VASc Score Research Articles

Rule-based definition of muscle bundles in patient-specific models of the left atrium.

Atrial fibrillation (AF) is the most common arrhythmia encountered clinically, and as the population ages, its prevalence is increasing. Although the CHA2DS2− VASc score is the most used risk-stratification system for stroke risk in AF, it lacks personalization. Patient-specific computer models of the atria can facilitate personalized risk assessment and treatment planning. However, a challenge faced in creating such models is the complexity of the atrial muscle arrangement and its influence on the atrial fiber architecture. This work proposes a semi-automated rule-based algorithm to generate the local fiber orientation in the left atrium (LA). We use the solutions of several harmonic equations to decompose the LA anatomy into subregions. Solution gradients define a two-layer fiber field in each subregion. The robustness of our approach is demonstrated by recreating the fiber orientation on nine models of the LA obtained from AF patients who underwent WATCHMAN device implantation. This cohort of patients encompasses a variety of morphology variants of the left atrium, both in terms of the left atrial appendages (LAAs) and the number of pulmonary veins (PVs). We test the fiber construction algorithm by performing electrophysiology (EP) simulations. Furthermore, this study is the first to compare its results with other rule-based algorithms for the LA fiber architecture definition available in the literature. This analysis suggests that a multi-layer fiber architecture is important to capture complex electrical activation patterns. A notable advantage of our approach is the ability to reconstruct the main LA fiber bundles in a variety of morphologies while solving for a small number of harmonic fields, leading to a comparatively straightforward and reproducible approach.

External validation of the biomarker based ABCD score in atrial fibrillation patients with a non gender CHA2DS2 VASc score 0 to 1, A Korean multicenter retrospective cohort

Abstract Background Patients with low to intermediate risk atrial fibrillation (AF), defined as non-gender CHA2DS2-VASc score of 0–1, are still at risk of stroke. This study verified the usefulness of ABCD score (Age [≥60 years], B-type natriuretic peptide [BNP] or N-terminal pro-BNP [≥300 pg/ml], Creatinine clearance [<50 ml/min/1.73 m2], and Dimension of the left atrium [≥45 mm]) for stroke risk stratification in non-gender CHA2DS2-VASc score 0–1. Methods This multi-center cohort study retrospectively analyzed AF patients with non-gender CHA2DS2-VASc score 0–1. The primary endpoint was the incidence of stroke with or without anti-thrombotic treatment (ATT). An ABCD score was also validated. Results Overall, 2694 patients (56.3±9.5 years; female, 726 [26.9%]) were followed-up for 4.0±2.8 years. The overall stroke rate was 0.84/100 person-years (P-Y), stratified as follows: 0.46/100P-Y for an ABCD score 0; 1.02/100P-Y for an ABCD score≥1. The ABCD score was superior to the non-gender CHA2DS2-VASc score in stroke risk stratification (C-index=0.618, P=0.015; net reclassification improvement=0.576, P=0.040; integrated differential improvement=0.033, P=0.066). ATT was prescribed in 2353 patients (86.5%), and the stroke rate was significantly lower in patients receiving non-vitamin K antagonist oral anticoagulant (NOAC) therapy and an ABCD score≥1 than in those without ATT (0.44/100P-Y versus 1.55/100 P-Y; hazard ratio=0.26, 95% confidence interval 0.11–0.63, P=0.003). Conclusion The biomarker-based ABCD score demonstrated improved stroke risk stratification in AF patients with non-gender CHA2DS2-VASc score 0–1. Furthermore, NOAC with an ABCD score≥1 was associated with significantly lower stroke rate in AF patients with a non-gender CHA2DS2-VASc score 0–1. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Disease Control and Prevention Agency

Evaluation of Risk Scores as Predictive Tools for Stroke in Patients with Retinal Artery Occlusion: A Danish Nationwide Cohort Study.

Purpose We investigated the 1-year risk of stroke in patients with retinal artery occlusion and evaluated the predictive and discriminating abilities of contemporary risk stratification models for embolic stroke. Methods This register-based cohort study included 7,906 patients with retinal artery occlusion from Danish nationwide patient registries between 1995 and 2018. The study population was stratified according to the number of points obtained in the stroke risk scores: the CHA 2 DS 2 -VASc score and the ESSEN Stroke Risk score. The 1-year risk of stroke within strata was evaluated and compared using the cox proportional hazards model. Furthermore, the discrimination of the risk scores as predictive tools for stroke risk assessment was investigated using C-statistics, Brier score, and the index of prediction accuracy. Results The stroke event rate in patients with retinal artery occlusion increased as the score increased for both risk scores, ranging from 3.62 (95% confidence interval [CI]: 2.46-5.31) per 100 person-years to 13.25 (95% CI: 11.78--14.89) per 100-person-years for increasing levels of the CHA 2 DS 2 -VASc score and from 3.97 (95% CI: 2.97-5.32) per 100 person-years to 16.43 (95% CI: 14.01-19.27) per 100 person-years for increasing levels of the ESSEN Stroke Risk score. Using a risk score of 0 as a reference, the difference was statistically significant for retinal artery occlusion patients with a CHA 2 DS 2 -VASc score of 2 or above and for all levels of the ESSEN Stroke Risk score. The C-statistics for the risk scores was 61% (95% CI: 58%-63%) and 62% (95% CI: 59-64%) for the CHA 2 DS 2 -VASc score and ESSEN Stroke Risk score, respectively. Conclusion The results suggested that the use of the CHA 2 DS 2 -VASc score and the ESSEN Stroke Risk score was applicable for risk stratification of stroke in patients with retinal artery occlusion, but discrimination was poor due to low specificity.

Asymptomatic left circumflex artery stenosis is associated with higher arrhythmia recurrence after persistent atrial fibrillation ablation.

BackgroundThe pathophysiology of persistent atrial fibrillation (AF) remains unclear. While several studies have demonstrated an association between myocardial infarction and atrial fibrillation, the role of stable coronary artery disease (CAD) is still unknown. As a result, we aimed to assess the association between CAD obstruction and AF recurrence after persistent AF ablation in patients with no history of CAD.Materials and methodsThis observational retrospective study included consecutive patients who underwent routine preprocedural cardiac computed tomography (CCT) before persistent AF ablation between September 2015 and June 2018 in 5 European University Hospitals. Exclusion criteria were CAD or coronary revascularization previously known or during follow-up. Obstructive CAD was defined as luminal stenosis ≥ 50%.ResultsAll in all, 496 patients (mean age 61.8 ± 10.0 years, 76.2% males) were included. CHA2DS2–VASc score was 0 or 1 in 225 (36.3%) patients. Obstructive CAD was present in 86 (17.4%) patients. During the follow-up (24 ± 19 months), 207 (41.7%) patients had AF recurrence. The recurrence rate was not different between patients with and without obstructive CAD (43.0% vs. 41.5%, respectively; P = 0.79). When considering the location of the stenosis, the recurrence rate was higher in the case of left circumflex obstruction: 56% vs. 32% at 2 years (log-rank P ≤ 0.01). After Cox multivariate analysis, circumflex artery obstruction (HR 2.32; 95% CI 1.36–3.98; P < 0.01) was independently associated with AF recurrence.ConclusionCircumflex artery obstruction detected with CCT was independently associated with 2-fold increase in the risk of AF recurrence after persistent AF ablation. Further research is necessary to evaluate this pathophysiological relationship.

In-hospital mortality of atrial fibrillation-associated acute ischemic stroke in the intensive care unit

Background: Although atrial fibrillation (AF)-associated acute ischemic stroke (AIS) is on the rise, is devastating, and life-threatening, there is limited data on the clinical course and in-hospital mortality of patients treated in the intensive care unit (ICU). This study aimed to describe the clinical course and factors associated with in-hospital mortality in AF-associated AIS patients admitted to the ICU.Methods: This study was a retrospective analysis of a prospective nationwide multicenter cohort including non-valvular AF-AIS patients receiving ICU care admitted to 14 stroke centers in South Korea from 2017 to 2020. In-hospital outcomes, including in-hospital mortality and neurological deterioration (ND) have been described.Result: Amongst 2,487 AF-associated AIS patients, 259 (10.4%) were treated in the ICU. In-hospital mortality and ND occurred in 8.5% and 17.0% of the patients, respectively. Higher rates of initial National Institute for Health Stroke Scale scores, symptomatic steno-occlusive lesions, and CHA&lt;sub&gt;2&lt;/sub&gt;DS&lt;sub&gt;2&lt;/sub&gt;-VASc (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74, Female) scores were found in those with in-hospital mortality. The CHA&lt;sub&gt;2&lt;/sub&gt;DS&lt;sub&gt;2&lt;/sub&gt;-VASc score after admission increased the risk of in-hospital mortality (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.00–2.18) were associated with in-hospital mortality. Antithrombotic use within 48 hours was related to decreased in-hospital mortality (OR, 0.26; 95% CI, 0.10–0.67).Conclusion: ICU care in AF-associated AIS is common, and the establishment of optimal treatment strategies in the ICU may be needed.

Oral anticoagulant treatment in rheumatoid arthritis patients with atrial fibrillation results of an international audit.

To describe the prevalence of atrial fibrillation (AF) in patients with rheumatoid arthritis (RA), and to evaluate the proportion of patients with AF receiving guideline-recommended anticoagulation for prevention of stroke, based on data from a large international audit. The cohort was derived from the international audit SUrvey of cardiovascular disease Risk Factors in patients with Rheumatoid Arthritis (SURF-RA) which collected data from 17 countries during 2014-2019. We evaluated the prevalence of AF across world regions and explored factors associated with the presence of AF with multivariable logistic regression models. The proportion of AF patients at high risk of stroke (CHA2DS2-VASc≥2 in males and≥3 in females) receiving anticoagulation was examined. Of the total SURF-RA cohort (n=14,503), we included RA cases with data on whether the diagnosis of AF was present or not (n=7,665, 75.1% women, mean (SD) age 58.7 (14.1) years). A total of 288 (3.8%) patients had a history of AF (4.4% in North America, 3.4% in Western Europe, 2.8% in Central and Eastern Europe and 1.5% in Asia). Factors associated with the presence of AF were older age, male sex, atherosclerotic cardiovascular disease, heart failure and hypertension. Two-hundred and fifty-five (88.5%) RA patients had a CHA2DS2-VASc score indicating recommendation for oral anticoagulant treatment, and of them, 164 (64.3%) were anticoagulated. Guideline-recommended anticoagulant therapy for prevention of stroke due to AF may not be optimally implemented among RA patients, and requires special attention.

Incidence and Predictors of Early Death in Patients Undergoing Percutaneous LeftAtrial Appendage Closure.

Left atrial appendage closure (LAAC) aims to prevent ischemic events in patients with atrial fibrillation. As a preventive procedure, early death after LAAC could render the procedure futile. The authors sought to evaluate the incidence and factors associated with early death in LAAC recipients. This was a multicenter study including consecutive patients undergoing LAAC in a 10-year period (2009-2019). Death was considered early when occurring in the first year after LAAC. A total of 807 patients (mean age 76 ± 8 years, mean CHA₂DS₂-VASc score 4.5 ± 1.5) were included. Early death occurred in 125 patients (15.5%). In the multivariable analysis, factors associated with early death after LAAC were older age HR: 1.03; 95%CI: 1.01-1.06 per year; P=0.01), lower body mass index (HR: 0.92; 95%CI: 0.88-0.97 per 1kg/m² increase; P&lt; 0.001), diabetes (HR: 1.71; 95%CI: 1.19-2.47; P=0.002), prior heart failure (HR:1.74; 95%CI: 1.20-2.53; P=0.001), and lower estimated glomerular filtration rate (HR: 1.09; 95%CI: 1.05-1.13 per 5mL/min/1.73m² decrease; P&lt; 0.001). There was a stepwise increase in risk of early death within the first year of LAAC with the combination of different risk factors (up to 48.9% in the presence of &gt;3 risk factors). In this multicenter international registry, close to 1 in 6 patients died within the first year of LAAC. Older age, low body mass index, impaired estimated glomerular filtration rate, prior diabetes, and prior heart failure are independently associated with an increased risk. The risk of early death appeared to be prohibitive (∼50%) in the presence of &gt;3 of these risk factors.

Hemorrhagic Versus Ischemic Risk in Patients with Atrial Fibrillation on Hemodialysis

Background Hemodialysis (HD) patients with atrial fibrillation (AF) have a particularly high risk of stroke and bleeding, but no high-quality evidence-based recommendations exist to properly manage these patients. Objectives We aim to evaluate the ischemic versus the hemorrhagic risk in a HD population with AF. Methods We selected incident patients that started hemodialysis between 2011 and 2015. All patients that had AF before HD, or developed AF during the follow-up, were included. Both CHA2DS2 -VASC and HAS-BLED scores were [...]

Validation of Embolic and Bleeding Risk Scores in Patients With Atrial Fibrillation and Cancer

Little is known about the prediction of atrial fibrillation (AF) risk scores in patients with cancer. The aim of this study was to assess the predictive ability of the CHA₂DS₂-VASc and HAS-BLED scores in patients with AF and cancer. Overall, 16,056 patients with AF diagnosed between 2014 and 2018 from a Spanish health area, including 1,137 patients with cancer, were observed during a median follow-up of 4.9years. Although discrimination was similar between patients with cancer and patients without cancer who were treated with anticoagulation therapy (0.56 and 0.58), in patients with cancer who were not treated with anticoagulation therapy, c-statistic of CHA₂DS₂-VASc was poor and significantly lower than in the patients without cancer (0.42 vs 0.65). The overall precision of the CHA₂DS₂-VASc score was good throughout the follow-up (Brier score &lt; 0.1), in patients with and without cancer. Regarding the HAS-BLED score, calibration and discrimination were poor in patients with cancer (c-statistic 0.51), similar to those in patients without cancer (c-statistic 0.53). In patients with cancer who were not treated with anticoagulation therapy, the embolic risk CHA₂DS₂-VASc score=1 was similar to CHA₂DS₂-VASc score ≥ 2. Only patients with AF and cancer and CHA₂DS₂-VASc score=0 presented a low risk of embolic events (negative predictive value 100%). A HAS-BLED score &gt; 3 was not associated with higher bleeding risk in patients with cancer (p &gt; 0.05). In summary, in patients with cancer and with AF, neither the CHA₂DS₂-VASc score nor the HAS-BLED score was useful for predicting embolic and hemorrhagic events, respectively. However, a CHA₂DS₂-VASc score 0 is useful to identify patients with AF and cancer who are at low embolic risk.

CHA2DS2-VASc and R2CHA2DS2-VASc scores predict mortality in high cardiovascular risk population.

The CHA2 DS2 -VASc score, widely used to estimate cardioembolic risk in patients with atrial fibrillation (AF), appears to be useful also in predicting vascular adverse events and death in different sets of patients without AF. The R2 CHA2 DS2 -VASc score, which includes renal impairment, allows a better prediction of death and thromboembolism in patients without AF. The aims of our study were to assess, in a large sample of patients at high cardiovascular (CV) risk, (i) the correlation between CHA2 DS2 -VASc and R2 CHA2 DS2 -VASc with all-cause mortality, and (ii) to compare the performances of CHA2 DS2 -VASc and R2 CHA2 DS2 -VASc in predicting all-cause mortality. In this single-centre prospective observational study, conducted at the Research Hospital 'Casa Sollievo della Sofferenza' between June 2016 and December 2018, 1017 CV patients at high risk of undergoing coronary angiography were enrolled. CHA₂DS₂-VASc and R2 CHA2 DS2 -VASc scores significantly associated with all-cause mortality. For each one-point increase in CHA2 DS2 -VASc or R2 CHA2 DS2 -VASc scores, mortality increased by almost 1.5-fold. The R2 CHA2 DS2 -VASc score (C-statistic=0.71; 95% CI=0.65-76) outperformed the CHA2 DS2 -VASc score (C-statistic=0.66; 95% CI=0.61-0.71) in predicting 4-year mortality (delta C-statistic=0.05; 95% CI=0.02-0.07). The better predictive ability of the R-CHA2 DS2 -VASc score was also demonstrated by an IDI=0.027 (95% CI=0.021-0.034, p < .00001) and a relative IDI=62.8% (95% CI=47.9%-81.3%, p < .00001). The R2 CHA2 DS2 -VASc score correctly reclassified the patients with a NRI=0.715 (95%=0.544-0.940, p < .00001). The CHA₂DS₂-VASc and R2 CHA2 DS2 -VASc scores are useful predictors of all-cause mortality in subjects at high CV risk, with the R2 CHA2 DS2 -VASc score being the best performer.

Systemic embolism in amyloid transthyretin cardiomyopathy.

AimsAlthough systemic embolism is a potential complication in transthyretin amyloid cardiomyopathy (ATTR‐CM), data about its incidence and prevalence are scarce. We studied the incidence, prevalence and factors associated with embolic events in ATTR‐CM. Additionally, we evaluated embolic events according to the type of oral anticoagulation (OAC) and the performance of the CHA2DS2‐VASc score in this setting.Methods and resultsClinical characteristics, history of atrial fibrillation (AF) and embolic events were retrospectively collected from ATTR‐CM patients evaluated at four international amyloid centres. Overall, 1191 ATTR‐CM patients (87% men, median age 77.1 years [interquartile range‐IQR 71.4–82], 83% ATTRwt) were studied. A total of 162 (13.6%) have had an embolic event before initial evaluation. Over a median follow‐up of 19.9 months (IQR 9.9–35.5), 41 additional patients (3.44%) had an embolic event. Incidence rate (per 100 patient‐years) was 0 among patients in sinus rhythm with OAC, 1.3 in sinus rhythm without OAC, 1.7 in AF with OAC, and 4.8 in AF without OAC. CHA2DS2‐VASc did not predict embolic events in patients in sinus rhythm whereas in patients with AF without OAC, only those with a score ≥4 had embolic events. There was no difference in the incidence rate of embolism between patients with AF treated with vitamin K antagonists (VKAs) (n = 322) and those treated with direct oral anticoagulants (DOACs) (n = 239) (p = 0.66).ConclusionsEmbolic events were a frequent complication in ATTR‐CM. OAC reduced the risk of systemic embolism. Embolic rates did not differ with VKAs and DOACs. The CHA2DS2‐VASc score did not correlate well with clinical outcome in ATTR‐CM and should not be used to assess thromboembolic risk in this population.

Implications of QRS Prolongation in Patients With Atrial Fibrillation (from a Multicenter Outpatient Registry)

Patients with atrial fibrillation (AF) at the highest risk of progression to heart failure (HF) need to be identified. We investigated whether QRS duration can stratify patients with AF at risk for poor clinical outcomes, including health-related quality of life (HR-QoL). We analyzed data from a multicenter registry-based cohort study of patients with AF. Patients were grouped according to the QRS duration (narrow: &lt;120 ms; wide: ≥120 ms) at registration (baseline). The primary outcome was a composite of all-cause death and HF hospitalizations during a 2-year follow-up. In addition, the AF effect on the quality-of-life overall summary score was compared between the groups. In 3,269 patients, 302 (9.2%) had a wide QRS; these patients were more likely to be older, male, and have higher CHA₂DS₂-VASc scores than those with a narrow QRS. The incidence of the composite outcome was higher in patients with a wide QRS than those with a narrow QRS (13.1% vs 4.9%, p &lt;0.001). After adjustment, a wide QRS was an independent predictor of the primary outcome (adjusted hazard ratio 1.58, 95% confidence interval 1.09 to 2.29, p=0.016), and the results persisted after the exclusion of patients with bundle branch block or cardiac implantable electronic devices. Regarding HR-QoL outcomes, patients with a wide QRS were less likely to improve AF effect on quality-of-life overall summary scores at 1 year than those with a narrow QRS (adjusted difference -2.31, 95% confidence interval -4.06 to -0.57, p=0.009). QRS prolongation, even for a nonspecific conduction disturbance, was an independent predictor of adverse outcomes and worse HR-QoL in patients with AF.

Oral Anticoagulants in Patients with Atrial Fibrillation and Active Cancer.

Atrial fibrillation (AF) is associated with an increased risk of heart failure, death and thromboembolism. AF is prevalent in patients with cancer. Although current guidelines suggest the application of oral anticoagulants (OACs) for thromboembolic event prevention in high-risk AF patients, owing to the high thromboembolic and bleeding risks of active-cancer patients, there is no consensus on the use of OACs in such a population. Therefore, we conducted this retrospective cohort study to investigate the applicability of the -VASc score and to evaluate the efficacy and safety outcomes of OAC therapy in active-cancer patients with AF. This retrospective cohort study enrolled patients diagnosed with cancer at National Cheng Kung University Hospital between November 2012 and August 2019. The primary outcomes included all-cause mortality, thromboembolic events (stroke/transient ischemic attack and systemic emboli), acute myocardial infarction (AMI), hospitalization for HF and major bleeding events. We enrolled 2429 patients with active cancer. Among these patients, 1060 patients (43.6%) had AF. After 1:2 propensity score matching, 690 cancer patients with AF were enrolled for the final analysis, grouped as follows: 225 patients taking OACs and 465 patients without OAC treatment. The OAC-treated group had lower all-cause mortality than the patients without OAC treatment (all-cause mortality rate in OAC treatment vs. non-OAC treatment: 24.4% vs. 37.4%, hazard ratio 0.58 [95% confidence interval (CI) 0.43-0.78], p 0.001). However, there was no difference in thromboembolic events, myocardial infarction or heart failure hospitalization between the OAC-treated and non-OAC-treated groups. Importantly, the risk of major bleeding composition (i.e., major gastrointestinal bleeding and intracranial hemorrhage) was similar between these two groups. Moreover, the -VASc score could not predict thromboembolic events in the enrolled active-cancer patients with AF (OR 1.23, 95% CI 0.98-1.56). OAC treatment may significantly reduce the risk of death, without safety concerns, in active-cancer patients with AF. OAC treatment may not prevent thromboembolic events in patients with active cancer and AF. However, we found that OAC treatment is associated with improved prognosis without increasing the risks of major bleeding, despite several limitations in this study. Further studies are required to determine the optimal use of anticoagulation therapy in this high-risk population.

CHA2 DS2 -VASc score, a simple clinical tool for early prediction of no-reflow phenomenon in patients undergoing emergency percutaneous coronary revascularization.

Introduction: Slow flow/no reflow (SF/NR) phenomenon during emergency percutaneous revascularization is a feared complication associated with increased risk of adverse outcomes. CHA2 DS2 -VASc score has been proposed for the risk stratification but a very limited evidences are available regarding the accuracy of this system. Therefore, we conducted this study to assess the predictive value of CHA2 DS2 -VASc score for predicting SF/NR phenomenon during primary percutaneous coronary intervention (PCI). Methods: This analytical cross-sectional study included 596 consecutive patients undergoing PCI for STEMI at a tertiary care cardiac center of Karachi, Pakistan. Baseline -VASc sore was calculated and development of SF/NR phenomenon during primary PCI was recorded. Predictive value of the score was assessed through area under the curve (AUC) of receiver operating characteristic curve analysis and sensitivity and specificity were computed. Logistic regression analysis was performed to assess the predictive strength of the score. Results: A total of 596 patients were included, mean age was 56.28±11.44 years, and 75.7%(451) were male. The slow/no reflow phenomenon during the procedure was observed in 36.6%(218) of the patients. CHA2 DS2 -VASc≥2 was observed in 50.2%(299) of the patients. The CHA2 DS2 -VASc score was significantly higher in SF/NR patients, 2.06±1.25 vs. 1.37±1.33; P<0.001. The AUC of CHA2 DS2 -VASc score was 0.652 [0.607-0.696], CHA2 DS2 -VASc≥2 had sensitivity and specificity of 65.6% [58.9% to 71.9%] and 58.3% [53.6% to 63.7%] respectively for predicting SF/NR. CHA2 DS2 -VASc≥2 was insignificant on multivariate with odds ratio of 1.48 [0.72 -3.04]; P=0.283. Conclusion: CHA2 DS2 -VASc risk stratification system has moderate discriminating power for the stratification of SF/NR phenomenon during primary PCI.

Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study.

Atrial fibrillation (AF) treatment includes anticoagulation for high stroke risk individuals and either rate or rhythm control strategies. We aimed to investigate the impact of age, geriatric factors, and medical comorbidities on choice of rhythm versus rate control strategy in older adults. Patients with AF aged ≥65 years with CHA2 DS2 VASc score ≥2 and eligible for anticoagulation were recruited for the Systematic Assessment of Geriatric Elements-AF (SAGE-AF) prospective cohort study. An interview that included measures of HRQoL, cognitive function, vision, hearing, and frailty was performed. The association between these elements and AF treatment strategy was examined by multivariable logistic regression models. One thousand two hundred forty-four participants (mean age 76 years; 49% female; 85% non-Hispanic white) were enrolled. Rate and rhythm control were used in 534 and 710 participants, respectively. Compared to participants <75 years, those ≥75 were more likely to be treated with a rate control strategy (age 75-84 adjusted odds ratio [aOR] 1.37 [95% CI 0.99, 1.88]; age 85+ aOR=2.05, 95% CI 1.30, 3.21). Those treated with a rate control strategy were more likely to have cognitive impairment (aOR=1.50, 95% CI 1.13, 1.99), and peripheral vascular disease (PVD) (aOR=1.82, 95% CI 1.22, 2.72) but less likely to have visual impairment (aOR 0.73 [0.55, 0.98]), congestive heart failure (CHF; aOR 0.68 [0.49, 0.94]) or receive anticoagulation (aOR 0.53, 95% CI 0.36, 0.78). Older age, cognitive impairment, and PVD were associated with use of rate control strategy. Visual impairment, CHF, and anticoagulation use were associated with a rhythm control strategy. There was no difference in HRQoL between the rate and rhythm control groups. This study suggests that certain geriatric elements may be associated with AF treatment strategies. Further study is needed to evaluate how these decisions affect outcomes.

Role of circulating long non-coding RNA for the improvement of the predictive ability of the CHA2DS2–VASc score in patients with atrial fibrillation

Background:The CHA2DS2–VASc score was initially applied to stratify stroke risk in patients with atrial fibrillation (AF) and was found to be effective in predicting all-cause mortality outcomes. To date, it is still unclear whether circulating long non-coding RNAs (lncRNAs) as emerging biomarkers, can improve the predictive power of the CHA2DS2–VASc score in stroke and all-cause mortality.Methods:Candidate lncRNAs were screened by searching the literature and analyzing previous RNA sequencing results. After preliminary verification in 29 patients with AF, the final selected lncRNAs were evaluated by Cox proportional hazards regression in 192 patients to determine whether their relative expression levels were associated with stroke and all-cause mortality. The c-statistic, net reclassification improvement (NRI), and integrated discrimination improvement of the patients were calculated to evaluate the discrimination and reclassification power for stroke and all-cause mortality when adding lncRNA expression levels to the CHA2DS2–VASc score model.Results:Five plasma lncRNAs associated with stroke and all-cause mortality in AF patients were selected in our screening process. Patients with elevated H19 levels were found to have a higher risk of stroke (hazard ratio [HR] 3.264, 95% confidence interval [CI]: 1.364–7.813, P = 0.008). Adding the H19 expression level to the CHA2DS2–VASc score significantly improved the discrimination and reclassification power of the CHA2DS2–VASc score for stroke in AF patients. In addition, the H19 level showed a marginally significant association with all-cause mortality (HR 2.263, 95% CI: 0.889–5.760, P = 0.087), although it appeared to have no significant improvement for the CHA2DS2–VASc model for predicting all-cause mortality.Conclusions:Plasma expression of H19 was associated with stroke risk in AF patients and improved the discriminatory power of the CHA2DS2–VASc score. Therefore, lncRNA H19 served as an emerging non-invasive biomarker for stroke risk prediction in patients with AF.

The performance of five models compared with atrial high rate episodes predicts new atrial fibrillation after cardiac implantable electronic devices implantation.

AimsSeveral predicting models have been evaluated for new‐onset atrial fibrillation (AF) in several clinical conditions, but never in patients with cardiac implantable electronic devices (CIED). We aimed to evaluate the five predicting models compared with atrial high rate episodes (AHRE) to predict new AF in patients with CIED.Methods and ResultsWe retrospective enrolled 470 consecutive patients with CIED and without a history of AF. The five predicting models, including CHA2DS2‐VASc score, C2HEST score, mCHEST score, HAT2CH2 score, and HAVOC score were used. The primary endpoint was new AF documented by 12‐lead electrocardiography (ECG) or 30‐s ECG strip. Multivariable Cox regression analysis was used to determine variables associated with independent factors of new AF. Patients' median age was 76 years and 58.7% were male. During follow‐up (median 29 months), 34 new AF occurred (incidence rate 2.99/100 patient‐years, 95% CI 1.67–6.20). Multivariable Cox regression analysis showed AHRE ≥6 min and 24 h, and HAT2CH2 score were independent predictors for new AF. Optimal AHRE cutoff value was 9.3 min with highest Youden index (AUC, 0.806; 95% CI, 0.722–0.889; p < .001). The AF occurrence rate of AHRE ≥9.3 min was 7 times AHRE <9.3 min (p < .001).ConclusionsWe compared 5 predicting models for new AF in patients with CIED and without a history of AF. AHRE ≥6 min and 24 h, and HAT2CH2 score were independent predictors for AF.

Patient-reported outcomes and costs associated with vascular closure and same-day discharge following atrial fibrillation ablation.

We aimed to measure patient-reported outcomes (PROs) and costs associated with same-day discharge (SDD) for atrial fibrillation(AF) ablation and vascular closure device implantation in clinical practice. PROs were prospectively measured in 50 AF ablation patients, comparing complete vascular device closure (n = 25) versus manual compression hemostasis (n = 25). Health-system costs for SDD patients receiving vascular device closure were compared to matched controls with one-night stays who did not receive any closure device. Prospectively enrolled patients receiving vascular device closure for AF ablation had a mean age of 65 years, 17% were female, with a mean CHA2 DS2 -VASc score of 3. The mean number of venous sheaths was higher among patients receiving vascular device closure (3.8 vs. 3.1,p < 0.001), and there was one case of rebleeding in a patient receiving a vascular closure device (no other complications). Same-day discharge rates (76% vs. 8.3%,p < 0.001), patient satisfaction with bedrest time (8.5 vs. 6,p = 0.004) and with pain (8 vs. 5.1,p = 0.009) were significantly better among patients receiving vascular closure. In matched analyses of health-system costs, patients with vascular closure had mean age 66, 32% were female, and the mean CHA2 DS2 -VASc score was 2 (p = NS vs. controls). SDD with vascular closure was associated with the significantly lower facility, pharmacy, and disposable costs, but higher implant costs. Overall costs for ablation were not significantly different (mean difference 1.10%, 95% confidence interval [CI] -3.03 to 5.42). Vascular closure for AF ablation improves patient experience in routine care. The use of vascular closure and SDD after AF ablation reduces several components of healthcare system costs, without an overall increase.

Novel computed tomography angiography-based sizing methodology for WATCHMAN FLX device in left atrial appendage closure.

While there is recent data suggesting an advantage of computed tomography angiography (CTA) over transesophageal echocardiography (TEE) for preprocedural left atrial appendage closure (LAAC) planning, there is limited published experience for sizing strategies. Device sizing for LAAC may be challenging and noninvasive algorithms that improve this selection process are warranted. We sought to evaluate the safety and the feasibility for the implementation of a novel CTA-based sizing methodology for WATCHMAN™ FLX device in a series of patients undergoing LAAC using the TruPlan™ software package. A prospective analysis of 136 consecutive patients who underwent LAAC over a 12-month period in a single, large academic hospital in the United States was conducted. CTA-guided preprocedural planning and intracardiac echocardiography (ICE) was performed in all. Procedural success, adverse events, length of procedure, number of devices used, and length of stay were evaluated. A total of 136 patients who underwent LAAC procedure with WATCHMAN™ FLX platform between October 1, 2020 until September 30, 2021 were included. The pre-specified protocol using CTA and ICE was implemented in all patients (100%). Mean CHA2 DS2 VASc score was 4.4 ± 1.3 and the mean HAS-BLED score was 3.9 ± 0.8. ICE-guided 100% transseptal puncture success rate was 100% with 98.5% of overall procedural success rate. Preprocedural CTA sizing strategy accurately predicted the implanted size in 91.1% of patients. Ten patients (7.4%) required another sized device and 2 cases were aborted. At 45-day follow-up, only 1 patient (0.7%) had significant peri-device leak (≥5 mm) on TEE. CTA-based preprocedural sizing methodology for WATCHMAN™ FLX in LAAC was safe, feasible and associated with excellent procedural outcomes. Further studies are warranted to confirm if the features specific to TruPlan™ may reduce the number of deployment attempts, the number of devices utilized in the procedure, and the risk of complications.

Association of income and educational levels with adherence to direct oral anticoagulant therapy in patients with incident atrial fibrillation: A Finnish nationwide cohort study.

Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry‐based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011–2018. The implementation analyses included 74 222 (mean age 72.7 ± 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 ± 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA2DS2‐VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR ≥0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135‐day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest: adjusted odds ratios 1.18 (1.12–1.25) and 1.21 (1.15–1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.