or sotalol in 2012 or later. We excluded those with prior conduction disease, pacemaker/ICDs, ventricular arrhythmia, cancer, renal failure, liver disease, or heart failure. We used 1:1 propensity score matching, based on patient demographics, comorbidities, and medications, and Cox regression to compare strategies. We performed falsification analysis against non-plausible outcomes. The matched cohort comprised 6212 patients (3106 dronedarone, 3106 sotalol; age 71±10 yrs, 2.5% female, CHA2DS2-VASC 2 ±1.3; 53.3% and 53.9% on anticoagulants, correspondingly). Dronedarone, compared to sotalol, was associated with lower risk of ventricular pro-arrhythmia and conduction disorders, but there was no significant difference in CV hospitalization or death (Figure). The findings did not falsify for the the composite falsification endpoint of hip fractures, cancer, or infections. Dronedarone had similar effectiveness to sotalol for CV hospitalization with lower risk of ventricular pro-arrhythmia and conduction disorders. These observational data provide the basis for prospective efficacy and safety trials.

Efficacy of intravenous magnesium for the management of non-post operative atrial fibrillation with rapid ventricular response: A systematic review and meta-analysis.

Intravenous magnesium (IV Mg), a commonly utilized therapeutic agent in the management of atrial fibrillation (AF) with rapid ventricular response, is thought to exert its influence via its effect on cellular automaticity and prolongation of atrial and atrioventricular nodal refractoriness thus reducing ventricular rate. We sought to undertake a systematic review and meta-analysis of the effectiveness of IV Mg versus placebo in addition to standard pharmacotherapy in the rate and rhythm control of AF in the nonpostoperative patient cohort given that randomized control trials (RCTs) have shown conflicting results. Randomized controlled trials comparing IV Mg versus placebo in addition to standard of care were identified via electronic database searches. Nine RCTs were returned with a total of 1048 patients. Primary efficacy endpoints were study-defined rate control and rhythm control/reversion to sinus rhythm. The secondary endpoint was patient experienced side effects. Our analysis found IV Mg in addition to standard care was successful in achieving rate control (odd ratio [OR] 1.87, 95% confidence interval [CI] 1.13-3.11, p = .02) and rhythm control (OR 1.45, 95% CI 1.04-2.03, p = .03). Although not well reported among studies, there was no significant difference between groups regarding the likelihood of experiencing side effects. IV Mg, in addition to standard-of-care pharmacotherapy, increases the rates of successful rate and rhythm control in nonpostoperative patients with AF with rapid ventricular response and is well tolerated.