Atrial Fibrillation Symptoms Research Articles

Symptoms Burden as a Clinical Outcomes Assessment in HeartFailure Patients With Atrial Fibrillation.

Safe and effective pharmacologic therapy for atrial fibrillation (AF) in heart failure (HF) is an unmet need. In AF clinical trials, the standard primary endpoint of time to first symptomatic AF event (TTFSE) has several disadvantages, which could theoretically be overcome by measurement of AF-specific symptoms burden during an entire follow-up period. The authors sought to develop and validate a method of measuring symptom burden of AF in a HF population. The authors constructed a patient-reported outcome instrument (Atrial Fibrillation Symptoms Questionnaire [AFSQ]) to function in the setting of AF/HF, and used it to measure symptoms throughout long-term follow-up. The AFSQ queries the presence of 10 new or worsening symptoms, equally divided between those associated with AF or HF. In a 267 patient AF/HF trial comparing 2 AF prevention treatments, the AFSQ was linked to electrocardiography documented AF to form a 2-component clinical outcome assessment (SxBAF) that was subjected to psychometric testing, anchor validation, and endpoint efficiency comparison to TTFSE. SxBAF exhibited greater efficiency than time to first symptomatic event for treatment difference detection, resulting in smaller projected clinical trial sample sizes. SxBAF correlated well with device-detected AF burden (Spearman's ρ=0.74; P< 0.0001), while permitting gradation in symptom severity. SxBAF also identified treatment group differences in cardiovascular serious adverse events and AF interventions and in recent-onset AF provided specificity for AF- or worsening HF-associated symptoms (P< 0.001 for each). Measurement of symptoms burden throughout clinical trial follow-up is feasible in AF/HF and should be useful for evaluating patient-centered outcomes in AF prevention trials. (Genetically Targeted Therapy for the Prevention of Symptomatic Atrial Fibrillation in Patients With HeartFailure [GENETIC-AF]; NCT01970501).

Impact of Atrial Fibrillation and Atrial Fibrillation Therapies on Sports Performance in Athletes

BACKGROUNDIt has been hypothesized that both atrial fibrillation (AF) and medications for AF, are poorly tolerated in athletes. OBJECTIVETo determine the impact of AF and AF treatments on sports performance METHODSAn internet-based survey, initiated via StopAfib.org, queried the impact of AF and treatment modalities on sports performance, training, and symptoms. Performance, (rated in comparison to personal best), frequency of training and competition were compared prior to onset of AF symptoms versus when symptoms at worst, via paired Wilcoxon, and then similarly compared in relation to participants’ AF treatments. RESULTSBetween 5/13/19 and 2/29/20, 1055 athletes responded, 78% male, median age 61-70 years. Most reported sports were cycling (25%) and running (20%). Development of AF was associated with declining sports performance, competition, and training frequency. Of 565 participants who detrained, 31% reported no change in symptoms, 56% reported decreased frequency, and 13% reported no further AF. Among athletes that received treatment, ablation was associated with greater improvement in sports performance than use of medications. Of 262 athletes currently on medication, 27% reported that it was completely effective, 58% partially effective, and 15% not effective. Of 653 athletes that have taken medication currently and/or in the past, 43% reported side effects, most commonly fatigue, low energy, or decreased athletic performance. CONCLUSIONAthletes reported that AF was associated with worsening sports performance. Among AF treatment modalities, ablation was associated with the greater reported improvement in sports performance than use of medications which also had a high frequency of side effects.

Symptoms and atrial fibrillation burden measured by an insertable cardiac monitor in endurance athletes

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia in athletes, but knowledge regarding AF burden, symptoms and quality of life (QoL) in endurance athletes with AF is limited. Purpose To study AF burden by continuous monitoring using insertable cardiac monitor (ICM), AF symptoms and QoL in endurance athletes with paroxysmal AF. Methods In endurance athletes diagnosed with paroxysmal AF who reported ≥2 episodes of AF, of which ≥1 during the past six months, we continuously monitored AF using ICM. Episodes recognized as AF by ICM were validated by a cardiologist. We defined AF burden as the cumulative duration of AF episodes lasting ≥30 secs divided by the total duration of monitoring. AF symptoms were assessed using the 21-item Atrial Fibrillation Effect on QualiTy-of-Life Questionnaire (AFEQT). AFEQT produces a summary score and three subscale scores (symptoms, daily activities, treatment concerns), ranging from 0 (complete AF-related disability) to 100 (no AF-related disability). We defined any score &amp;lt;80 as clinically relevant AF symptoms. We classified athletes according to the modified European Heart Rhythm Association (mEHRA) classification. Sport participation was obtained by questionnaires. Height and weight were measured and physical fitness was examined during cardiopulmonary exercise testing. Results A total of 38 athletes (3 female, 8%) were included. Table 1 shows their characteristics. Eight of the athletes (21%) had recurrent AF after previous AF ablation therapy. ICM recordings were available in 30 athletes who were monitored for an average of 53±21 days (mean±SD). Eighteen athletes (60%) had ≥1 AF episode, the median number of AF episodes was 2 (interquartile range 8.75), and the mean AF burden was 1.4±2.5%. The mean AFEQT summary score was 84±12 and 11 athletes (29%) had an AFEQT summary score &amp;lt;80. The mean AFEQT symptom subscale score was 78±18). While 21 athletes (55%) had a symptom subscale score &amp;lt;80, indicating clinically relevant symptomatic AF, 9 (24%) scored &amp;lt;60, indicating more severely symptomatic AF. Figure 1 shows ICM-detected AF burden across categories of mEHRA classes and categories of the AFEQT summary score. The AF burden corresponded to both AFEQT scores and mEHRA categories, with a higher AF burden associated with more symptomatic AF (Figure 1). AF burden was numerically lower in athletes with recurrent AF after previous AF ablation therapy, compared to athletes previously not treated with AF ablation (0.6% vs. 1.7%, p= 0.66), but previously ablated athletes were more symptomatic (AFEQT symptom subscale score 68 vs. 80, p= 0.04). Conclusions Despite a relatively low AF burden during continuous monitoring with ICM, a majority of the athletes had clinically relevant symptomatic AF. Athletes with recurrent AF after previous ablation therapy had a numerically lower AF burden, but were more symptomatic compared to athletes with paroxysmal AF not previously treated with AF ablation.

Sex differences in the substrate of atrial fibrillation and the outcome of thoracoscopic ablation

Abstract Background Women with atrial fibrillation (AF) suffer more from AF symptoms, a lower quality of life, and have an enhanced risk of stroke. The AF recurrence after ablation is higher in women than in men. We hypothesize that sex specific differences in the atrial fibrotic substrate underlie these differences in clinical outcome. Here, we sought to characterize atrial fibrosis and fibrosis formation in the left atrial appendage (LAA) of women and men undergoing thoracoscopic ablation of AF. Methods We used the excised LAA of 30 female and 30 male patients with persistent AF undergoing thoracoscopic AF ablation. Patients were matched for age. In addition propensity score matching was also conducted for adjusting intermediary variables such as AF duration, Age ≥ 75, Body mass index (BMI), and CHA2DS2-VASc score ≥ 4. LAAs were stained with picrosirius red to quantify collagen and with vimentin for fibroblasts. Images were analyzed automatically (Image J version 1.50i) using color deconvolution to identify the area fraction of collagen and fibroblast. Results Women had similar age as men (66.4±7.76 vs 66.1 ±7.57, P= 0.85) but had a trend toward more cardiovascular risk factors [CHA2DS2-VASc score ≥ 4, (23.3 vs 6.7)%, P=0.07]. The total percentage of fibroblasts was larger in women 14.98 (9.79-24.95) % than men 13 (5.85-17.46) %, P=.018. In addition, in women fibroblasts were located more in epicardially and endocardially than in the interstitium.[women 8.18 (5.06-13.36) % vs men 6.49 (2.73-9.92) % , P=0.005].There was not a remarkable differences in total amount of collagen between the groups [women 16.03 (9.67-26.98) % vs men 15.50 (9.50-20.90) %, P=0.57 ], but there was a trend towards more epicardial and endocardial collagen in women than men [11.81(5.75-22.11)% vs 10.24 (6.06-15.10) % , P=0.06]. Conclusion We demonstrate more epicardial and endocardial fibroblasts in the LAA of women compared to men with persistent AF. There was similarly a trend towards more epicardia and endocardial but not interstitial collagen deposition. These findings may –at least in part- underlie sex specific differences in AF pathophysiology and ablation outcome.

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

Development of a systematic referral model to primary care health interventions for patients with atrial fibrillation. a delphi study

Abstract Background The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) recommend integrated care in AF, combining medical treatment with lifestyle modifications and psychosocial management in a multi-disciplinary set-up. Research show that patients with AF can benefit from lifestyle interventions and psychosocial management, like patient education. According to World Health Organization recommendations, these health interventions are moving from hospitals to primary healthcare settings. Therefore, patients with AF should be systematically referred to these interventions. Yet, an evidence-based referral model that can support this transition is lacking. Purpose The purpose is to develop a systematic referral model for primary care health interventions for patients with AF. Methods We used the Delphi-technique with three rounds of questionnaires (figure 1). International and national clinical experts in AF across disciplines and health sectors were invited to participate. In the first round, the expert panel evaluated items that could be part of a referral model on relevance, improvability and self-reporting. In the second round, the expert panel evaluated each item as either an inclusion or exclusion criteria, important knowledge to have, or not relevant. In the third round, the expert panel evaluated the items according to data source and outcome status. A final model was drawn based on items reaching consensus. The study was reported according to the guidance on conducting and reporting Delphi studies (CREDES). Results In total, 69 of 139 invited experts accepted to participate (50%). These were mostly academics or clinicians (90%), stemming from primary sector (16%), secondary sector (35%) and research (32%). Most were medical doctors (36%) and nurses (35%). However physiotherapist, psychologists, dieticians, and other disciplines along with six patients with AF were also represented. The expert panel (60% females) had a mean age of 50 years, and 65% were from Denmark. For the final referral model (figure 2), AF symptom burden and impaired health-related quality of life, anxiety and poor medicine compliance combined with a risk factor profile were the main inclusion criteria. Furthermore, it was important to know about the patients’ mental well-being, self-management abilities and comorbidities. Conclusion Consensus was reached for a generic referral model, which can be further adjusted in the appropriate clinical context. The model includes inclusion criteria which closely correlate with guidelines for AF management focusing on reducing the patients’ symptom and risk factor burden. The referral model is expected to increase the number of patients with AF referred to primary care health interventions, which could lead to better quality of life, fewer hospital admissions and lowered health care costs in AF.

Persistence and predictors for non-persistence to edoxaban therapy in patients with atrial fibrillation: 4-year follow-up data from the ETNA-AF-Europe study

Abstract Background Non-persistence to non-vitamin K antagonist oral anticoagulants (NOACs) is associated with increased stroke risk in atrial fibrillation (AF) patients. To date, most NOAC persistence studies have been retrospective and often did not include patients receiving edoxaban. Identifying predictors for non-persistence may be useful when considering the design of future studies and help develop strategies to reduce non-persistence in clinical practice. Purpose To define and describe patients who did not reach the end of the study period and were non-persistent to edoxaban during the 4-year follow-up of ETNA-AF-Europe. Methods ETNA-AF-Europe was a prospective, observational study conducted in AF patients receiving edoxaban. In this subanalysis, patients not reaching the end of the study period and patients who were non-persistent (defined as permanent discontinuation of edoxaban) after 4 years of treatment were examined, including patients switching to other NOACs and reasons for discontinuation. Baseline predictors for not reaching the end of the study period and baseline predictors for non-persistence with edoxaban treatment during 4 years of follow-up were also examined. Persistent patients may have missed dose/interruption. Results Overall, 13,164 patients were included in the analysis. During the whole study period, 14.3% died. At the end of the study, 27.3% of patients prematurely terminated the study and 71.5% were classified as completing the study. Of patients who left the study (n=3598), 30.2% were lost-to-follow-up, 6.9% withdrew consent, and 5.9% transferred to another institution. Of patients who completed the study (n=9417), 87.4% were classified as persistent within the 4 years. Only 6.2% permanently discontinued edoxaban without switching to another NOAC (Table). Following backwards elimination, baseline characteristics associated with premature study termination (excluding death) were male sex, low body mass index, low renal function, chronic hepatic disease, long standing persistent/permanent AF, smoking, low compliance as judged by investigator, vitamin K antagonist-naïve, and no rate/rhythm control drug at baseline. Characteristics associated with non-persistence were increasing age, male sex, body weight extremes, low renal function, heart failure, vascular disease, chronic hepatic disease, alcohol use, perceived frailty, chronic obstructive pulmonary disease, smoking, current AF symptoms, and ablation (Figure). The criterion for backward elimination was p=0.05. Conclusions Most patients in ETNA-AF-Europe reached the end of the study. Less than a quarter were classified as non-persistent during the 4-year follow-up. The majority of patients who were non-persistent switched to another NOAC with a small number completely stopping anticoagulant therapy. Male sex, low renal function, chronic hepatic disease, and smoking were associated with both treatment discontinuation and non-persistence.Termination and persistence

Association between ablation-induced baroreceptor reflex modification and procedure efficacy in patients with atrial fibrillation.

The autonomic nervous system (ANS) plays a significant role in atrial fibrillation (AF). Catheter ablation (CA) is a well-established treatment method for AF and significantly affects the ANS, including baroreceptor (BR) function. However, little is known about the changes in BR function caused by radiofrequency (RF) or cryoballoon energy (CB) and its impact on future AF recurrences. To assess 1-year efficacy of CA of AF in relation to BR function modification and type of ablation energy used. The study group consisted of 78 patients (25 females, mean age 58 ± 9 years) with paroxysmal AF and first CA (39 patients in the RF group and 39 in the CB group). The BR function was assessed non-invasively, using tilt testing before and after CA, and three BR parameters were calculated: event count (BREC) depicting overall BR activity, slope mean depicting BR sensitivity (BRS), and BR effectiveness index (BEI). The efficacy of CA was assessed during 1-year follow-up, which consisted of ambulatory visits and 24-h Holter ECG recordings at 3, 6, and 12 months after CA. The quality of life was assessed by using a dedicated scale [University of Toronto Atrial Fibrillation Severity Scale (AFSS)]. The two groups did not show differences in terms of clinical or demographic data. One-year follow-up was completed for 35 (89.7%) patients from the CB group and for 34 (87.2%) from the RF group. The rates of efficacy of CB and RF were similar [31/35 (88.6%) vs. 26/34 (76.5%), respectively]. After CA, the BR function decreased in both groups, with a significantly greater decrease in the CB group. The changes in BR parameters were similar in both responders and non-responders after CA in the whole group [BREC 10.0 (2.0-24.0) vs. 12.0 (4.0-21.5), p = 0.939; BRS 5.4 (3.7-6.5) vs. 4.8 (3.6-7.2), p = 0.809; BEI 24.8 (15.9-27.4) vs. 17.5 (8.9-27.5), p = 0.508, respectively]. According to the AFSS, the AF symptoms were significantly reduced in both groups to a similar extent. CA for AF significantly decreased the BR function, especially in patients undergoing CB. There was no correlation between CA-induced changes in BR parameters and ablation outcome.

Symptom Network and Clusters of the Multidimensional Symptom Experience in Patients With Atrial Fibrillation

Background The symptom network can provide a visual insight into the symptom mechanisms. However, few study authors have explored the multidimensional symptom network of patients with atrial fibrillation (AF). Objectives We aimed to identify the core symptom and symptom clusters of patients with AF by generating a symptom network. Furthermore, we wanted to identify multiple characteristics related to symptom clusters. Methods This is a cross-sectional study. A total of 384 patients with AF at Tianjin Medical University General Hospital were enrolled. The University of Toronto Atrial Fibrillation Severity Scale was used to assess AF symptoms. Network analysis was used to explore the core symptom and symptom cluster. Results Shortness of breath at rest (r s = 1.189, r c = 0.024), exercise intolerance (r s = 1.116), shortness of breath during physical activity (r s = 1.055, r c = 0.022), and fatigue at rest (r c = 0.020) have the top centrality for strength and closeness. The top 3 symptoms of bridge strength were shortness of breath at rest (r s = 0.264), dizziness (r s = 0.208), and palpitations (r s = 0.207). Atrial fibrillation symptoms could be clustered into the breathless cluster and the cardiac cluster. We have identified multiple factors such as mental health status, left ventricular ejection fraction, heart failure, sex, B-type natriuretic peptide, and chronic obstructive pulmonary disease as significant contributors within the breathless cluster, whereas sex, mental health status, and history of radiofrequency ablation were strongly associated with the cardiac cluster, holding promise in elucidating the underlying mechanisms of these symptoms. Conclusion Special attention should be given to shortness of breath at rest as its core and bridging role in patients' symptoms. Furthermore, both the breathless and cardiac clusters are common among patients. Network analysis reveals direct connections between symptoms, symptom clusters, and their influencing factors, providing a foundation for clinicians to effectively manage patients' symptoms.

Impact of Preoperative Sinus Rhythm on Concomitant Surgical Ablation's One-Year Success in Patients with Atrial Fibrillation: A Prospective Registry Cohort Study.

Background: The surgical ablation (SA) of atrial fibrillation (AF) during cardiac surgery is performed in only 8-40% of patients. We performed a subgroup analysis of the 1-year follow-up from the German CArdioSurgEry Atrial Fibrillation (CASE-AF) registry to determine how preoperative sinus rhythm (SR) prior to SA affected the outcomes. Methods: The CASE-AF registry enrolled AF patients scheduled for cardiac surgery with concomitant SA. The in-hospital and one-year follow-up data were collected prospectively and analyzed retrospectively. Results: From September 2016 to August 2020, 964 patients were enrolled in the CASE-AF registry. Among them, 333 patients were in SR immediately before surgery (study cohort). A complete follow-up was achieved for 95.6%. Both the severity of the AF (modified European Heart Rhythm Association symptom classification, p < 0.001) and the frequency of AF symptoms (p = 0.006) were significantly reduced at one year compared to the preoperative baseline. Almost 90 percent of the patients underwent left atrial appendage occlusion (LAAO) during the procedure. The one-year mortality (4.1%) and stroke rates (3.2%) were low. SR was evident in 70.3% of the patients at the one-year follow-up. Conclusions: Patients with AF who have SR at the time of surgery should not be excluded from SA, as it appears to be a safe and effective procedure.

Mediating effect of coping strategy and psychological status between illness perception and quality of life among patients with atrial fibrillation: a cross-sectional study

BackgroundThis study investigated the mediating effects of coping strategies and psychological status on the relationship between illness perception and health-related quality of life (HRQoL) among patients with atrial fibrillation (AF).MethodsThis cross-sectional study enrolled 178 patients with AF who were admitted to a tertiary hospital in Beijing City in mainland from March 2020 and June 2022. Assessments were made for HRQoL using the Short Form Health Survey depressive symptoms using the Patient Health Questionnaire-9, anxiety using the Generalized Anxiety Disorder-7 (GAD-7), illness perception using the Brief Illness Perception Questionnaire (BIPQ), AF symptoms using the Atrial Fibrillation Severity Scale (AFSS), and coping strategies using the Brief-COPE Scale.ResultsSignificant correlations were observed between illness perception, emotional variables, coping strategies, and HRQoL scores. The regression analysis found that BIPQ, GAD, Maladaptive coping and Problem-focused coping are significant predictors of PCS (F = 20.906, R2 = 0.326, p < 0.01) and MCS (F = 31.24, R2 = 0.419, p < 0.01). Bootstrap samples were used to conduct mediation analysis. The indirect effects of GAD-7 and Problem-focused coping (PC) on the impact of BIPQ on QoL were significant. GAD accounted for 13.2–19.3% of the variance in the total effect across different models, while PC accounted for 22.1–25.8%. The results also indicated a significant chain effect in the illness percepitong-anxiety-coping style-QoL model, which can explain 4.3–10.2% of the total effect, respectively.ConclusionsThe perception of illness significantly influenced HRQoL in patients with AF, as mediated by emotional symptoms and coping strategies. This highlights the importance of anxiety and problem-focused coping mechanisms. These findings underscore the need for a holistic, patient-centered approach to AF management that incorporates emotional well-being and coping strategies.Trial registrationRetrospectively registered with ClinicalTrials.gov (NCT05974098). The date of registration: 1 August 2023.

Diet and risk of atrial fibrillation: a systematic review.

Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia. Comprehensive modification of established AF risk factors combined with dietary interventions and breaking deleterious habits has been shown to reduce AF burden and recurrence. Numerous AF risk factors, such as diabetes, obesity or hypertension can be partially related to dietary and lifestyle choices. Therefore, dietary interventions may have potential as a therapeutic approach in AF. Based on available data, current guidelines recommend alcohol abstinence or reduction to decrease AF symptoms, burden, and progression, and do not indicate the need for caffeine abstention to prevent AF episodes (unless it is a trigger for AF symptoms). Uncertainty persists regarding harms or benefits of other dietary factors including chocolate, fish, salt, polyunsaturated and monounsaturated fatty acids, vitamins, and micronutrients. This article provides a systematic review of the association between AF and both dietary patterns and components. Additionally, it discusses potentially related mechanisms and introduces different strategies to assess patients' nutrition patterns, including mobile health solutions and diet indices. Finally, it highlights the gaps in knowledge requiring future investigation.

Associations between atrial fibrillation symptom clusters and major adverse cardiovascular events following catheter ablation

Associations between atrial fibrillation symptom clusters and major adverse cardiovascular events following catheter ablation

Outcomes of Atrial Fibrillation Ablation in Heart Failure Subtypes.

Catheter ablation (CA) improves clinical outcomes in patients with atrial fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF). We aimed to evaluate the impact of CA on clinical and quality-of-life outcomes across HF subtypes. All patients undergoing AF ablation at a tertiary center were enrolled in a prospective registry and included in this study (2013-2021). The primary end point was AF recurrence. Secondary end points included AF-related hospitalizations and quality-of-life outcomes. Patients were categorized according to their HF status: no HF, HFrEF, HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). A total of 7020 patients were included (80% no HF, 8% HFrEF, 7% HFmrEF, and 5% HFpEF). Over 3 years, the cumulative incidence of AF recurrence after ablation was as follows: HFpEF (53%), HFmrEF (41%), HFrEF (41%), and no HF (34%); P<0.01. Multivariable Cox analyses confirmed these findings using no HF group as reference (HFpEF: hazard ratio, 1.47 [95% CI, 1.21-1.78]; HFmrEF: hazard ratio, 1.23 [95% CI, 1.04-1.45]; and HFrEF: hazard ratio, 1.17 [95% CI, 1.01-1.37]; P<0.05 for all). In all groups, CA resulted in a significant reduction of AF-related hospitalization (mean rate per 1 patient-years [before and after CA]; HFpEF [1.8 versus 0.3], HFmrEF [1.1 versus 0.2], HFrEF [1.1 versus 0.2], and no HF [1 versus 0.1]; P<0.01 for each comparison) and significant improvement in quality of life as measured by both the AF symptom severity score and the AF burden score (P<0.01 for the comparison between baseline and follow-up for each score when tested separately). AF recurrence rates after CA were higher in patients with HF compared with those without HF, with patients with HFpEF being at the highest risk of recurrence. Nonetheless, CA was associated with a significant reduction in AF symptoms, AF-related hospitalization, and HF symptoms in most patients irrespective of HF subtypes.

Discordant Treatment Goals for Patients With Atrial Fibrillation and Clinical Trials Metrics

BackgroundMost clinical trials define successful atrial fibrillation (AF) treatment as no AF episodes longer than 30 seconds. Yet, there has been minimal study of how patients define successful treatment and whether their perspectives align with trial outcomes. ObjectivesSurvey patients with AF to identify: 1) what aspect of AF is most important to address (frequency, duration, or severity of AF episodes); 2) what AF burden would be considered acceptable to consider treatment successful; and 3) to establish patient preferences for successful treatment thresholds for a validated patient-reported outcome (PRO) score. MethodsWe surveyed patients receiving active care for AF at a single tertiary care center modeled after the Toronto AF Severity Scale (AFSS). The survey consisted of current and “successful treatment” AF frequency, burden, and symptom domains; and baseline socioeconomic information. ResultsOf 7,000 invitations, 852 individuals completed the survey (12% response) with a mean age of 65 ± 13 years, 36.5% were female, and they had a mean CHA2DS2-VAsc score of 2.9 ± 1.9. Overall, 114 (13%) selected a decrease in AF episode duration as their top treatment priority, 505 (59%) episode frequency, and 230 (27%) episode severity. Overall, 207 (24%) patients would only consider a treatment successful if they never had AF again, whereas 645 (76%) patients considered success to be fewer AF episodes. A total of 341 (40%) patients would only consider a treatment successful if AF episodes lasted less than a few minutes, whereas 509 (60%) patients would accept AF episodes lasting >30 minutes. An AFSS symptom score ≤5 was considered a good outcome by 80% of respondents. ConclusionsPatients prioritize decreased AF frequency over improvements in severity or duration, and an AFSS ≤5 would be a reasonable outcome of AF treatment. Most patients would consider treatment successful if they had more than 1 AF episode lasting longer than 30 seconds. Future clinical trial design should consider patients’ perspectives when designing outcomes.

WHAT SCALES SHOULD THE CARDIOLOGIST USE IN PATIENTS WITH ATRIAL FIBRILLATION? WHAT IS NEW?

The current treatment algorithm for patients with non-valvular atrial fibrillation (AF) includes anticoagulation to prevent stroke and systemic embolism, improvement of AF symptom control by heart rate reduction or restoration and maintenance of sinus rhythm, and treatment of cardiovascular and other comorbidities. The evaluation of patients with AF should be structured and include assessment of stroke risk, symptom severity, severity of the AF burden (type of arrhythmia, number and duration of episodes, etc.) and predisposing condition. The use of the CHA2DS2-VASc (risk of stroke), HAS-BLED (risk of bleeding), EHRA (severity of AF symptoms), and 2MACE (risk of cardiovascular outcomes) scales is important to help assess the likelihood of adverse outcomes and select the optimal treatment to protect not only against stroke but also against cardiovascular events. It should be noted that the HAS-BLED scale is primarily necessary for identification of bleeding risk factors, the modification of which allows to increase the safety of anticoagulant therapy, and a high index value according to this scale can’t serve as a reason to refuse anticoagulation in a patient with AF. New scales of stroke and hemorrhagic complications risk assessment in patients with AF on the basis of clinical parameters and laboratory biomarkers have been proposed, but their possible advantages over the existing indices need to be confirmed in special studies

Ablation Compared to Pharmacological Treatment for the Reduction of Atrial Fibrillation Recurrence: A Meta-Analysis.

Atrial fibrillation (AF) is one of the most common heart arrhythmias, and due to its variable presentation, detecting and treating AF appropriately can reduce some of its serious complications. Among treatment options, surgical ablation and antiarrhythmic drug therapy are two of the most widely used choices. A systematic review and meta-analysis were conducted to examine the rates of AF recurrence in those treated with ablationcompared to pharmacological treatment. Google Scholar and PubMed were searched for study trials published within the last decade that calculated the recurrence of AF symptoms in patient groups that received ablation or pharmacological treatment. Selected studies were analyzed in RevMan 5.4 software (The Cochrane Collaboration, London, England, UK), and each study's odds ratio and overall odds ratio were calculated using a 95% confidence interval. A total of seven studies with 2324 patients were analyzed for the meta-analysis, with 1162 patients receiving ablation and 1162 patients receiving pharmacological treatment. There was a statistically significant decrease in the recurrence of AF in the ablation group compared to the pharmacological treatment group, with a pooled odds ratio of 0.24 (CI 95% 0.14-0.39). AF treated with ablation was more effective in reducing AF recurrence than general pharmacological treatment.

Sex Differences in Outcomes of an Intensive Risk Factor Modification Program in Patients With Atrial Fibrillation.

The outcomes of atrial fibrillation (AF) seem to be variable between males and females. We therefore aimed to determine sex differences in weight loss, cardiorespiratory fitness gain, and recurrence and progression of AF following risk factor management. Of 1415 consecutive patients referred for electrophysiology management of AF, 825 had a body mass index of ≥27 kg/m2; after exclusions, 355 (males, 234; females, 121) were offered risk factor management and participation in a tailored exercise program. Females were older than males (65.5±10.4 versus 62.5±10.6 years; P=0.013) with a higher body mass index (34.1±5.4 versus 32.6±4.1 kg/m2; P=0.003) and more commonly paroxysmal AF (67.8% versus 48.3%; P<0.001). There was no sex difference in clinic attendance (58.7% versus 60%; P=0.82), weight loss (P=0.86), fitness gain (P=0.44), or improvement in AF symptoms (P=0.35). Weight loss (≥10% compared with <10%) was associated with lower total AF recurrence in males (hazard ratio, 0.41 [95% CI, 0.23-0.73]) and females (hazard ratio, 0.41 [95% CI, 0.20-0.83]). Fitness gain (≥2 metabolic equivalents compared with <2 metabolic equivalents) was associated with lower total AF recurrence in females (hazard ratio, 0.13 [95% CI, 0.05-0.30]) but not in males (hazard ratio, 0.63 [95% CI, 0.38-1.04]; P=0.002). There was a trend toward more reversal from persistent to paroxysmal AF in males compared with females (21.8% versus 14.0%; P=0.079). Males and females with AF demonstrate a similar degree of weight loss and fitness gain through structured risk factor management. However, fitness had a much greater benefit for total arrhythmia recurrence in females compared with males, whereas there was a trend toward more AF reversal in males. URL: https://anzctr.org.au; Unique identifier: ACTRN12614001123639.

Atrial fibrillation burden, symptoms and medication use after left bundle branch area pacing combined with AV-node ablation in patients with symptomatic atrial fibrillation

Abstract Background AV node ablation combined with permanent pacing is an established therapy for rate control in patients with symptomatic atrial fibrillation (AF) refractory or intolerant to pharmacological rate or rhythm control and not eligible for rhythm control by left atrial catheter ablation. The threshold for performing this so-called "pace-and-ablate" strategy has decreased since the introduction of conduction system pacing, and especially left bundle branch area pacing (LBBAP). Purpose To investigate the AF burden, AF related symptoms and anti-arrhythmic drug (AAD) use after AV-node ablation combined with LBBAP. Methods Consecutive patients with symptomatic AF, intolerant or refractory to pharmacological rate and symptom control and deemed not eligible for left atrial catheter ablation, were included. At baseline, AF related symptoms classified according to the EHRA classification and AAD use were scored. After DDD-pacemaker implantation with an LBBAP lead and subsequent AV-node ablation device detected AF burden was assessed six weeks, six months and twelve months later. AF burden at six weeks after AV-node ablation was considered the baseline measurement for AF burden. AF related symptoms and AAD use were collected at twelve months follow-up. Results Twenty-four patients (67% female, mean age 79±4 years) scheduled for pace-and-ablate therapy were prospectively included. Eighteen patients had persistent (75%) and three long-standing persistent (12.5%) AF with enlarged left atria (left-atrial volume index (LAVI) 52 ± 18ml/m2) and EHRA class IIb or higher in twenty (69%) patients. Twenty-three patients (96%) used at least one AAD with fifteen patients (63%) using &amp;gt;1 AAD at baseline, fig. 1. AF burden did not change at six months (-1.3 [-17, 15] %, p=0.87) and twelve months (-2.9 [-40,35] %, p=0.86) follow-up relative to six weeks follow-up, fig 2A. AF symptoms were significantly reduced with most patients in EHRA class I (6, 25%) or class IIa (17, 71%; p&amp;lt;0.001) at twelve months follow-up, fig 2B. There was a significant reduction in AAD use with fourteen patients (58%) using no AAD at twelve months follow-up and no patients using &amp;gt;1 AAD at twelve months follow up (p&amp;lt;0.001), fig 2C. Conclusion AV node ablation followed by permanent LBBAP did not reduce AF burden in an AF population with advanced disease. However, a significant reduction in AF symptoms and medication use was demonstrated with this therapy. Figure 2. AF burden (panel A), symptoms (panel B) and AAD use (panel C) at baseline and twelve months after ‘pace-and-ablate’ therapy. AF = atrial fibrillation; EHRA = EHRA = European Heart Rhythm Association symptom classification for AF; AAD = anti-arrhythmic drug. *relative to AF burden at six weeks follow-up.Baseline characteristicsBaseline and follow-up measurements

Hybrid ablation versus repeated catheter ablation in persistent atrial fibrillation: long-term results of the HARTCAP-AF trial

Abstract Background The HARTCAP-AF study compared the efficacy and safety outcomes in forty-one ablation-naive patients with persistent atrial fibrillation (AF) randomized to thoracoscopic hybrid ablation (HA) or stand-alone catheter ablation (CA). One-year results have shown that thoracoscopic HA has superior rhythm outcomes than CA, without increasing complications. Purpose Here, we evaluated the efficacy, safety and quality of life (QOL) of thoracoscopic HA and CA within a long-term follow-up (FU) duration of three years. Methods Efficacy outcomes included freedom from atrial tachyarrhythmia (ATA) recurrences ≥5 minutes off and allowing antiarrhythmic drugs (AAD) after 24 and 36 months. Safety outcomes, including serious adverse events (SAEs), and QOL, measured by the EHRA AF symptom score, were evaluated after 36 months. Results After a mean FU duration of 25±3 and 38±3 months, freedom from ATA recurrences was higher in the HA group compared to the CA group off AAD (68.4% vs. 22.7%, P=0.002 and 57.0% vs. 22.7%, P=0.005) and allowing AAD (73.7% vs. 22.7%, P=0.001 and 63.2% vs. 22.7%, P=0.001) (Figure 1, Table 1). The number of redo catheter procedures was higher in the CA arm than the HA arm (n=15 vs. n=3, P=0.021). The total number of SAEs was low and did not differ between groups (HA: n=6 vs. CA: n=7, P=0.989). Moreover, QOL measured by the EHRA AF-symptom score improved for both groups post-procedure (3.2±0.7 and 1.6±0.78, P&amp;lt;0.001) and were better for HA than CA after 3 years (1.3±0.7 and 1.9±0.8, P=0.029). Conclusion After three years, (thoracoscopic) HA continues to have superior rhythm outcomes compared to CA with a comparable long-term safety profile. While both procedures resulted in a reduction in AF symptoms, EHRA scores were more favorably scored by patients in the HA arm. Therefore, in experienced centers thoracoscopic HA should be considered as a first-line treatment to percutaneous approaches for ablation-naive patients with persistent AF.Figure 1Table 1