Therapy For Atrial Fibrillation Research Articles

Effect of early cryoballoon ablation on atrial fibrillation recurrence - a nationwide register study

Abstract Introduction Cryoballoon ablation seems a viable first-line therapy in atrial fibrillation (AF) patients and outperforms antiarrhythmic drugs (AAD) regarding sinus rhythm maintenance. Despite this, guidelines in general recommend AAD use before ablation for AF, delaying a potential ablation. Therefore, data regarding the impact of the timing of cryoballoon ablation on AF recurrence in large, unselected cohorts is highly warranted. Purpose To examine AF recurrence after AF cryoballoon ablation by time from AF diagnosis to AF ablation. Methods From nationwide registers, we included all AF patients above 18 years who underwent first-time cryoballoon ablation from January 2010 to December 2018. The AF patients were stratified by ablation timing: Early ablation (< 1 year after AF diagnosis) and late ablation (≥1 year after AF diagnosis). The primary endpoint was recurrent AF, defined as a composite endpoint of AF hospitalization, claimed prescriptions of AAD, re-ablation or electrical cardioversions. The cumulative incidence of recurrent AF at 5-year follow-up after a blanking period of 90 days was estimated using the Aalen-Johansen estimator, taking the competing risk of death into account. The relative rates of recurrent AF were examined using cox models adjusted for sex, age, procedure-year, left atrial size, body mass index, AF-type (paroxysmal or persistent), hypertension, heart failure, ischemic heart disease, and chronic obstructive pulmonary disease. Results The study cohort consisted of 677 patients, 204 in the early ablation group and 473 in the late ablation group. Median age increased from 59 in the early ablation group to 65 in the late ablation group. In the early ablation group 71% had paroxysmal AF compared to 66% in the late ablation group. Use of amiodarone and Class 1C antiarrhythmic medication were higher in the late ablation group. The 5-year cumulative incidence of recurrent AF was 41% and 51% in the early and late ablation groups. The Hazard ratio (HR) and 95% confidence interval (95% CI) were 1.44 and (CI 1.10-1.89) in the late ablation group compared to the early ablation group (Figure 1). For paroxysmal AF the 5-year cumulative incidence of recurrent AF was 41% and 49% in the early and late ablation groups with a HR of 1.32 (CI 0.95-1.84) in the late ablation group compared to the early ablation group. For persistent AF the 5-year cumulative incidence of recurrent AF was 39% and 59% in the early and late ablation groups with a HR of 1.74 (CI 1.05-2.87) in the late ablation group compared to the early ablation group (Figure 2). Conclusion In this nationwide register study examining recurrent AF after cryoballoon ablation, we found lower recurrence rates when early ablation was performed. Based on this, early cryoballoon ablation could potentially provide considerable benefits and improve outcomes after ablation, indicating that cryoballoon ablation as first-line therapy might be ideal.Figure 1Figure 2

The transcription factor ETV1 regulates expression of the atrial specific potassium channel TASK-1 and modulates cardiac action potentials

Abstract Background In recent years, the two-pore domain potassium channel TASK-1 has been identified to play an important role in the pathophysiology of atrial fibrillation (AF). In cardiac tissue, TASK-1 is almost exclusively expressed in the atria and significantly upregulated in AF patients. Moreover, it has been characterized as a key player in action potential (AP) shortening observed during AF, making it a promising target for antiarrhythmic therapy. However, the underlying transcriptional mechanisms responsible for TASK-1 upregulation during AF are still unclear. A few years ago, the transcription factor ETV1 has been described to induce atrial remodeling and arrhythmia. Similar to TASK-1, ETV1 is predominantly expressed in the atria and upregulated in AF patients. Therefore, investigating possible interactions between ETV1 and TASK-1 is crucial to further understand atrial remodeling and develop new antiarrhythmic strategies. Purpose The purpose of this study was to investigate the effects of ETV1 regulation on TASK-1 expression. For that, electrophysiological effects of ETV1 modulation on TASK-1 currents and action potential formation were studied on HL-1 cardiomyocytes. Methods ETV1 modulation was achieved either through application of the pharmacological ETV1-inhibitor BRD32048 (1 µM) or transfection of HL-1 cells with a specific ETV1-siRNA. Electrophysiological effects of ETV1 inhibition were assessed using two-electrode voltage clamp experiments on Xenopus laevis oocytes heterologously expressing TASK-1 as well as whole-cell patch clamp measurements on HL-1 cells after pharmacological- and siRNA-mediated ETV1 inhibition. Chromatin immunoprecipitation combined with real-time qPCR (ChIP-qPCR) and ATAC-seq experiments were performed to identify the epigenetic interaction between ETV1 and the KCNK3 gene encoding TASK-1. Results TASK-1 currents were markedly reduced in Xenopus laevis oocytes after inhibition of ETV1. Furthermore, both pharmacological inhibition and siRNA-mediated knockdown of ETV1 caused a significant decrease of TASK-1 currents in HL-1 cells by 35.8% and 39.3%, respectively. These effects were associated with a statistically significant prolongation of the action potential duration at 90% repolarization (APD90) by 28.5% after functional inhibition and 24.9% after siRNA-knockdown. This correlated with a significant decrease of TASK-1 expression on mRNA and protein level. In addition, ATAC-seq data and ChIP-qPCR revealed an enrichment of ETV1 binding within accessible regulatory elements at the KCNK3 gene locus. Conclusions ETV1-knockdown shows strong inhibitory effects on TASK-1 while ChIP-qPCR and ATAC-seq data suggest that ETV1 acts as a direct transcriptional activator of KCNK3. The finding that ETV1 is involved in the regulation of TASK-1 improves our understanding of the pathomechanisms underlying AF and will hopefully help to advance TASK-1-based AF therapy.

Atrial fibrillation catheter ablation: electroporation against high-power short duration radiofrequency

Abstract Background Pulmonary vein isolation (PVI) is one of the cornerstones of rhythm-control therapy for symptomatic atrial fibrillation (AF) patients. The new ablation technologies of pulse field ablation (PFA) and high-power short-duration radiofrequency ablation (HPSD) with the new QDOT® catheter have been recently introduced in the EP lab. Aims To evaluate and compare the efficacy, and safety of single-shot PFA and HPSDRA for PVI in AF symptomatic patients. Methods Single centre, retrospective study of consecutive patients undergoing PVI with PFA or HPSD between May-December 2022. Data on demographic, procedural and clinical/ electrocardiographic recurrence (assessed after a 3-months blanking period) were analysed. Comparative analysis between both techniques was performed. Results One hundred and ten consecutive patients were included (63 ± 11 years, 75% men), with a mean CHA2DS2-VASc score of 2±1 points, median LVEF of 61% [IQR 57-62%] and a median left atrial volume index (by CT scan) of 56 mL/m2 [IQR 51-67 mL/m2]. 55% patients presented paroxysmal-AF and 19 patients (17%) performed a redo ablation. 47% (n=52) patients performed HPSD and 53% (n=58) PFA (all with CARTO®3D system v.7 and high-density mapping). In the HPSD: median RF ablation time was 792 sec [IQR 614-919sec], while in PFA was 90 sec [IQR 30-138 sec]. Median time of catheter inside the LA for PFA was 18 min [IQR 2-33 min]. Comparing HPSD and PFA (Fig 1): median procedure time was similar (91 min [IQR 71-107 min] vs 89 min [IQR 66-111 min], p=0.261), while median fluoroscopy time was lower with HPSD (5.4 min [IQR 3.1-6.8 min] vs 13.2 min [IQR 10.3-15.6 min], p<0.001); posterior wall isolation (PWI) was performed in 5 (10%) HPSD vs 21 (37%) PFA patients (p<0.001). All PFA patients undergoing PWI had first pass isolation, while only 40% of HPSD had first pass isolation. When performed PVI only, PFA presents a lower median procedure time than HPSD (76 min [IQR 62-93 min] vs 97 min [IQR 69-135 min], p=0.048). There was only one major complication, a cardiac tamponade with PFA, treated with pericardiocentesis. At 3 months of follow-up, 17% (n=10) patients had clinical or electrocardiographic AF recurrence: 7 PFA patients and 3 HPSD patients (p=0.127). Conclusions PFA and HPSD were both feasible and safe. When undergoing PVI-only, procedure time was lower with PFA. In patients undergoing PWI, PFA achieved higher first pass isolation. Although still in its early real-world evaluation, both techniques seem to be efficient, providing low AF recurrence during follow-up.

Real-time interactive 3d simulation of Atrial Fibrillation for education

Abstract Background The mechanistic understanding of atrial fibrillation (AF) has burgeoned over the past decades. However, the interplay between triggers, reentry, drivers and therapies is rarely fully appreciated despite being ultimately fundamental to patient care. Readily accessible, high-fidelity interactive simulation has the potential to address this knowledge gap across healthcare providers. Objective To develop a, interactive simulation system to allow deep understanding of AF mechanisms and therapies. Methods An application for e-Training was developed to be accessible on consumer smartphones and tablets, based on a validated electromechanical simulation model of the heart, with real-time interactive 3D image output. A virtual heart is represented in normal and arrhythmic states, enabled with simulated models for administering antiarrhythmic drugs, performing Pulmonary Vein Isolation (PVI), AV Node ablation, ventricular pacing, DC Cardioversion, plus the formation of atrial thrombus leading to a stroke event. Electrogram and ECG signals are generated from the underlying simulation and respond realistically to drugs, pacing and ablation. A self-study tutorial introduces the arrhythmia and treatment procedures. Learning outcomes are assessed with MCQ tests and receive Continuous Professional Development CPD credits. Results The AFib Sim app has received CPD accreditation in the UK and has so far been used at the Universities of Oxford, Cambridge and Leeds medical schools. All trainees and medical students followed the self-study tutorials and took the interactive MCQ test, which are embedded within the AFib Sim app. Development was based on Unity 3D and was made available on iOS, Android, macOS, MS Windows and WebGL platforms. Conclusion This project meets an urgent training need whilst expanding expertise and market scope into clinical training. The impact on clinical training was high and the societal benefit came from better and quicker trained staff. Learning Objective Upon completion of this session, the attendee will be able understand how a simulation of Atrial Fibrillation can be used for training and deepening the clinical understanding of atrial fibrillation.

Interactions of circulating, digoxin-like, steroids with rate control therapy for atrial fibrillation in the RATE-AF randomised clinical trial

Abstract Background Numerous endogenous cardiotonic steroids (CTS) similar to digoxin are thought to exist in humans, but this remains unproven and their clinical impact is unknown. Purpose To identify and quantify CTS in patients with atrial fibrillation (AF) and heart failure (HF), and assess their interaction with the clinical efficacy of digoxin treatment within a randomised controlled trial. Methods Patients with permanent AF and symptoms of HF were randomised to low-dose digoxin or beta-blockers for rate control (Rate control Therapy Evaluation in permanent Atrial Fibrillation trial, RATE-AF). EDTA plasma was collected at baseline and 6 months, with a range of CTS measured using a novel ultra-high-performance liquid chromatography tandem-mass spectrometry assay. Outcomes at 6-months were the mEHRA class score, New York Heart Association (NYHA) class, NT-pro B-type natriuretic peptide (BNP), and a composite of all adverse events. Multiple regression models were used to assess treatment efficacy (intention-to-treat analysis) adjusted for age, sex and ejection fraction, with interaction terms for baseline CTS. Results 160 patients were randomised and contributed to this study. Mean age was 76 years (SD 8), 46% women and median NT-proBNP 1057 pg/mL (interquartile range [IQR] 778), with demographics comparable between group. 80 patients were randomised to digoxin and 80 patients were randomised to beta-blockers, principally bisoprolol. Patients randomised to digoxin had significantly better functional outcomes compared to beta-blockers, with two-class improvement in mEHRA score odds ratio 5.95 (95% CI 2.78 to 24.06; p<0.001) and mean adjusted difference in NYHA class -0.60 (95% CI -0.86 to -0.34; p<0.001). There were fewer patients with adverse events in those allocated to digoxin (13/76; 17.1%) versus beta-blockers (44/74; 59.5%), with odds ratio 0.29 (95% CI 0.12 to 0.52; p<0.001). The CTS bufalin, cinobufagin, cinobufotalin, digoxigenin, digitoxigenin, dihydroouabain, marinobufagenin, ouabain, ouabagenin and telinobufagenin were all identified in patient samples, but most were at low concentrations or below the lower quantification limits; Figure 1. Digoxigenin and digitoxigenin were the most abundant CTS, with median quantifications of 0.079 nM (IQR 0.152) and 0.024 nM (IQR 0.051). Baseline CTS concentrations did not interact with digoxin treatment efficacy for any outcome; Figure 2. No significant change was seen in CTS concentrations from baseline to 6-months in those treated with digoxin. Digoxin quantification using mass spectrometry was strongly correlated with the clinical immunoassay at 6-months (r=0.88; p<0.001). Conclusions Low-dose digoxin improves symptoms and functional class compared to beta-blockers in patients with permanent AF and HF, independently from a range of CTS with similar chemical structure. The role of CTS in humans remains uncertain, however they do not appear to interact with the therapeutic effect of digoxin.Figure 1

Outcomes with oral anticoagulation resumption or discontinuation after an anticoagulation-related event in patients with atrial fibrillation

Abstract Background There are uncertainties on the resumption of anticoagulation therapy in patients with non-valvular atrial fibrillation who experience a thrombotic or haemorrhagic event while on oral anticoagulation. Purpose We assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, after stroke or major bleeding during anticoagulation therapy for atrial fibrillation. Methods We included anticoagulated patients with atrial fibrillation that were discharged (2013-2020) from hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, thromboembolism, intracranial haemorrhage, and major bleeding were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Results 1029 patients (mean age 77 years) were included in the final cohort: 23% were ischemic stroke, 18% were ICH, and 59% major bleeding; of these, 77% resumed anticoagulation. Among patients with stroke as the index event (92% resumed anticoagulation) the cumulative incidence of events was significantly lower in patients resuming therapy (HR 0.2, 95%CI 0.1-0.4, p<0.01). In patients with ICH (64% resumed therapy) the cumulative incidence of events was lower in patients resuming anticoagulation (HR 0.4, 95%CI 0.2-0.7, p<0.01). Same was true for patients with major bleeding, with patients resuming therapy (76%), experiencing fewer events (HR 0.5, 95%CI 0.2-0.7, p<0.01). In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the cumulative event rate (HR 0.5, 95%CI 0.4-0.6, p<0.01). Conclusion In patients with atrial fibrillation who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.Stacked Area Charts and Cox regression

Anticoagulant therapy in patients with atrial fibrillation and chronic kidney disease: Arguments for or against

Atrial fibrillation and chronic renal failure are common diseases in the population with similar risk factors. Both conditions are independent riskfactors for the development of thromboembolic complications. There is compelling evidence to support the benefits of anticoagulant therapy for atrial fibrillation in the general population, but in patients with advanced chronic renal failure, the use of anticoagulants may be limited. A number of studies have shown conflicting results, and this topic is of interest for further discussion and a comprehensive analysis of the existing data.

Abstract 15017: Chromatin Regulators as Potential Players in Atrial Fibrillation: Locus Analysis and Regulatory Role Investigation

Background: Atrial fibrillation (AF), a prevalent cardiac arrhythmia, has multiple biomarkers identified, yet their roles remain partially understood. Research Questions and Aims: The study sought to investigate the expression and prognostic value of Chromatin Regulators (CRs) in AF, their correlation with the immune microenvironment, and to identify potential prognostic markers, therapeutic drugs, and miRNAs. Methods: We filtered three GEO database datasets containing AF and normal samples, identifying 23 differentially expressed CRs. Sequence analysis and protein-protein interaction (PPI) network construction led to the identification of 10 AF prognosis-related CRs. The biological roles and potential pathways of these CRs were analyzed through Gene Ontology (GO) and ssGSEA algorithm. Moreover, we examined the correlation between hub genes and immune cells/immune function, identifying the top 5 immunity-relevant CRs. Results: Ten CRs linked to AF prognosis were identified, achieving an AUC of 0.901997 in a nomogram model. GO analysis demonstrated the involvement of these CRs in processes associated with cardiovascular diseases. The ssGSEA algorithm showed a connection between the identified CRs and immune infiltration. The study also identified the top 5 immunity-related CRs, and potential drugs and miRNAs for AF therapy. Conclusions: This study elucidates the role of specific CRs in AF, presenting a promising risk model and potential therapeutic targets. Further validation and evaluation of potential therapeutic targets' efficacy and safety are required. This underscores CRs as potential biomarkers and therapeutic targets for AF.

Genetic basis of atrial fibrillation-on the road to precision medicine

Atrial fibrillation (AF) is the most common cardiac arrhythmia and has complex genetic underpinnings. Despite advancements in treatment, mortality of AF patients remains high. This review discusses the genetic basis of AF and its implications for diagnosis and therapy. Although AF pathology has long been known to include ahereditary component, the first genes associated with AF were not identified until the early 2000s. Subsequent research with genome-wide association studies (GWAS) has implicated other genes and numerous genetic variants in AF. These studies have revealed nearly 140 different regions in the DNA with genome-wide significance associated with AF. In addition to common variants, rare variants with large effects have also been identified. The integration of these genetic findings into clinical practice holds promise for improving AF diagnosis and treatment, moving us closer to precision medicine. However, challenges remain, including the need for more diverse genetic data of non-European ancestry and improved genetic analyses of responses to AF therapy.

Atrial fibrillation and mortality after ischemic stroke: An observational study using an insurance claim database

ObjectivesIn this study, we aimed to examine the association between atrial fibrillation and mortality after ischemic stroke and evaluate the use of anticoagulation therapy for atrial fibrillation before stroke onset in patients who experienced stroke. MethodsIn this retrospective observational study, we used a combined database of medical and long-term care insurance claims data from one prefecture in Japan. The data of 25,352 patients aged ≥ 65 years who were hospitalized in acute care hospitals with a diagnosis of ischemic stroke between April 2012 and March 2015 were extracted. Cox proportional hazard modeling, with adjustment for age, sex, comorbidities, and long-term care dependency level (based on the activities of daily living), was performed to evaluate the relationship between mortality and atrial fibrillation. ResultsThe prevalence of atrial fibrillation was 21.8% in the study population. A significant association was noted between mortality and atrial fibrillation (adjusted hazard ratio: 1.28, 95% confidence interval: 1.16–1.41, p < 0.001). Anticoagulant drugs were used in 32.2% of the patients with atrial fibrillation. ConclusionsThese results indicate that atrial fibrillation is associated with mortality after stroke; however, the use of anticoagulation therapy for atrial fibrillation is unsatisfactory. Efforts to improve the use of atrial fibrillation therapy are required in Japan.

Safety and effectiveness of the first contact force ablation catheter with a flexible tip

Catheter ablation is an established therapy for paroxysmal atrial fibrillation (PAF). The TactiFlex Ablation Catheter, Sensor Enabled (TactiFlex SE) is a next-generation radiofrequency ablation catheter incorporating fiber optics-based contact force-sensing technology with a flexible, laser-cut tip. The study sought to evaluate the safety and effectiveness of the TactiFlex SE ablation catheter for treatment of drug-refractory PAF. The TactiFlex AF investigational device exemption was a prospective, nonrandomized, multicenter clinical study. Enrollment began on June 26, 2020 and completed June 18, 2021. Subjects with PAF underwent de novo pulmonary vein isolation and, if indicated, ablation for typical atrial flutter. Subjects were followed for 12 months. Of the 355 subjects enrolled at 37 sites worldwide, 334 underwent ablation with the TactiFlex SE catheter. The Kaplan-Meier estimate of 12-month freedom from AF/atrial flutter (AFL)/atrial tachycardia recurrence was 72.9% (95% confidence interval [CI] 95% CI 67.2%-77.8%) and clinical success was 83.6% (95% CI 95% CI 78.1%-87.2%). As-treated analyses compared subjects treated at high power (left atrium time-averaged power setting 40-50 W; n = 222) vs low power (<40 W; n = 97). The Kaplan-Meier estimate of 12-month freedom from AF/AFL/atrial tachycardia recurrence was 76.4% (95% CI 69.3%-82.0%) and clinical success was 83.9% (95% CI 77.5%-88.6%) in the high-power group compared with 66.8% (95% CI 56.1%-75.5%) and 80.7% (95% CI 70.8%- 87.5%), respectively, in the low-power group. The primary safety event rate in all treated subjects was 4.3%; 4.1% in the HP group and 5.2% in the LP group (P = .7671). TactiFlex SE is safe and effective for treatment of drug-refractory PAF and concomitant AFL and enables more efficient procedures than previous generation catheters.

Russian Club of Arrhythmologists has discussed important aspects of antiarrhythmic therapy for atrial fibrillation

Russian Club of Arrhythmologists has discussed important aspects of antiarrhythmic therapy for atrial fibrillation

Trends in use of Direct Oral Anticoagulants and Warfarin in Atrial Fibrillation Patients

Treatments used in atrial fibrillation therapy, such as those of anticoagulants, consist of vitamin K antagonists (warfarin) and direct oral anticoagulants (dabigatran, apixaban, rivaroxaban, and edoxaban). The use of warfarin requires regular monitoring of prothrombin time (PT) and international normalised ratio (INR). The therapeutic dose range is narrow, but the price is cheaper. Oral anticoagulants are directed, the incidence of major bleeding is lower, ease of use, food and drug interactions are minor, the half-life is shorter, and there is a lack of laboratory monitoring needs. Based on this problem, researchers conducted a study to determine the trend of using warfarin and oral anticoagulants in patients with atrial fibrillation at a public hospital in Jakarta. This study uses a qualitative approach, with longitudinal methods and retrospective data using outpatient medical records for the period 2014 to 2018. The trend of using warfarin anticoagulants decreased from 82.3% in 2014 to 62% in 2016, while oral anticoagulants were reduced. Direct oral anticoagulants are rivaroxaban and dabigatran, which are more widely used than apixaban, and edoxaban; no data on their use has been obtained. The opposite was true from 2017 to 2018, when the use of warfarin increased and caused a decrease in the use of direct oral anticoagulants. This research is expected to contribute to various parties, both health practitioners and academics, in terms of selecting therapies for atrial fibrillation.

Limitations in Contemporary Pharmacological Stroke Prevention Therapies in Atrial Fibrillation: A Descriptive Literature Review.

The most common arrhythmia, atrial fibrillation (AF), increases with age and is associated with a 5-fold increased risk of stroke. Although lifelong oral anticoagulation (OAC) is strongly recommended for stroke prevention in patients with AF and CHA2DS2-VASc ≥ 2 only 50-60% of patients in Western countries belonging to this group are treated with oral anticoagulants, and less than half of these adhere to therapy over time. Before 2010, the numerous limitations associated with vitamin K antagonists (VKAs) were considered to be the reason behind OAC underuse; however, the approval of direct oral anticoagulants (DOACs) that require once- or twice-daily intake, no regular blood tests and fewer drug-food interactions has resulted in only modest improvements in OAC use and adherence.

MicroRNAs in atrial fibrillation target genes in structural remodelling

We aim to elucidate how miRNAs regulate the mRNA signature of atrial fibrillation (AF), to gain mechanistic insight and identify candidate targets for future therapies. We present combined miRNA–mRNA sequencing using atrial tissues of patient without AF (n = 22), with paroxysmal AF (n = 22) and with persistent AF (n = 20). mRNA sequencing previously uncovered upregulated epithelial to mesenchymal transition, endothelial cell proliferation and extracellular matrix remodelling involving glycoproteins and proteoglycans in AF. MiRNA co-sequencing discovered miRNAs regulating the mRNA expression changes. Key downregulated miRNAs included miR-135b-5p, miR-138-5p, miR-200a-3p, miR-200b-3p and miR-31-5p and key upregulated miRNAs were miR-144-3p, miR-15b-3p, miR-182-5p miR-18b-5p, miR-4306 and miR-206. MiRNA expression levels were negatively correlated with the expression levels of a multitude of predicted target genes. Downregulated miRNAs associated with increased gene expression are involved in upregulated epithelial and endothelial cell migration and glycosaminoglycan biosynthesis. In vitro inhibition of miR-135b-5p and miR-138-5p validated an effect of miRNAs on multiple predicted targets. Altogether, the discovered miRNAs may be explored in further functional studies as potential targets for anti-fibrotic therapies in AF.

Harmonising Anticoagulation Therapy in Atrial Fibrillation: Navigating the Waters of Efficacy and Safety

Harmonising Anticoagulation Therapy in Atrial Fibrillation: Navigating the Waters of Efficacy and Safety

Characteristics of patients with atrial fibrillation treated with direct oral anticoagulants and new insights into inappropriate dosing: results from the French National Prospective Registry: PAFF.

Since the introduction of direct oral anticoagulant (DOAC) for atrial fibrillation (AF) therapy, inappropriate and/or underdosing of these drugs has been a major clinical challenge. We evaluated the characteristics of patients with AF treated with inappropriate and low-dose DOACs. Patients with AF treated with inappropriate and low-dose DOACs from October 2021 to December 2021 were evaluated from the French National Prospective Registry (PAFF). We evaluated 1890 patients with AF receiving DOACs (apixaban 55%, dabigatran 7%, and rivaroxaban 38%). Inappropriate dosing was noted in 18% of the population. Patients with appropriate dosing had less comorbidities: younger age (75 ± 10 vs. 82 ± 8 years old, P < 0.0001), reduced chronic renal failure (26 vs. 61%, P < 0.0001), and lower CHA2DS2VASc and HASBLED scores (3 ± 2 vs. 4 ± 3, P < 0.0001; 2 ±1 vs. 2 ± 2, P < 0.0001), respectively. In multivariate analysis, older age (P < 0.0001) and a higher CHA2DS2VASc score (P = 0.0056) were independently associated with inappropriate DOAC dosing. Among 472 patients (27%) treated with low-dose rivaroxaban or apixaban, 46% were inappropriately underdosed. Patients inappropriately underdosed were younger (82.3 ± 8.4 vs. 85.9 ± 5.9 years, P < 0.0001) with less chronic renal disease (47 vs. 98%, P < 0.0001). However, these patients had higher rates of prior haemorrhagic events (18 vs. 10%, P = 0.01), clopidogrel use (11 vs. 3%, P = 0.0002), and apixaban prescription (74 vs. 50%, P < 0.0001). Within this large registry, DOACs were associated with inappropriate dosing in 18% of cases. Independent predictors of inappropriate dosing were high CHA2DS2VASc scores and older age. Moreover, 46% of patients treated with low-dose DOACs were inappropriately underdosed and more frequently in patients treated with apixaban.

Catheter ablation versus medical therapy for atrial fibrillation with prior stroke history: a prospective propensity score-matched cohort study.

Patients with atrial fibrillation (AF) and prior stroke history have a high risk of cardiovascular events despite anticoagulation therapy. It is unclear whether catheter ablation (CA) has further benefits in these patients. AF patients with a previous history of stroke or systemic embolism (SE) from the prospective Chinese Atrial Fibrillation Registry study between August 2011 and December 2020 were included in the analysis. Patients were matched in a 1:1 ratio to CA or medical treatment (MT) based on propensity score. The primary outcome was a composite of all-cause death or ischemic stroke (IS)/SE. During a total of 4.1 ± 2.3 years of follow-up, the primary outcome occurred in 111 patients in the CA group (3.3 per 100 person-years) and in 229 patients in the MT group (5.7 per 100 person-years). The CA group had a lower risk of the primary outcome compared to the MT group [hazard ratio (HR) = 0.59, 95% CI: 0.47-0.74, P < 0.001]. There was a significant decreasing risk of all-cause mortality (HR = 0.43, 95% CI: 0.31-0.61, P < 0.001), IS/SE (HR = 0.73, 95% CI: 0.54-0.97, P = 0.033), cardiovascular mortality (HR = 0.32, 95% CI: 0.19-0.54, P < 0.001) and AF recurrence (HR = 0.33, 95% CI: 0.30-0.37, P < 0.001) in the CA group compared to that in the MT group. Sensitivity analysis generated consistent results when adjusting for time-dependent usage of anticoagulants. In AF patients with a prior stroke history, CA was associated with a lower combined risk of all-cause death or IS/SE. Further clinical trials are warranted to confirm the benefits of CA in these patients.

S794 Effectiveness of Somatostatin Analogues for Gastrointestinal Angiodysplasia in Patients on Anticoagulation Therapy for Atrial Fibrillation: A Propensity Matched Study

S794 Effectiveness of Somatostatin Analogues for Gastrointestinal Angiodysplasia in Patients on Anticoagulation Therapy for Atrial Fibrillation: A Propensity Matched Study

Comparison of the 11-Day Adhesive ECG Patch Monitor and 24-h Holter Tests to Assess the Response to Antiarrhythmic Drug Therapy in Paroxysmal Atrial Fibrillation.

Accurate assessment of the response to the antiarrhythmic drug (AAD) in atrial fibrillation (AF) is crucial to achieve adequate rhythm control. We evaluated the effectiveness of extended cardiac monitoring using an adhesive ECG patch in the detection of drug-refractory paroxysmal AF. Patients diagnosed with paroxysmal AF and receiving AAD therapy were enrolled. The subjects simultaneously underwent 11-day adhesive ECG patch monitoring and a 24-h Holter test. The primary study outcome was a detection rate of drug-refractory AF or atrial tachycardia (AT) lasting ≥30 s. A total of 59 patients were enrolled and completed the study examinations. AF or AT was detected in 28 (47.5%) patients by an 11-day ECG patch monitor and in 8 (13.6%) patients by a 24-h Holter test (p < 0.001). The 11-day ECG patch monitor identified an additional 20 patients (33.8%) with drug-refractory AF not detected by the 24-h Holter, and as a result, the treatment plan was changed in 11 patients (10 catheter ablations, one medication change). In conclusion, extended cardiac rhythm monitoring using an adhesive ECG patch in patients with paroxysmal AF under AAD therapy led to over a threefold higher detection of drug-refractory AF episodes, compared to the 24-h Holter test.