Rhythm Monitoring Research Articles

The influence of atrial high-rate episodes on stroke and cardiovascular death: an update.

Atrial high-rate episodes (AHRE) are atrial tachyarrhythmias detected by continuous rhythm monitoring by pacemakers, defibrillators, or implantable cardiac monitors. Atrial high-rate episodes occur in 10-30% of elderly patients without atrial fibrillation. However, it remains unclear whether the presence of these arrhythmias has therapeutic consequences. The presence of AHRE increases the risk of stroke compared with patients without AHRE. Oral anticoagulation would have the potential to reduce the risk of stroke in patients with AHRE but is also associated with a rate of major bleeding of ∼2%/year. The stroke rate in patients with AHRE appears to be lower than the stroke rate in patients with atrial fibrillation. Wearables like smart-watches will increase the absolute number of patients in whom atrial arrhythmias are detected. It remains unclear whether anticoagulation is effective and, equally important, safe in patients with AHRE. Two randomized clinical trials, NOAH-AFNET6 and ARTESiA, are expected to report soon. They will provide much-needed information on the efficacy and safety of oral anticoagulation in patients with AHRE.

An overview of the electrocardiographic monitoring devices in sports cardiology: Between present and future.

Athletes represent a mainly healthy population, which however could be considered at risk of major arrhythmic events, especially in case of undiagnosed cardiomyopathies. For this reason, the periodical sports medicine examination and the electrocardiography are essential tools in the cardiovascular screening, even though they do not always succeed in identifying rhythm disturbances, particularly when asymptomatic or rarely symptomatic. Prolonged cardiac monitoring often enables clinicians to stratify the arrhythmic risk and reach the diagnosis. The technological progress of the last decades has produced an always-increasing number of heart rhythm monitoring devices, starting from the 24-hourelectrocardiogram Holtermonitoring and ending with the wide world of wearable devices. In the literature, the extreme utility of this equipment in the patients affected by cardiovascular diseases and in the general population is well established. On the contrary, athletes-based randomized trials or large-scale epidemiological studies targeting the frequency of cardiac symptoms and the use of cardiac monitoring are missing, while an ever-growing number of case series and small observational studies are flourishing in recent years. The present review showcases the available electrocardiographic monitoring options, principally in the medical setting, listing their characteristics, their indications, their supporting evidence, and their general pros and cons. The ultimate goal of this review is guiding physicians through the wide variety of heart rhythm monitoring options in the specific subfield of sports cardiology, when an arrhythmia is suspected in an athlete, to tailor the diagnostic process and favor the best diagnostic accuracy.

Assessment of left atrial appendage flow velocities to unmask atrial fibrillation in cryptogenic stroke

Abstract Funding Acknowledgements Type of funding sources: None. Background Hemostasis in the left atrial (LA) appendage (LAA) is a common cause of stroke, particularly in atrial fibrillation (AF). LAA flow have been determined to quantify LAA function. Objectives To investigate whether LAA peak flow velocities early after cryptogenic stroke have a predictive value for AF occurrence and to determine the determinants of impaired flow. Methods Consecutive cryptogenic stroke patients (139) were enrolled. LAA flow velocities during sinus rhythm were assessed early post-stroke with transesophageal echocardiography. All patients received rhythm monitoring using 7-day Holter and if negative, an implantable cardiac monitor. Results 47 Patients (34%) developed AF during a median follow-up of 554 days, median time to AF diagnosis was 93 days. Both, LAA filling (LAAfv) and emptying (LAAev) velocities were lower in stroke patients who developed AF (resp. 44.3±14.2 cm/s and 50.7±13.3 cm/s) compared with those who didn’t (resp. 59.8±14.0 cm/s and 76.8±17.3 cm/s). LAAev was the strongest predictor of AF with an AUC of 0.878 in ROC curve analysis and with optimal cut-off value of 55 cm/s. Age and mitral regurgitation were independent determinants of reduced LAAev. Conclusions Reduced LAA flow velocities can identify cryptogenic stroke patients at high risk of occult AF, and who may benefit from intensive rhythm monitoring or anticoagulation strategies.

Epicardial adipose tissue and subclinical incident atrial fibrillation in a population at risk of stroke - a cardiac magnetic resonance imaging study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Innovation Fund Denmark. Background Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and is associated with a substantially increased risk of morbidity and mortality, including heart failure and stroke(1,2). Epicardial adipose tissue (EAT) is believed to provide both thermoregulation and mechanical protection to the heart and coronary arteries in healthy human beings(3,4), but the role of EAT in the development and severity of AF suggests deleterious effects of EAT. Since EAT shares blood circulation with the myocardium, it offers the opportunity for paracrine- and neuroendocrine signaling(5), which contributes to an arrhythmogenic- and pro-inflammatory state. Purpose While EAT assessed by cardiac magnetic resonance imaging (CMR) has been found predictive of clinical AF(5,6), the association with subclinical AF has not yet been established. This study aimed to investigate the association between EAT, determined by CMR, and incident AF following long-term continuous heart rhythm monitoring by implantable loop recorder (ILR) in an at-risk population. Methods This study is a sub-study of the LOOP study. In total, 203 participants without a history of AF received an ILR and underwent advanced CMR. All participants were at least 70 years of age at inclusion and had at least one of the following conditions: hypertension, diabetes, previous stroke, or heart failure. Volumetric measurements of atrial- and ventricular EAT were derived from CMR, as seen in Picture 1, and the time to incident AF was subsequently determined. Results A total of 78 patients (38%) were diagnosed with AF during a median of 40 (37–42) months of monitoring. Of these, only 7 (9%) participants reported symptoms of AF during arrhythmia episodes, i.e., 91% had subclinical AF. In multivariate Cox regression analyses adjusted for age, sex, body mass index (BMI), and comorbidities, we found EAT to be an independent marker for time to AF with hazard ratios (95% confidence intervals) up to 1.66 (1.17–2.36; p = 0.005) when analyzing the risk of new-onset AF episodes lasting ≥ 24 hours. The Cox regression analyses are presented in Picture 2, where we furthermore have adjusted for left atrial size (LAMIN) and left atrial function (LATEF). Conclusion Atrial EAT assessed by volumetric measurements on CMR images was significantly associated with the incident AF episodes as detected by ILR.

Electrical Accidents

Electrical Accidents Abstract: When persons seek medical help after an electrical injury, physicians have to inquire on the type (AC/DC) and strength of current (>1000V is considered "high voltage") as well as the exact circumstances (loss of consciousness, falls) of the accident. In the advent of high-voltage accidents, loss of consciousness, arrhythmias, abnormal ECG or elevated troponin levels, in-hospital rhythm monitoring is warranted. In all other cases, the type of extra cardiac injury primarily directs the management. Superficial skin marks may disguise more extensive thermal injuries of inner organs.

Outcomes After Development of Ventricular Arrhythmias in Single Ventricular Heart Disease Patients With Fontan Palliation.

With the advent of more intensive rhythm monitoring strategies, ventricular arrhythmias (VAs) are increasingly detected in Fontan patients. However, the prognostic implications of VA are poorly understood. We assessed the incidence of VA in Fontan patients and the implications on transplant-free survival. Medical records of Fontan patients seen at a single center between 2002 and 2019 were reviewed to identify post-Fontan VA (nonsustained ventricular tachycardia >4 beats or sustained >30 seconds). Patients with preFontan VA were excluded. Hemodynamically unstable VA was defined as malignant VA. The primary outcome was death and heart transplantation. Death with censoring at transplant was a secondary outcome. Of 431 Fontan patients, transplant-free survival was 82% at 15 years post-Fontan with 64 (15%) meeting primary outcome of either death (n=16, 3.7%), at a median 4.6 (0.4-10.2) years post-Fontan, or transplant (n=48, 11%), at a median of 11.1 (5.9-16.2) years post-Fontan. Forty-eight (11%) patients were diagnosed with VA (90% nonsustained ventricular tachycardia, 10% sustained ventricular tachycardia). Malignant VA (n=9, 2.0%) was associated with younger age, worse systolic function, and valvular regurgitation. Risk for VA increased with time from Fontan, 2.4% at 10 years to 19% at 20 years. History of Stage 1 surgery with right ventricular to pulmonary artery conduit and older age at Fontan were significant risk factors for VA. VA was strongly associated with an increased risk of transplant or death (HR, 9.2 [95% CI, 4.5-18.7]; P<0.001), with a transplant-free survival of 48% at 5-year post-VA diagnosis. Ventricular arrhythmias occurred in 11% of Fontan patients and was highly associated with transplant or death, with a transplant-free survival of <50% at 5-year post-VA diagnosis. Risk factors for VA included older age at Fontan and history of right ventricular to pulmonary artery conduit. A diagnosis of VA in Fontan patients should prompt increased clinical surveillance.

Left Atrial Function Predicts Atrial Arrhythmia Recurrence Following Ablation of Long-Standing Persistent Atrial Fibrillation.

Left atrial (LA) function following catheter or surgical ablation of de-novo long-standing persistent atrial fibrillation (AF) and its impact on AF recurrence was studied in patients participating in the CASA-AF trial (Catheter Ablation vs. Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation). All patients underwent echocardiography preablation, 3 and 12 months post-ablation. LA structure and function were assessed by 2-dimensional volume and speckle tracking strain measurements of LA reservoir, conduit, and contractile strain. Left ventricular diastolic function was measured using transmitral Doppler filling velocities and myocardial tissue Doppler velocities to derive the e', E/e', and E/A ratios. Continuous rhythm monitoring was achieved using an implantable loop recorder. Eighty-three patients had echocardiographic data suitable for analysis. Their mean age was 63.6±9.7 years, 73.5% were male, had AF for 22.8±11.6 months, and had a mean LA maximum volume of 48.8±13.8 mL/m2. Thirty patients maintained sinus rhythm, and 53 developed AF recurrence. Ablation led to similar reductions in LA volumes at follow-up in both rhythm groups. However, higher LA emptying fraction (36.3±10.6% versus 27.9±9.9%; P<0.001), reservoir strain (22.6±8.5% versus 16.7±5.7%; P=0.001), and contractile strain (9.2±3.4% versus 5.6±2.5%; P<0.001) were noted in the sinus rhythm compared with AF recurrence group following ablation at 3 months. Diastolic function was better in the sinus rhythm compared with the AF recurrence group with an E/A ratio of 1.5±0.5 versus 2.2±1.2 (P<0.001) and left ventricular E/e' ratio of 8.0±2.1 versus 10.3±4.1 (P<0.001), respectively. LA contractile strain at 3 months was the only independent predictor of AF recurrence. Following ablation for long-standing persistent AF, improvement in LA function was greater in those who maintained sinus rhythm. LA contractile strain at 3 months was the most important determinant of AF recurrence following ablation. URL: https://www. gov; Unique identifier: NCT02755688.

Summary of evidence for threshold setting of multi-parameter electrocardiograph monitor in intensive care unit

To retrieve the evidence for threshold setting of multi-parameter electrocardiograph (ECG) monitors in intensive care unit (ICU), and summarize the best evidence. After literature retrieval, clinical guidelines, expert consensus, evidence summary and systematic review that met the requirements were screened. Guidelines were evaluated by the appraisal of guidelines for research and evaluation II (AGREE II), expert consensus and systematic review were evaluated by the Australian JBI evidence-based health care center authenticity evaluation tool, and evidence summary was evaluated by the CASE checklist. High-quality literature was selected to extract evidence related to the use and setup of multi-parameter ECG monitors in the ICU. A total of 19 literatures were included, including 7 guidelines, 2 expert consensus, 8 systematic reviews, 1 evidence summary, and 1 national industry standard. After evidence extraction, translation, proofreading and summary, a total of 32 pieces of evidence were integrated. The included evidence involved the environmental preparation for the application of the ECG monitor, the electrical requirements of the ECG monitor, ECG monitor use process, ECG monitor alarm setting principles, ECG monitor alarm heart rate or heart rhythm monitoring setting, ECG monitor alarm blood pressure monitoring setting, ECG monitor alarm respiratory and blood oxygen saturation threshold setting, alarm delay warning time setting, adjusting alarm setting method, evaluating alarm setting time, improving the comfort of monitoring patients, reducing nuisance alarm report the occurrence, alarm priority processing, alarm intelligent processing and so on. This summary of evidence involves many aspects of the setting and application of ECG monitor. According to the latest guidelines and expert consensus, it is updated and revised to guide healthcare workers to monitor patients more scientifically and safely, and aims to ensure patient safety.

Prevalence and Incidence of Atrial Fibrillation in Heart Failure with Mildly Reduced or Preserved Ejection Fraction: (Additive) Value of Implantable Loop Recorders.

Atrial fibrillation (AF) is common in heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) and has a negative impact on outcome. Reliable data on prevalence, incidence, and detection of AF from contemporary, prospective HFmrEF/HFpEF studies are scarce. This was a prespecified sub-analysis from a prospective, multicenter study. Patients with HFmrEF/HFpEF underwent 12-lead electrocardiography (ECG), 24 h Holter monitoring, and received an implantable loop recorder (ILR) at the study start. During the 2 year follow-up, rhythm monitoring was performed via ILR, yearly ECG, and two yearly 24 h Holter monitors. A total of 113 patients were included (mean age 73 ± 8 years, 75% HFpEF). At baseline, 70 patients (62%) had a diagnosis of AF: 21 paroxysmal, 18 persistent, and 31 permanent AF. At study start, 45 patients were in AF. Of the 43 patients without a history of AF, 19 developed incident AF during a median follow-up of 23 [15-25] months (44%; incidence rate 27.1 (95% confidence interval 16.3-42.4) per 100 person-years). Thus, after the 2-year follow-up, 89 patients (79%) had a diagnosis of AF. In 11/19 incident AF cases (i.e., 58%), AF was solely detected on the ILR. Yearly 12-lead ECG detected six incident AF cases and four of these cases were also detected on two yearly 24 h Holter monitors. Two incident AF cases were detected on an unplanned ECG/Holter. Atrial fibrillation is extremely common in heart failure with HFmrEF/HFpEF and may inform on symptom evaluation and treatment options. AF screening with an ILR had a much higher diagnostic yield than conventional modalities.

The tip of the eventberg: incidental rhythm disturbances by remote monitoring following pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Implantable loop recorders (ILR) are increasingly used for continuous rhythm monitoring following pulmonary vein isolation (PVI) for atrial fibrillation (AF). However, the impact of non-AF episodes in this patient population is unknown. Purpose Firstly, the aim of our study was to asses the incidence of clinically important non-AF events. Secondly, we wanted to identify possible risk factors leading to incidental non-AF events. Methods In this retrospective single center study, all patients implanted with ILR following PVI in our center between 2016 and 2022 were analysed. The indication to ILR implantation and remote monitoring after successful PVI was based on patient preference. Transmissions were carefully reviewed by two independent electrophysiologists. Bradycardic events were defined as documented symptomatic bradycardia, AV-Block II˚, AV-Block III˚ or Sick-Sinus Syndrom. Tachycardic events were defined as documented symptomatic supraventricular tachycardia (non-AF) or ventricular tachycardia &amp;gt;160/min with at least 30 seconds duration. Results A total of 219 patients underwent PVI and consequent ILR implantation. We evaluated a mean 2.1±1.1 years of follow up (FU) with a median 68 events/patient (25th–75th IQR: 13-590 events/patient). Overall, 49 patients (22.4%) developed at least one bradycardic event, 6 patients (2.7%) were later implanted with a pacemaker. In univariate logistic regression analysis age, persistent AF, left atrial diameter and prior cardioversion correlated with an increased risk of bradycardic events. Upon a multivariate logistic regression age and prior cardioversion predicted bradycardic events. At least one tachycardic non-AF event was observed in a total of 9 patients (3.6%). Supraventricular tachycardia was observed by 4 patients (1.8%), one (0.4%) were ablated by an atrioventricular nodal reentry tachycardia (AVNRT), others (1.4%) were ectopic atrial tachycardia treated conservatively. Sustained wide complex tachycardia was recorded in 5 patients (2.2%), thereof two (0.9%) received a secondary prophylactic implantable cardioverter defibrillator (ICD). The multivariate analysis did not show any statistically significant value predicting tachycardic events. Conclusion Use of ILR for rhythm monitoring following PVI could increase the early detection of incidental rhythm events, especially bradycardic episodes. However, to asses this possibly beneficial effect further prospective, multicenter studies are needed.

Changes in healthcare utilisation and declarable care products during the implementation of a remote atrial fibrillation management pathway: The TeleCheck-AF project

Abstract Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a digital care pathway, which consists of a structured teleconsultation ("Tele") preceded by an app-based on-demand heart rate and rhythm monitoring infrastructure ("Check") and the consecutive integration of the app-derived findings in a comprehensive atrial fibrillation (AF) management. Purpose To evaluate changes in healthcare utilisation and declarable care products during the implementation of the TeleCheck-AF approach in a Dutch AF-clinic. Methods Healthcare provided to patients in the Netherlands is based on a diagnosis-treatment combination (Dutch: DBC). Once a patient visits the hospital, a treatment trajectory is opened, which contains the DBC care product. The DBC care products contain diagnostic and therapeutic performances for a certain diagnosis as well as information about reimbursement and are weighted in light (≤ € 200), medium (€ 300-500) and heavy (≥ € 600) depending on the performed diagnostic tests. Patients with AF who were treated with both a conventional approach in 2019 (standard care) and by the TeleCheck-AF approach in 2020 in a Dutch AF-clinic, were compared in this prospective case-crossover analysis. Healthcare utilisation in terms of numbers and modes of outpatient contacts (teleconsultation vs face-to-face), number of emergency department (ED) presentations, use of diagnostic resources (i.e. ECG, Holter) and related reimbursement were analysed. A patient experience survey which encompassed five questions regarding use of the app and patient satisfaction with the remote heart rate and rhythm control was performed. Results Ninety-one patients with AF from a Dutch AF-clinic (median age 68 years; 43% women) were analysed. Within the conventional approach in 2019, 113 face-to-face consultations and 1 teleconsultation were performed. After the implementation of TeleCheck-AF in 2020 the number of face-to-face consultations reduced by 53% and teleconsultations increased by 2900%. While 151 ECGs and 42 Holter-ECGs were performed within the conventional approach, the number of ECGs in the TeleCheck-AF approach decreased by 48% and number of Holters decreased by 35%. ED presentations did not differ significantly in the conventional compared to TeleCheck-AF approach (22 vs 17). Patients’ satisfaction within the TeleCheck-AF approach was high. The change in healthcare utilisation in TeleCheck-AF treated patients resulted in a mutation in declarable care products weights (towards light weighted DBC) and associated reimbursement. Conclusion The implementation of TeleCheck-AF was associated with a change in health care utilisation which resulted in a disproportional drop in reimbursement by health insurances due to a shift in declarable care products weights. Results of this analysis were basis to design a new reimbursement code for the TeleCheck-AF approach in the Netherlands.

New onset, recurrence and progression of atrial fibrillation after cardiac surgery during 2.5 years of continuous rhythm monitoring

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the Netherlands Heart Foundation (CVON2014-09, RACE V: Reappraisal of Atrial fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF). Background Atrial fibrillation (AF) in the early postoperative phase (POAF) is a frequent complication after cardiac surgery with an incidence of up to 50%. Recent studies have shown that early-POAF is a one of the strongest predictors of late recurrences. However, it is unknown how POAF-burden (percentage of time in AF) progresses in the months and years following surgery. Recent studies suggested that AF-burden is associated with increased risk of stroke and therefore identifying factors associated with a higher POAF-burden is desirable. Purpose To investigate AF-burden progression patterns and factors associated with increased AF-burden after cardiac surgery during 2.5 years of continuous rhythm monitoring. Methods Patients with and without history of AF undergoing cardiac surgery were included. Preoperatively, all patients underwent transthoracic echocardiography, electrocardiography, and blood biomarker analysis. Intraoperatively, all patients received an implantable loop recorder. Continuous rhythm monitoring was performed over a period of 2.5 years. AF-burden progression was calculated as percentage of time in AF for different time intervals (0-3, 3-12, and 12-30 months) and presented in alluvial-plots. Classification of burden was performed based on the cut-off values for tertiles. In addition, AF-characteristics such as episode duration and ventricular rate were analyzed as potential surrogate markers of AF-burden. Results The study population consisted of 134 patients undergoing cardiac surgery. Median follow-up (FU) was 2.7 years (IQR: 2.2-2.9 years) and 98 patients completed 2.5 years of FU. Eighty-one (60.4%) patients developed AF during the follow-up period. Early-POAF (first 3 months) occurred in 75 patients (56.0%) and late-POAF (after first 3 postoperative moths) in 47 patients (35.1%). Highest AF-burden was observed in the first 3 postoperative months with a significant reduction between 3-12 moths (p=0.007) (Figure 1). In the period between 12-30 months an increase in AF burden was observed for all groups (p&amp;lt;0.001), however the burden remained lower as compared to the first 3 postoperative months (Figure 1). Overall, 50% of patients showed a reduction of AF burden and only 11% an overall increase. Individual postoperative AF-burden was strongly associated with the longest AF-episode (Spearman’s rho=0.86, 95%CI: 0.75-0.92, p&amp;lt;0.001) (Figure 2A), and to a lower extent with the duration of the median episode (Spearman’s rho=0.38, 95%CI: 0.13-0.58, p=0.001) (Figure 2B). Conclusion POAF is a frequent complication in the early and late postoperative phase with the highest AF-burden present in the first 3 postoperative months. Also, AF-burden seems to be highly correlated to the longest individual episode duration.

Number of comorbidities is associated with symptom severity and arrhythmia progression in paroxysmal atrial fibrillation - Data from the RACE V study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): We acknowledge the support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF (RACE V). Unrestricted grant support from Medtronic Trading NL B.V. Background Atrial fibrillation (AF) progression is associated with morbidity and mortality. Both comorbidities and symptom severity are pillars in the ABC treatment pathway as proposed by the ESC guidelines. Interaction between comorbidities, symptom severity and AF progression seems evident, but evidence is lacking. Aims The aim of the present study is to investigate whether the number of comorbidities is related with severity of AF symptoms, and whether AF symptom severity is associated with AF progression in patients with paroxysmal AF. Methods Patients Underwent extensive phenotyping at baseline and received continuous rhythm monitoring with an implantable loop recorder during follow-up. We studied the relation between comorbidities, AF symptom severity [quantified with the Toronto AF Severity Scale (AFSS)], and AF progression in patients with paroxysmal AF included in the RACE V study. Multivariate regression analysis was performed to study the association between comorbidities and AFSS tertiles, and the association between AF progression and AFSS tertiles. Results Of 417 paroxysmal AF patients, AFSS questionnaires at baseline were available in 403 patients (97%). Mean age was 65 (IQR 58-71) years, 174 (43%) were women. 132 patients (33%) reported a low score [score 0–2; lowest tertile (T1)], 129 patients (32%) reported a moderate score [score 3–7; middle tertile (T2)], and 142 (35%) reported a high score [score 8–35; highest tertile (T3)]. Patients with the most severe symptoms were older, more often women, more often had coronary artery disease, kidney dysfunction, and a higher body mass index (BMI). The number of comorbidities [defined as hypertension, heart failure, age &amp;gt;65 years, diabetes mellitus; coronary artery disease, BMI &amp;gt;25kg/m2, moderate or severe mitral valve regurgitation and kidney dysfunction (estimated glomerular rate (eGFR) &amp;lt;60)] was a significant determinant of higher AFSS scores [2 (1-3) in T1, 2 (2-3) in T2, 3 (2-4) in T3, respectively P &amp;lt;0.001], with a coefficient of 1.417 (P &amp;lt;0.001) for each extra comorbidity. AF progression occurred most frequently in T3 of the AFSS [10 (7%) in T1, 19 (15%) in T2, 21 (15%) in T3, respectively, P = 0.01]. After adjusting the AFSS tertile for age, coronary artery disease, BMI and eGFR there was no significant association for AFSS with AF progression, AFSS T2 versus T1 OR 2.19 (CI 0.92 - 5.63, P = 0.087), and AFSS T3 versus T1 OR 2.23 (CI 0.92 - 5.84, P = 0.085). AF progression occurred in 14% of AF patients with multimorbidity, defined as ≥2 comorbidities, in comparison to 5% in the AF patients with ≤1 comorbidity (P = 0.023) Conclusions In paroxysmal AF, multimorbidity was associated with symptom severity and AF progression. However, symptom severity was not associated with AF progression.

Brady- and tachyarrhythmias in paroxysmal atrial fibrillation: results from long-term continuous electrocardiographic monitoring in RACE V

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, and grant support from Medtronic to the institution. MHJPF was funded by a grant from the Karen Elise Jensen Foundation. JCN was supported by a grant from the Novo Nordisk Foundation Background Atrial fibrillation (AF) has been associated with adverse events and constitutes a significant, global healthcare challenge. Paucity exists on the occurrence of brady- and ventricular tachyarrhythmias. Purpose The aim of this predefined sub-analysis of the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilization in the progression of AF (RACE V) study was to examine the prevalence of brady- and tachyarrhythmias using continuous rhythm monitoring in patients with paroxysmal self-terminating AF (PAF). Methods We identified 417 patients with PAF and at least two years of follow-up in RACE V; 25 patients with pacemakers at baseline were excluded. All remaining patients (n=392) received an implantable loop recorder and performed daily automated and weekly manual transmissions. Throughout follow-up, all detected episodes of tachycardia ≥182 BPM (cycle length ≤330ms) of ≥24 beats, bradycardia ≤30 BPM (cycle length ≥2000ms) of ≥12 beats, and pauses ≥5 seconds were adjudicated by three cardiologists. Results Over 1,272 patient years of continuous rhythm monitoring, we validated 1,940 episodes in 175 patients with paroxysmal self-terminating PAF (45%); 106 (27%) patients experienced AF or atrial flutter (AFL) with a rapid rate, pauses ≥5 seconds or bradycardias ≤30 BPM occurred in 47 (12%) patients (figure 1), and in 22 (6%) patients, both rapid AF/AFL and bradyarrhythmias were observed. No sustained ventricular tachycardias occurred. In the multivariable analysis, age &amp;gt;70 years (HR 2.4, 95% CI 1.4-3.9), longer PQ interval (HR 1.9, 1.1-3.1), CHA2DS2-VASc score ≥2 (HR 2.2, 1.1-4.5), and treatment with verapamil or diltiazem (HR 0.4, 0.2-1.0) were significantly associated with bradyarrhythmia episodes. For tachyarrhythmia episodes, age &amp;gt;70 years was associated with a significantly lower tachyarrhythmia risk (HR 0.4, 95% CI 0.2-0.7) in the multivariable analysis. Conclusions In a cohort exclusive to patients with self-terminating PAF, severe bradyarrhythmia episodes or AF/AFL with rapid ventricular rates occurred in 45% of patients. Our data highlight a higher than anticipated bradyarrhythmia risk in PAF.

Diagnostic accuracy of smart gadgets/wearable devices in detecting atrial fibrillation in primary prevention: a meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart. Recent technology advances have allowed for heart rhythm monitoring using smart gadgets/wearable devices which can be used for early AF diagnosis. Purpose We performed a systemic review and meta-analysis to assess the accuracy of AF diagnosis by smart gadgets/wearable devices in primary prevention. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to September 22th, 2022 for observational studies of the diagnostic accuracy of smartphone application, wrist-worn wearables and external devices in detecting AF in primary prevention. Studies with 12-lead ECG or single-lead ECG interpreted by a cardiologist as gold standard were included. We calculated the area under the curve (AUC) of the summary receiver operating characteristic curves (SROC) and pooled sensitivities and specificities. Results A total of 28 studies were included enrolling 13463 patients, 57%(95% CI: 55-59%) male with average age of 65.3years (95% CI: 60.1 – 70.4). The pooled prevalence of AF was found to be 13% (95% CI 10 – 15%). In the overall analysis of all devices, the AUC was 0.99 (95% CI: 0.97-0.99)(Figure 1), the sensitivity 93%(95% CI: 89 – 95%) and the specificity 97%(95% CI: 95 – 98%) (Figure 2). Wrist-worn wearables had AUC of 0.97 (95% CI: 0.94-0.99), the sensitivity 83%(95% CI: 52 – 96%) and the specificity 98%(95% CI: 87 – 100%). Smartphone applications had AUC of 0.97 (95% CI: 0.96-0.98), the sensitivity 92%(95% CI: 77 – 98%) and the specificity 95%(95% CI: 91 – 97%). External devices had AUC of 0.99 (95% CI: 0.97-0.99), the sensitivity 94%(95% CI: 91 – 96%) and the specificity 97%(95% CI: 95 – 98%). Single-lead ECG had AUC of 0.99 (95% CI: 0.97- 0.99), the sensitivity 93%(95% CI: 88 – 96%) and the specificity 91%(95% CI: 78 – 97%). photoplethysmography pulse waveform technology (PPG) had AUC of 0.97 (95% CI: 0.96-0.98), the sensitivity 91%(95% CI: 78 – 97%) and the specificity 95%(95% CI: 91 – 97%). Pulse beat interval technology had AUC of 0.99 (95% CI: 0.98-0.99), the sensitivity 95%(95% CI: 90 – 98%) and the specificity 96%(95% CI: 93 – 98%) Conclusions Smartphone application, wrist-worn devices and external devices have excellent diagnostic accuracy in atrial fibrillation diagnosis in primary prevention.

Impact of catheter ablation on atrial fibrillation burden and symptoms in patients with hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial Fibrillation (AF) is more common in patients with hypertrophic cardiomyopathy (HCM) and is often very symptomatic in this cohort. The impact of catheter ablation (CA) in this context is controversial with low success rates using the guideline mandated end-point of freedom from arrhythmia. Purpose To determine whether CA of AF in patients with HCM would be associated with a significant reduction in AF burden and symptoms. Methods Patients diagnosed with HCM undergoing CA of AF between February 2017 and June 2021 were identified from a prospective, single-centre registry. Patients with CIED in situ were selected. Patients were followed up for objective evaluation of symptom severity. Interval device interrogation and remote CIED monitoring was used to determine first AF/AT recurrence and percentage AF/AT burden on continuous rhythm monitoring 12-months before and after CA. Results Of 257 HCM patients undergoing CA of AF, 33 had CIEDs and were followed up for 32±15 months. The mean age was 56.4±10.2 years and 22 (67%) were male. The maximal wall thickness on echocardiography was 1.7±0.3cm and LA diameter was 4.8±0.9. The left ventricular ejection fraction was 50±15%. 17 (52%) patients had paroxysmal AF and 16 (48%) had persistent AF of which 6 (18%) were longstanding persistent AF. Mean AF burden prior to CA was 36.9±26.5% and 24 (73%) reported EHRA III-IV symptom severity. AF recurred in 27 (82%) patients with a median time to first recurrence of 8 (3-17) months. AF burden significantly reduced after index AF CA (27% (7,59) to 2% (0, 41)) (Z=-2.2, p= 0.03)) and reduced further when allowing for repeat procedures in 10 (30%) patients to 0% (0-30%). This represented a &amp;gt;50% relative reduction in 22 (67%) patients and &amp;gt;95% relative reduction in 16 (48%) patients. This correlated with a reduction in symptom score with 20 (60.6%) patients reporting a change of ≥1 EHRA class, and 20 (60.6%) patients reporting EHRA class I-IIa status at 12 months. A positive relationship was seen on regression analysis, with a 16.4% absolute reduction in AF burden associated with a reduction of one EHRA class. (R2= 0.206, F=7.5, p=0.01). Amongst the 24 (72%) patients who had an AF/AT recurrence after the final procedure who would conventionally be called failures by guideline definitions, 11 (45.8%) patients improved by ≥ 1 EHRA class and 11 (45.8%) were class I-IIa. Conclusion Although AF recurrence is common after CA in HCM patients, there is a significant reduction in AF burden and symptoms in a majority of patients. A more comprehensive evaluation of AF burden, symptoms, quality of life and impact on hard end-points is needed to determine the utility of CA in this context.

Rigorous and long-term cardiac monitoring strategy in cryptogenic stroke or TIA patients in a tertiary care centre results in a two-fold increase in AF detection

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Special Research Fund (Bijzonder Onderzoeksfonds, BOF) Hasselt University. This study is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Background Atrial fibrillation (AF) is a major cause of ischaemic stroke. Oral anticoagulation is recommended in stroke survivors with AF to prevent recurrence. Prolonged ECG monitoring using insertable cardiac monitors (ICMs) has been shown to increase the detection rate of AF compared to standard 24-hour ECG monitoring in cryptogenic stroke patients. However, prolonged ambulatory ECG monitoring is underutilized, likely contributing to an underdiagnosis of AF and missed anticoagulation treatment opportunities for secondary stroke prevention. Purpose This study aims to evaluate how our evolving cardiac monitoring strategy affected AF detection rates one year after cryptogenic ischaemic stroke or transient ischaemic attack (TIA) in a tertiary care centre. Methods We retrospectively identified all consecutive cryptogenic stroke or TIA patients admitted to our centre between 1/01/2017 – 1/01/2022. Patients with a pacemaker or implantable cardioverter-defibrillator were excluded from the analysis. Data were collected from the electronic medical record. Available cardiac monitoring modalities included 24-hour Holter monitoring, 7-day Holter monitoring, and insertable cardiac monitors (ICM). After October 2020 (i.e., period 2), the latter became part of our routine diagnostic workup for AF detection in case extended (7-day) Holter monitoring was negative. Results All 691 cryptogenic stroke or TIA patients admitted to our hospital during the inclusion period were considered. These were elderly patients (69.7 ± 13.2 years) with a CHA2DS2-VASc score of 3 [2 - 5]. Figure 1 shows evolving trends in the use of the different cardiac monitoring tools before and after October 2020. In particular, the use of 7-day Holter monitoring and long-term continuous monitoring with ICM increased after implementing our new diagnostic protocol compared to 24-hour Holter monitoring (p&amp;lt;.001). ICMs were inserted 95 [66 – 145] days after index stroke or TIA. The new diagnostic protocol detected more AF one year after the index stroke or TIA (3.7% vs. 10.1%, p&amp;lt;.001, Figure 2). In 95.6% of patients with AF detected within one year, oral anticoagulation was initiated. Future research should determine whether adopting a strategy of routine ICM following cryptogenic stroke and, thus, more appropriate anticoagulant therapy may improve clinical outcome in these patients. Conclusions The increased use of prolonged cardiac monitoring in cryptogenic stroke or TIA patients resulted in a two-fold increase in AF detection one year after stroke. Therefore, our results underscore the need to implement guideline-recommended prolonged rhythm monitoring using ICMs in addition to short-term ECG monitoring to ensure adequate secondary stroke prevention.

Diagnostic accuracy of smartwatch in detecting atrial fibrillation: a systemic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Atrial fibrillation (AF) is the most common sustained arrhythmia and an important risk factor for stroke and heart. Recent technology advances allowed for heart rhythm monitoring using Smartwatches which can be used for early AF diagnosis. Purpose We performed a systemic review and meta-analysis to assess the accuracy of AF diagnosis by smartwatches. Methods We systematically searched Medline, Embase and Cochrane electronic databases up to September 28th, 2022 for observational studies of the diagnostic accuracy of smartwatches devices in detecting AF. Studies with 12-lead ECG or single-lead ECG interpreted by a cardiologist as gold standard were included. We calculated the area under the curve (AUC) of the summary receiver operating characteristic curves (SROC) and pooled sensitivities and specificities. Results A total of 20 studies were included enrolling 3447 patients, 57%(95% CI: 55-59%) male with average age of 68.3years (95% CI: 63 – 74). The pooled prevalence of AF was found to be 40% (95% CI 27 – 53%). In the overall analysis of all smartwatches, the AUC was 0.99 (95% CI: 0.98-1.00) (Figure 1), the sensitivity 94%(95% CI: 90 – 96%) and the specificity 97%(95% CI: 95 – 98%) (Figure 2). Smartwatches in primary prevention showed an AUC of 0.97 (95% CI: 0.96-0.99), sensitivity of 83%(95% CI: 52 – 96%) and specificity of 98%(95% CI: 87 – 100%) whereas in secondary prevention showed an AUC of 0.99 (95% CI: 0.98-1.00), sensitivity of 95%(95% CI: 94 – 97%) and specificity of 97%(95% CI: 96 – 98%). In the subgroup analysis by technology, smartwatches with single lead ECG showed an AUC of 0.99 (95% CI: 0.98-1.00), sensitivity of 95%(95% CI: 89 – 97%) and specificity of 97%(95% CI: 94 – 99%) whereas smartwatches with photoplethysmography pulse waveform technology showed an AUC of 0.99 (95% CI: 0.97-0.99), sensitivity of 95%(95% CI: 92 – 96%) and specificity of 97%(95% CI: 95 – 99%). Conclusions Smartwatches proved an excellent diagnostic accuracy for AF diagnosis.

Monitoring for arrhythmia in transthyretin cardiac amyloidosis with remote patch devices

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Transthyretin cardiac amyloidosis (ATTR-CA) is associated with an increased incidence of arrhythmias. We hypothesized that non-invasive, two-week outpatient cardiac rhythm monitoring of patients with ATTR-CA would detect high rates of ventricular tachycardia and atrial fibrillation/flutter (AF). Purpose To characterize arrhythmia in patients with ATTR-CA on two-week, non-invasive cardiac rhythm monitors. Methods 38 patients with ATTR-CA (mean age 76.9 SD 10.0 years, 89.5% male) who underwent two-week remote external patch monitoring were included in this single center retrospective study. An age-matched control group included 38 patients (mean age 73.9 SD 12.3, 76.3% male) who underwent the same cardiac rhythm monitoring as part of neurological workups. Results NSVT was detected on the remote monitor in 81.6% of ATTR-CA patients and AF was detected in 26.3% of patients. ATTR-CA was associated with higher rates of NSVT and AF compared to the control group (28.9% with NSVT and 5.3% with AF). As seen in Figure 1, there were only three ATTR-CA patients without either AF, NSVT, advanced atrioventricular block, or a significant pause detected on remote monitor. Among the ATTR-CA group, at median 45 weeks follow-up, there were 4 heart failure hospitalizations, 2 cardiovascular events (1 episode of sustained VT and 1 stroke), 6 permanent pacemakers placed, and 3 implantable cardioverter-defibrillators placed, including one for sustained VT. NSVT and AF were not associated with a composite of these adverse outcome. Conclusion ATTR-CA was associated with high rates of NSVT and AF on noninvasive remote monitors. While evidence regarding the management of arrhythmias, particularly NSVT/VT, in ATTR-CA remains limited, two-week noninvasive cardiac monitoring can be considered to aid in risk stratification for both atrial and ventricular arrhythmias in ATTR-CA.

Wrist-worn arrhythmia monitoring devices are well accepted for long-term rhythm assessment by the elderly

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): This study was funded by PulseOn Oy. Background Wearable devices such as patch ECG monitors and wrist-worn intermittent ECG devices have recently emerged to fill the gap between Holter monitors and implantable loop recorders in diagnosing paroxysmal cardiac arrhythmias. Unlike patch ECG, wrist-worn devices require active participation of the patient, for example, for taking the ECG recordings. The incidence of cardiac arrhythmias increases with age, so it is important that the devices are easy enough to use also for older people. Purpose We evaluated the usability of a wrist-worn arrhythmia monitoring device among elderly. The device is exclusively targeted for health care providers to be handed out to patients for planned monitoring period instead of being targeted directly to consumers. Another purpose was to obtain feedback on the comfortability of wearing the device and possible skin irritation caused by continuous wearing. Methods We recruited 200 subjects of at least 65 years of age (average 71, range 65-92) with no previous atrial fibrillation diagnosis through a newspaper advertisement. The subjects came for a visit in a local cardiac clinic where they received a short introduction for using the wrist device. The monitoring period was defined as two weeks. The participants were instructed to take four scheduled ECG measurements daily and every time they had arrhythmia symptoms or if the continuous photoplethysmography-based rhythm monitoring of the device detected irregular rhythm and notified the user. The subjects had to recharge the device once during the monitoring period using the accompanied charging dock. The subjects were instructed to keep a diary on the device usage. The subjects also filled a feedback questionnaire regarding device usability at the end of the monitoring period. Results On a scale of 1 to 5, the overall easiness of using the device obtained an average score of 4.4 (standard deviation 0.7), the easiness of taking the ECG recordings 4.7 (std 0.6), and the easiness of device charging 4.8 (std 0.6). All except one study subject were capable of using the device in the correct way for the whole monitoring period. Average score for the device causing skin irritation was 1.6 (std 1.0) when score 1 was considered ‘no irritation’. However, one subject had to stop using the device prematurely due to skin irritation. Three of the previously undiagnosed subjects had paroxysmal AF episode during the monitoring period and another eleven subjects had other atrial tachycardia events. Conclusion Based on the obtained feedback, the studied wrist-worn arrhythmia monitor was found easy to use and was well received by the study participants. The studied wrist-worn monitoring device seems thus suitable for arrhythmia diagnosis in elderly patients. A wearable device, being immediately available at the wrist for taking ECG measurements, additionally provides the benefit of being able to record also short-lasting atrial tachycardia episodes.