Untreated Atrial Fibrillation Research Articles

Detection of atrial fibrillation in persons aged 65years and above using amobile electrocardiogram device.

Untreated atrial fibrillation (AF) often results in increased morbidity and mortality. Opportunistic AF screening in persons aged ≥ 65years is recommended to identify patients with AF in order to prevent AF-related complications. The aim of this study was to assess the feasibility of screening persons for AF with the Kardia mobile electrocardiogram device (MED) and to determine the percentage of newly detected AF cases by selective population screening in the Netherlands. Persons aged ≥ 65years, without amedical history of AF, in nursing homes, at public events or visiting the general practitioner (GP) were approached to participate. AKardia MED smartphone ECG (sECG) was recorded and the CHA2DS2-VASc score was calculated. An automated AF algorithm classified the sECGs as 'sinus rhythm', 'AF' or 'unclassified'. In the case of AF, participants were referred to their GP. All sECGs were assessed by blinded experts. Atotal of 2168 participants were screened for AF. According to the expert's interpretation, 2.5% had newly detected AF, of whom 76.4% never experienced palpitations and 89.1% had aCHA2DS2-VASc score ≥ 2. The algorithm result was unclassified in 12.2% of cases, of which 95.5% were interpretable by experts. With expert opinion as the gold standard and excluding unclassified sECGs, the Kardia MED's negative and positive predictive value for detecting AF was 99.8% and 60.0%, respectively. Screening for AF using the Kardia MED is feasible and results in 2.5% newly detected AF cases. Expert interpretation of algorithm outcomes AF and unclassified is recommended.

Association of underlying untreated cardiovascular risk factors with mortality and functional outcome in ischaemic stroke patients

ObjectivesThe study aimed to determine the prevalence of untreated pharmacologically modifiable cardiovascular risk factors (PMRF) among patients with ischaemic stroke and the association with in-hospital mortality and functional outcome. MethodsWe analysed the data from ischaemic stroke cases admitted to Sarawak General Hospital between June 2013 and June 2021. We matched the underlying PMRFs with prior medications and categorised them as treated, untreated, or no PMRF. We calculated the prevalence and assessed the association between untreated PMRFs and in-hospital mortality or favourable functional outcome (FFO) at discharge, which was adjusted for age, sex, and other covariates in multivariable models. ResultsWe included 1963 patients [65.4% male, 59.8 (SD 13.4) years]; 43.8% who had at least one untreated PMRF had triple the odds of in-hospital mortality [adjusted OR (aOR) 2.86, (95%CI 1.44, 5.70)], whereas 30.2% who had all PMRFs treated showed no significant association. Untreated hypertension [aOR 2.19 (95%CI 1.21, 3.98)], treated [aOR 3.02 (95%CI 1.32, 6.92)], and untreated atrial fibrillation [aOR 1.89 (95%CI 1.18, 3.03)] were significantly associated with more in-hospital death, whereas treated prior stroke was associated with fewer in-hospital death [aOR 0.31 (95%CI 0.11, 0.84)]. Treated diabetes [aOR 0.66 (95%CI 0.49, 0.88)] and untreated prior stroke [aOR 0.53 (95%CI 0.33, 0.83)] were associated with fewer FFO. ConclusionThe high prevalence of untreated underlying PMRFs was significantly associated with poorer outcomes among Malaysian patients with ischaemic stroke in Sarawak. Efforts are needed to promote early screening and treatment of cardiovascular risk factors to reduce the burdens and improve stroke outcomes in this region.

Catheter ablation as first-line treatment in patients with atrial fibrillation: a Bayesian network meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Clinical trials suggest that early catheter ablation (CA) can be superior to anti-arrhythmic drugs (AADs) in "naïve" patients with AF. A low power to examine the outcomes, the use of a single technology ablation, and the short follow-up period are significant limitations of the studies. The EARLY-AF (Early Aggressive Invasive Intervention for Atrial Fibrillation) trial recently reported the results over three years of follow-up. Our research aims to update the comparison among different CA technologies with AADs as reference treatment. Interest outcomes included freedom from atrial tachycardia recurrences (ATRs) for efficacy and serious adverse events (AEs) for safety. Methods A systematic literature search was carried out up to Oct 31, 2022. We considered studies of patients with untreated atrial fibrillation who were enrolled in a trial in which they had been assigned to undergo initial rhythm-control therapy with cryoballoon (CRYO) or radiofrequency (RF) CA in at least one arm or to receive antiarrhythmic drugs (AADs). A Bayesian random-effects network meta-analysis (NMA) model comparing ATRs and AEs among the treatment arms was performed using MetaInsight V 4.0.0 web-based tool. Estimates are presented as Odds Ratio (OR) with a 95% Credible Interval (CrI). The surface under the cumulative ranking area (SUCRA) probabilities was selected to calculate the ranking and hierarchy of the different treatments. The larger SUCRA indicates the greater likelihood of becoming the best intervention. Results Six randomised control trials (RCTs) and one observational study (OBS) with 1,418 patients (mainly paroxysmal AF) were included. The follow-up period ranged from 12 to 36 months. The NMA demonstrates that ATRs were significantly lower with CRYO (OR [95% CrI], 0.36 [0.17-0.72]) and RF (OR [95% CrI], 0.39 [0.16-0.72]) compared with AADs. No significant difference was observed between CRYO and RF (OR [95% CrI], 1.09 [0.39-2.4]). The higher SUCRA value for CRYO (79%) indicated the likelihood that the treatment is the best, followed by RF (70%) and AADs (8%) (Figure 1). A total of 228 AEs were observed in 1,565 patients. The cumulative AEs associated with RF (OR [95% CrI], 1.31 [0.65-2.72]) and CRYO (OR [95% CrI], 0.72 [0.39-1.29]) were statistically similar in comparison with AADs. The indirect comparison showed no significant difference between the two ablative techniques. The probability of avoiding an AE was highest for CRYO (91%), followed by AADs (45%) and RF (14%) (Figure 2). In both analyses, the assessment of inconsistency for all studies was not significant (P > 0.05). Conclusions Our NMA demonstrated a lower rate of ATRs in patients treated with CRYO or RF CA than AADs. Furthermore, CA had a safety profile comparable to AADs. These results suggest recommending CA as a first-line treatment when early rhythm control is warranted, mainly in patients with paroxysmal AF.

PO-01-036 THE OUTCOMES OF ABLATION WITH VEIN OF MARSHALL ETHANOL INFUSION VS. ABLATION ALONE IN PATIENTS WITH UNTREATED PERSISTENT ATRIAL FIBRILLATION: CASE-CONTROL, SINGLE-CENTER STUDY

Ablation with the vein of Marshall ethanol infusion (VOM-ABL) is a relatively new therapeutic option for persistent atrial fibrillation (AF) compared with pulmonary vein isolation (PVI). We aimed to explore whether VOM-ABL showed better efficacy compared with PVI alone in untreated persistent AF. The study included consecutive patients who underwent VOM-ABL for untreated persistent AF at a single center between September 2021 and August 2022 as the study group. Consecutive patients who underwent PVI alone for untreated persistent AF between October 2019 and December 2020 were retrospectively included as the control group. The primary endpoint was freedom from AF/atrial tachycardia (AT) for longer than 30 seconds after the procedure during follow-up. The study group consisted of 88 patients (56.18±10.63 years) undergoing adjunctive VOM-ABL. The control group consisted of 102 patients (57.42±11.50 years) undergoing PVI alone. The proportion of patients with recurrences of AF/AT after a single procedure was 22 (25.0%) in the VOM-ABL group compared with 18 (17.6%) in the PVI alone group (P = 0.215) (Table 1). During a median follow-up of 4 months in the VOM-ABL group, and a median follow-up of 6 months in the PVI alone group, the time to recurrence of AF/AT was not significantly different either (P = 0.052) (Figure1). In addition, the perioperative complications and readmission incidence were similar between groups (Table 1). In patients with untreated persistent AF, the rate and time of recurrences of AF/AT after a single procedure were not significantly different between patients undergoing adjunctive VOM-ABL and patients undergoing PVI alone. Therefore, the need for adjunctive VOM-ABL in patients with persistent AF treated for the first time still requires longer follow-up and more in-depth exploration.

Progression of Atrial Fibrillation after Cryoablation or Drug Therapy

BackgroundAtrial fibrillation is a chronic, progressive disorder, and persistent forms of atrial fibrillation are associated with increased risks of thromboembolism and heart failure. Catheter ablation as initial therapy may modify the pathogenic mechanism of atrial fibrillation and alter progression to persistent atrial fibrillation.MethodsWe report the 3-year follow-up of patients with paroxysmal, untreated atrial fibrillation who were enrolled in a trial in which they had been randomly assigned to undergo initial rhythm-control therapy with cryoballoon ablation or to receive antiarrhythmic drug therapy. All the patients had implantable loop recorders placed at the time of trial entry, and evaluation was conducted by means of downloaded daily recordings and in-person visits every 6 months. Data regarding the first episode of persistent atrial fibrillation (lasting ≥7 days or lasting 48 hours to 7 days but requiring cardioversion for termination), recurrent atrial tachyarrhythmia (defined as atrial fibrillation, flutter, or tachycardia lasting ≥30 seconds), the burden of atrial fibrillation (percentage of time in atrial fibrillation), quality-of-life metrics, health care utilization, and safety were collected.ResultsA total of 303 patients were enrolled, with 154 patients assigned to undergo initial rhythm-control therapy with cryoballoon ablation and 149 assigned to receive antiarrhythmic drug therapy. Over 36 months of follow-up, 3 patients (1.9%) in the ablation group had an episode of persistent atrial fibrillation, as compared with 11 patients (7.4%) in the antiarrhythmic drug group (hazard ratio, 0.25; 95% confidence interval [CI], 0.09 to 0.70). Recurrent atrial tachyarrhythmia occurred in 87 patients in the ablation group (56.5%) and in 115 in the antiarrhythmic drug group (77.2%) (hazard ratio, 0.51; 95% CI, 0.38 to 0.67). The median percentage of time in atrial fibrillation was 0.00% (interquartile range, 0.00 to 0.12) in the ablation group and 0.24% (interquartile range, 0.01 to 0.94) in the antiarrhythmic drug group. At 3 years, 8 patients (5.2%) in the ablation group and 25 (16.8%) in the antiarrhythmic drug group had been hospitalized (relative risk, 0.31; 95% CI, 0.14 to 0.66). Serious adverse events occurred in 7 patients (4.5%) in the ablation group and in 15 (10.1%) in the antiarrhythmic drug group.ConclusionsInitial treatment of paroxysmal atrial fibrillation with catheter cryoballoon ablation was associated with a lower incidence of persistent atrial fibrillation or recurrent atrial tachyarrhythmia over 3 years of follow-up than initial use of antiarrhythmic drugs. (Funded by the Cardiac Arrhythmia Network of Canada and others; EARLY-AF ClinicalTrials.gov number, NCT02825979.)

Variations in atrial fibrillation screening after ischemic stroke or transient ischemic attack in Sweden

Abstract Background/Introduction The risk of recurrent stroke and mortality is high among patients with ischemic stroke or transient ischemic attack (TIA) and untreated atrial fibrillation (AF). Hence, AF screening after an event has high priority in national and international guidelines. Despite the abundance of evidence on AF detection using different AF screening modalities, there is still no evidence on a prognostic benefit of ECG monitoring post ischemic stroke. There is a risk for variations in clinical practice for AF screening after ischemic cerebrovascular events due to this gap of evidence. Purpose The aim of this study was to investigate the clinical practice of AF screening after TIA or ischemic stroke at Swedish stroke units. Methods In collaboration with the stakeholders of the Swedish stroke register (Riksstroke) important fields to study were identified, e.g. AF screening method, first choice of method (multiple answers possible), monitoring duration, clinical follow-up etc. A draft for a digital survey was constructed and then tested and revised by 5 stroke consultants. The survey consisted of 18 multiple choice questions with free text comments and was sent by e-mail to the medical supervisors at all stroke units in Sweden in November 2021. Results All 72 stroke units in Sweden responded to the survey. Almost all (69/72) stroke units reported that ≥75% of ischemic stroke patients are screened for AF. Of the stroke units 81% had inpatient telemetry as their first choice of AF screening method (Figure 1), but 7% had no access to inpatient telemetry. In case of inpatient telemetry, 30% reported 0–24 hours and 54% reported 24–48 hours as their standard monitoring time. Most had the attending physician at the stroke unit as the primary ECG reader, some with access to support from cardiologist. Different standard monitoring durations for Holter were used (Figure 2) and 17% reported Holter as their first choice of AF screening method. Approximately 85% reported repeated ECG monitoring if high suspicion of cardiac embolization, preferably with repeated Holter (73%) or handheld ECG (49%). Implantable loop recorder (6%), event loop recorder (14%) and 2 weeks registration with ECG-patch (3%) was more infrequently used for this purpose. Conclusions Clinical practice for AF screening after ischemic stroke or TIA at Swedish stroke units showed considerable variations with a range of different AF screening methods and monitoring durations. Further, the standards and quality of inpatient ECG monitoring is unknown. There is an urgent need for evidence and evidence-based recommendations in this field, the present situation also implies inequality in care. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Stiftelsen Hjartat

PREVALENCE OF UNREPORTED ATRIAL FIBRILLATION IN ELECTROCARDIOGRAMS WITH VENTRICULAR-PACED RHYTHM: A MULTICENTER EXPERIENCE

PREVALENCE OF UNREPORTED ATRIAL FIBRILLATION IN ELECTROCARDIOGRAMS WITH VENTRICULAR-PACED RHYTHM: A MULTICENTER EXPERIENCE

Screening for untreated atrial fibrillation in the elderly population: A community-based study

BackgroundStrokes are common in people with atrial fibrillation (AF), and can have devastating consequences, especially in the elderly and if AF is untreated. However, community-based studies on screening for untreated AF have not been conducted in Japan, and there has been no evaluation of the effectiveness of early screening for AF in the elderly (≥65 years).MethodsThe Kyoto Prefectural University of Medicine (KPUM) Education Initiative has conducted an AF awareness campaign consisted of screening tests using a blood pressure (BP) monitor with electrocardiogram (ECG) (the Complete, Omron Healthcare Co., Ltd., Kyoto, Japan) and educational lectures for the elderly (≥65 years) from 2019 to 2020. A modeled effectiveness analysis was performed comparing the life-years and QALYs (quality-adjusted life-years) between direct-acting oral anticoagulation (DOAC)-treated AF and untreated AF in a Japanese setting. The basic description of the Markov model was used for the analysis.ResultsA total of 1648 participants were screened, and after excluding those with missing information or data (n = 41), 1607 were finally enrolled. The mean (± standard deviation) age of participants was 72.4±5.8 years, 827 (51.5%) were female, 628 (39.1%) had hypertension, and 1368 (85.1%) had CHA2DS2-VASc score ≥2. After cardiologists’ evaluation of all ECG recordings of the Complete, 15 (0.93%) AF were newly detected. For each AF treated with DOAC, 0.859 QALYs gained over the lifetime for 65 years-old men, and 0.856 QALYs for 65 years-old women compared to non-treatment.ConclusionA moderate number of untreated AF were identified in the community-based study. Identification of an increased number of patients with AF, if properly treated with DOAC, ultimately leads to a reduction in the number of strokes occurred over subjects’ lifetime.

Documentation of atrial fibrillation among non-conveyed ambulance patients: a new primary prevention opportunity?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a significant risk factor for stroke. Prescription of oral anticoagulant (OAC) medication reduces the risk of AF-related stroke by 64% - yet over 400,000 people in England have undiagnosed (and therefore untreated) AF.Emergency medical services (EMS) encounter a wide range of patients, some of whom may not engage with other healthcare services. AF may be detected by EMS in connection with the cause of the call, or as an incidental finding. While EMS are not traditionally utilised for public health screening, they may offer an opportunity to identify patients with undiagnosed or untreated AF and refer onward.This study aimed to explore what proportion of patients seen by EMS who were not transported to hospital had AF and to estimate how many would potentially benefit from OAC. A retrospective service evaluation was conducted using routinely collected data from a large UK regional ambulance service. The sample included adults attended by EMS on the 15th of each month in 2019, who were not transported to hospital and where an electrocardiogram was recorded. Of those with AF, we calculated the proportion in whom this was possibly new and report whether OAC was prescribed. There were 859 patients who met the inclusion criteria, of whom 91 (11%) had AF documented. Of the 91 patients with AF, 23 (25%) had no documented history of AF or OAC prescription, so were potentially new diagnoses of AF, who would benefit from consideration of OAC therapy. The EMS assessment offers an opportunity for AF to be identified in patients who were not transported to hospital. EMS may have a role in primary prevention of harm, including stroke, by identifying and referring patients with AF for consideration of OAC.

The Chinese burden of atrial fibrillation review of atrial fibrillation studies in China.

Atrial fibrillation (AF) is one of the most common heart rate disorders, but most relevant studies are mainly focused on Europe and The United States, while information about AF in the Chinese population is scarce. The purpose of this study was to provide a review of the literature on atrial fibrillation in China. A literature search (Medline 2001-2021) identified studies reporting the prevalence or incidence of AF, risk factors for AF, comorbidities of AF, and use of antithrombotic therapy in China. This report focuses on descriptive analytical data. Studies reported a wide variation in the prevalence of AF, with a range of community-based and hospital-based AF rates (from 0.49% to 8.8% and 4.4% to 35.7%). Aspirin and warfarin use was found to be particularly low in community-based studies in China, and warfarin and amiodarone use was higher in hospital-based studies than in other countries. Stroke is the most common complication of atrial fibrillation. More high-quality studies are needed to improve our understanding of the burden of atrial fibrillation in China. Efforts should be made to improve community delivery and monitoring of antithrombotic therapy after AF. Due to China's large population, the number of patients with untreated AF and the risk of accompanying complications can be high, so the impact on healthcare resources can be significant.

PO-712-02 URGENT CATHETER ABLATION FOR TREATMENT REFRACTORY SYMPTOMATIC ATRIAL FIBRILLATION: HEALTHCARE UTILIZATION AND OUTCOMES

Catheter ablation has become increasingly common elective therapy for symptomatic atrial fibrillation (AF). Recent clinical trials (STOP AF First and EARLY AF) have shown an improvement in arrhythmia free survival via early rhythm control in symptomatic, untreated atrial fibrillation. However real word data on outcomes of urgent AF ablation performed during AF related admissions, and the impact of these on healthcare utilization remains to be ascertained.

Development and validation of a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in inpatients with Atrial Fibrillation (STEWARxD-AF)

ObjectiveAnticoagulation is highly effective for stroke prevention in atrial fibrillation (AF), reducing the risk by about 64%. Despite overwhelming evidence in support of anticoagulation, up to 40% of AF patients remain untreated. We aimed to develop and validate STEWARxD-AF: a Screening Tool to Evaluate and Warrant Anticoagulation Treatment prior to Discharge in Atrial Fibrillation. Materials and methodsSTEWARxD-AF was developed by integrating information extracted from the electronic health record (EHR). A stepwise decision process was applied, based on AF diagnosis, estimated CHA2DS2-VASc-score and anticoagulant use. A priority score was assigned accordingly, ranging from 0 (no risk) to 5 (highest risk of undertreatment). A cross-sectional study was performed to assess the accuracy of STEWARxD-AF. Criterion and tool validity were ascertained by determining sensitivity and specificity, compared to a manual check of the EHR in an inpatient sample (n = 800). Consistency regarding the priority score was determined by estimating Cohen’s kappa. ResultsA tool to screen for un(der)treated AF was developed and embedded into the EHR. Sensitivity and specificity for AF diagnosis were 98.4% and 87.6%, respectively. Overall sensitivity and specificity for identification of a CHA2DS2-VASc-score ≥ 2 was 97.7% and 72.7%. Sensitivity and specificity to determine the presence of anticoagulant treatment was at least 87.8% and 97.1% There was good agreement for the priority score (κ 0.74 (unweighted); 0.66 (weighted)). ConclusionsSTEWARxD-AF was able to identify untreated AF inpatients reliably and with a high sensitivity. Nearly no patients were missed. We will now implement this AF-screening tool in clinical practice to improve the use of anticoagulation and reduce the risk of stroke.

SUPPORT-AF III: supporting use of AC through provider prompting about oral anticoagulation therapy for AF.

Only half of atrial fibrillation (AF) patients with elevated stroke risk receive anticoagulation (AC). Electronic health record (EHR) alerts have the potential to close the gap. We designed an outpatient EHR alert (linked to an order set for ordering AC, labs, and specialty referrals) that fired when cardiology and primary care providers (PCPs) saw AF patients not on AC. We assigned all untreated patients seen by cardiology providers and PCPs in the 8months before and after the alert launch to pre- and post-launch intervention cohorts, respectively. Untreated AF patients seeing other types of providers became controls. We then compared the difference in AC starts between intervention and control patients post-launch to the same difference prelaunch (adjusting for covariates). We measured alert responsiveness as how often patients had at least one encounter with a provider, who interacted with the alert. The adjusted percentage of AC starts for the prelaunch cohort was 20% for intervention patients and 17% for controls (difference = 3%); post-launch, the percentage was 13% for both post-launch intervention and controls (difference = 0%). The difference in difference was - 3% (p value 0.63). For half of patients, at least one provider was responsive to our alert. Reasons for no AC commonly included relative contraindications (e.g. fall, gastrointestinal bleed). Our alert did not increase AC starts but responsiveness to it was high. Increasing AC starts will likely require education surrounding relative contraindications.

Abstract P676: Rates of Preventable Thrombectomy in Acute Ischemic Stroke

Introduction: The AHA notes that more than 76% of strokes are the first occurrence. There are class 1 recommendations for the management of common risk factors such as atrial fibrillation (AF), hyperlipidemia (HLD), hypertension (HTN), diabetes (DM), and vascular disease. The purpose of this study is to investigate the percentage of large vessel strokes that are potentially preventable with adequate management of vascular risk factors. Methods: A retrospective chart review was conducted on all patients undergoing endovascular therapy (EVT) from 2012-2019. Data was collected on vascular risk factors present prior to admission including HTN, DM, HLD, AF, and smoking. Preventable stroke was defined as having at least one of the following: untreated AF, untreated HLD, poorly controlled HTN (presence of left ventricular hypertrophy on transthoracic echo), history of vascular disease not on an antiplatelet agent, poorly controlled DM (A1c>10), current smoking. Groups were compared based on age, sex and 90 day functional outcomes, with favorable outcome defined as mRS ≤ 2. Results: Our sample included 396 patients who underwent EVT (mean age 65, 50% female). 42% of patients with Afib were not on anticoagulation, 31% of patients with HLD were untreated, 39% of patients with HTN were poorly controlled, 27% of patients with a history of vascular disease were not on an antiplatelet, 14% of patients with DM were poorly controlled, and 46% of all patients were smokers. In total, 78% of patients had at least 1 poorly controlled risk factor and 37% had at least 2. There was no difference in rates of preventable stroke between males and females (48% vs 52%, p=0.30) and between age groups above and below 70 (40% vs 60%, p=0.68). 64% of patients with well controlled risk factors had a favorable outcome compared to 51% with at least one poorly controlled risk factor (p=0.03). Conclusions: Our data suggests that despite guidelines on management of vascular risk factors, a large number of these are poorly controlled prior to admission for large vessel stroke, leading to a potentially preventable procedure. Not only could improved primary prevention save the wide array of resources utilized in EVT, but it could also influence long term outcomes in this cohort of patients.

Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation

BackgroundGuidelines recommend a trial of one or more antiarrhythmic drugs before catheter ablation is considered in patients with atrial fibrillation. However, first-line ablation may be more effective in maintaining sinus rhythm.MethodsWe randomly assigned 303 patients with symptomatic, paroxysmal, untreated atrial fibrillation to undergo catheter ablation with a cryothermy balloon or to receive antiarrhythmic drug therapy for initial rhythm control. All the patients received an implantable cardiac monitoring device to detect atrial tachyarrhythmia. The follow-up period was 12 months. The primary end point was the first documented recurrence of any atrial tachyarrhythmia (atrial fibrillation, atrial flutter, or atrial tachycardia) between 91 and 365 days after catheter ablation or the initiation of an antiarrhythmic drug. The secondary end points included freedom from symptomatic arrhythmia, the atrial fibrillation burden, and quality of life.ResultsAt 1 year, a recurrence of atrial tachyarrhythmia had occurred in 66 of 154 patients (42.9%) assigned to undergo ablation and in 101 of 149 patients (67.8%) assigned to receive antiarrhythmic drugs (hazard ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66; P<0.001). Symptomatic atrial tachyarrhythmia had recurred in 11.0% of the patients who underwent ablation and in 26.2% of those who received antiarrhythmic drugs (hazard ratio, 0.39; 95% CI, 0.22 to 0.68). The median percentage of time in atrial fibrillation was 0% (interquartile range, 0 to 0.08) with ablation and 0.13% (interquartile range, 0 to 1.60) with antiarrhythmic drugs. Serious adverse events occurred in 5 patients (3.2%) who underwent ablation and in 6 patients (4.0%) who received antiarrhythmic drugs.ConclusionsAmong patients receiving initial treatment for symptomatic, paroxysmal atrial fibrillation, there was a significantly lower rate of atrial fibrillation recurrence with catheter cryoballoon ablation than with antiarrhythmic drug therapy, as assessed by continuous cardiac rhythm monitoring. (Funded by the Cardiac Arrhythmia Network of Canada and others; EARLY-AF ClinicalTrials.gov number, NCT02825979.)

Determinants of outcome impact of vein of Marshall ethanol infusion when added to catheter ablation of persistent atrial fibrillation: A secondary analysis of the VENUS randomized clinical trial

The VENUS trial demonstrated that adding vein of Marshall (VOM) ethanol infusion to catheter ablation (CA) improves ablation outcomes in persistent atrial fibrillation (AF). There was significant heterogeneity in the impact of VOM ethanol infusion on rhythm control. The purpose of this study was to assess the association between outcomes and (1) achievement of bidirectional perimitral conduction block and (2) procedural volume. The VENUS trial randomized patients with persistent AF (N = 343) to CA combined with VOM ethanol or CA alone. The primary outcome (freedom from AF or atrial tachycardia [AT] lasting longer than 30 seconds after a single procedure) was analyzed by 2 categories: (1) successful vs no perimitral block and (2) high- (>20 patients enrolled) vs low-volume centers. In patients with perimitral block, the primary outcome was reached 54.3% after VOM-CA and 37% after CA alone (P = .01). Among patients without perimitral block, freedom from AF/AT was 34.0% after VOM-CA and 37.0% after CA (P = .583). In high-volume centers, the primary outcome was reached in 56.4% after VOM-CA and 40.2% after CA (P = .01). In low-volume centers, freedom from AF/AT was 30.77% after VOM-CA and 32.61% after CA (P = .84). In patients with successful perimitral block from high-volume centers, the primary outcome was reached in 59% after VOM-CA and 39.1% after CA (P = .01). Tests for interaction were significant (P = .002 for perimitral block and P = .04 for center volume). Adding VOM ethanol infusion to CA has a greater impact on outcomes when associated with perimitral block and performed in high-volume centers. Perimitral block should be part of the VOM procedure.

Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation

Catheter ablation of persistent atrial fibrillation (AF) has limited success. Procedural strategies beyond pulmonary vein isolation have failed to consistently improve results. The vein of Marshall contains innervation and AF triggers that can be ablated by retrograde ethanol infusion. To determine whether vein of Marshall ethanol infusion could improve ablation results in persistent AF when added to catheter ablation. The Vein of Marshall Ethanol for Untreated Persistent AF (VENUS) trial was an investigator-initiated, National Institutes of Health-funded, randomized, single-blinded trial conducted in 12 centers in the United States. Patients (N = 350) with persistent AF referred for first ablation were enrolled from October 2013 through June 2018. Follow-up concluded in June 2019. Patients were randomly assigned to catheter ablation alone (n = 158) or catheter ablation combined with vein of Marshall ethanol infusion (n = 185) in a 1:1.15 ratio to accommodate for 15% technical vein of Marshall ethanol infusion failures. The primary outcome was freedom from AF or atrial tachycardia for longer than 30 seconds after a single procedure, without antiarrhythmic drugs, at both 6 and 12 months. Outcome assessment was blinded to randomization treatment. There were 12 secondary outcomes, including AF burden, freedom from AF after multiple procedures, perimitral block, and others. Of the 343 randomized patients (mean [SD] age, 66.5 [9.7] years; 261 men), 316 (92.1%) completed the trial. Vein of Marshall ethanol was successfully delivered in 155 of 185 patients. At 6 and 12 months, the proportion of patients with freedom from AF/atrial tachycardia after a single procedure was 49.2% (91/185) in the catheter ablation combined with vein of Marshall ethanol infusion group compared with 38% (60/158) in the catheter ablation alone group (difference, 11.2% [95% CI, 0.8%-21.7%]; P = .04). Of the 12 secondary outcomes, 9 were not significantly different, but AF burden (zero burden in 78.3% vs 67.9%; difference, 10.4% [95% CI, 2.9%-17.9%]; P = .01), freedom from AF after multiple procedures (65.2% vs 53.8%; difference, 11.4% [95% CI, 0.6%-22.2%]; P = .04), and success achieving perimitral block (80.6% vs 51.3%; difference, 29.3% [95% CI, 19.3%-39.3%]; P < .001) were significantly improved in vein of Marshall-treated patients. Adverse events were similar between groups. Among patients with persistent AF, addition of vein of Marshall ethanol infusion to catheter ablation, compared with catheter ablation alone, increased the likelihood of remaining free of AF or atrial tachycardia at 6 and 12 months. Further research is needed to assess longer-term efficacy. ClinicalTrials.gov Identifier: NCT01898221.

Of Equestrians and Endocarditis

an 80-year old female was transferred from an outside hospital for concerns of a mitral valve vegetation and sepsis. Her past medical history included untreated chronic lymphocytic leukemia (CLL) and atrial fibrillation on warfarin therapy. The patient was otherwise very active and enjoyed daily rides on her horses. She initially presented with altered mental status and was found to be in septic shock with respiratory failure requiring intubation. Initial head CT showed an ischemic stroke in the bilateral frontal lobes. Echocardiogram showed a large mitral valve vegetation. A repeat CT of her head obtained for clinical decline revealed hemorrhagic conversion of her ischemic stroke. She began to have seizure activity that was treated with Keppra. Blood cultures grew Streptococcus zooepidemicus, and she was subsequently transferred to our tertiary medical center for increased level of care.

Detection rate and treatment gap for atrial fibrillation identified through screening in community health centers in China (AF-CATCH): A prospective multicenter study.

Atrial fibrillation (AF) is underdiagnosed and especially undertreated in China. We aimed to investigate the prevalence of unknown and untreated AF in community residents (≥65 years old) and to determine whether an education intervention could improve oral anticoagulant (OAC) prescription. We performed a single-time point screening for AF with a handheld single-lead electrocardiography (ECG) in Chinese residents (≥65 years old) in 5 community health centers in Shanghai from April to September 2017. Disease education and advice on referral to specialist clinics for OAC treatment were provided to all patients with actionable AF (newly detected or undertreated known AF) at the time of screening, and education was reinforced at 1 month. Follow-up occurred at 12 months. In total, 4,531 participants were screened (response rate 94.7%, mean age 71.6 ± 6.3 years, 44% male). Overall AF prevalence was 4.0% (known AF 3.5% [n = 161], new AF 0.5% [n = 22]). The 183 patients with AF were older (p < 0.001), taller (p = 0.02), and more likely to be male (p = 0.01), and they had a higher prevalence of cardiovascular disease than those without AF (p < 0.001). In total, 85% (155/183) of patients were recommended for OAC treatment by the established guidelines (CHA2DS2-VASc ≥ 2 for men; ≥ 3 for women). OAC prescription rate for known AF was 20% (28/138), and actionable AF constituted 2.8% of all those screened. At the 12-month follow-up in 103 patients (81% complete), despite disease education and advice on specialist referral, only 17 attended specialist clinics, and 4 were prescribed OAC. Of those not attending specialist clinics, 71 chose instead to attend community health centers or secondary hospital clinics, with none prescribed OAC, and 15 had no review. Of the 17 patients with new AF and a class 1 recommendation for OAC, only 3 attended a specialist clinic, and none were prescribed OAC. Of the 28 AF patients taking OAC at baseline, OAC was no longer taken in 4. Ischemic stroke (n = 2) or death (n = 3) occurred in 5/126 (4%), with none receiving OAC. As screening was performed at a single time point, some paroxysmal AF cases may have been missed; thus, the rate of new AF may be underestimated. We demonstrated a noticeable gap in AF detection and treatment in community-based elderly Chinese: actionable AF constituted a high proportion of those screened. Disease education and advice on specialist referral are insufficient to close the gap. Before more frequent or intensive screening for unknown AF could be recommended in China, greater efforts must be made to increase appropriate OAC therapy in known AF to prevent AF-related stroke.

SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation

Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions. We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA2DS2-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (P=0.21). Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03583008.