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AbstractBackground Atrial fibrillation (AF) is a common treatable risk factor for stroke. Screening for paroxysmal AF in general practice is difficult, but biomarkers might help improve screening strategies.Objectives We investigated six blood biomarkers for predicting paroxysmal AF in general practice.Methods This was a pre-specified sub-study of the SCREEN-AF RCT done in Germany. Between 12/2017-03/2019, we enrolled ambulatory individuals aged 75 years or older with a history of hypertension but without known AF. Participants in the intervention group received active AF screening with a wearable patch, continuous ECG monitoring for 2x2 weeks and usual care in the control group. The primary endpoint was ECG-confirmed AF within six months after randomisation. High-sensitive Troponin I (hsTnI), brain natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-pro BNP), N-terminal pro atrial natriuretic peptide (NT-ANP), mid-regional pro atrial natriuretic peptide (MR-pro ANP) and C-reactive protein (CRP) plasma levels were investigated at randomisation for predicting AF within six months after randomisation.Results Blood samples were available for 291 of 301 (96.7%) participants, including 8 with AF (3%). Five biomarkers showed higher median results in AF-patients: BNP 78 vs. 41 ng/L (p = 0.012), NT-pro BNP 273 vs. 186 ng/L (p = 0.029), NT-proANP 4.4 vs. 3.5 nmol/L (p = 0.027), MR-pro ANP 164 vs. 125 pmol/L (p = 0.016) and hsTnI 7.4 vs. 3.9 ng/L (p = 0.012). CRP levels were not different between groups (2.8 vs 1.9 mg/L, p = 0.1706).Conclusion Natriuretic peptide levels and hsTnI are higher in patients with AF than without and may help select patients for AF screening, but larger trials are needed.

Background: Perioperative atrial fibrillation (POAF) after cardiac surgery is associated with an increased risk of stroke. However, the efficacy and safety of using anticoagulation therapy in this population are unknown. Methods: We performed a systematic review and meta-analysis of studies comparing use of anticoagulation therapy vs no anticoagulation therapy in patients with POAF after cardiac surgery. Outcomes included arterial thromboembolism (ie, stroke ± systemic embolism) and bleeding. Data were pooled using fixed-effects models. We reported summary risk ratios (RRs) for studies with multivariable adjustment and estimated absolute risk differences with 95% confidence intervals (CIs). Results: Nine observational studies met eligibility criteria. No randomized trials were identified. Of the 254,200 POAF patients included, 27.3% received anticoagulation. Six studies reported outcomes after long-term follow-up (median 5.0 years; range 4.2-10.0). The risk of arterial thromboembolism was lower in patients receiving anticoagulation therapy (RR 0.83; 95% CI, 0.69-0.99; I2 = 57%; P = 0.04; 6 studies). The estimated short-term and long-term absolute risk reductions in arterial thromboembolism with use of anticoagulation therapy were 0.8% (95% CI, 0.4-1.4) and 2 events per 1000 person-years (95% CI, 0-4), respectively. The risk of bleeding was higher in patients receiving anticoagulation therapy (RR 3.22; 95% CI, 2.82-3.68; I2 = 98%; P < 0.001; 2 studies). The estimated short-term and long-term absolute risk increases in bleeding with use of anticoagulation therapy were 0.5% (95% CI, 0.4-0.6) and 42 events per 1000 person-years (95% CI, 35-51), respectively. Conclusions: Use of anticoagulation therapy is associated with a small reduction in the risk of arterial thromboembolism, but also an increased risk of bleeding. Randomized controlled trials are needed to address this issue. Résumé: Introduction: La fibrillation auriculaire périopératoire (FAPO) après l’intervention chirurgicale au cœur est associée à une augmentation du risque d’accident vasculaire cérébral (AVC). Toutefois, on ne connaît pas l’efficacité et l’innocuité de la l’anticoagulothérapie de cette population. Méthodes: Nous avons réalisé une revue systématique et une méta-analyse d’études qui comparaient l’utilisation de l’anticoagulothérapie vs l’absence d’anticoagulothérapie chez les patients atteints de FAPO après l’intervention chirurgicale au cœur. Les résultats étaient notamment la thromboembolie artérielle (c.-à-d. l'AVC ± l’embolie systémique) et les hémorragies. Nous avons regroupé les données à l’aide de modèles à effets fixes. Nous avons rapporté les risques relatifs (RR) sommaires d’études avec l’ajustement multivarié et l’estimation des différences du risque absolu avec des intervalles de confiance (IC) à 95 %. Résultats: Neuf études observationnelles répondaient aux critères d’admissibilité. Aucun essai à répartition aléatoire n’a été trouvé. Parmi les 254 200 patients atteints de FAPO sélectionnés, 27,3 % avaient reçu une anticoagulation. Six études révélaient des résultats après le suivi à long terme (médiane 5,0 ans ; fourchette 4,2-10,0). Le risque de thromboembolie artérielle était plus faible chez les patients qui avaient reçu une anticoagulothérapie (RR 0,83 ; IC à 95 %, 0,69-0,99 ; I2 = 57 % ; P = 0,04 ; six études). Les estimations de réduction du risque absolu à court terme et à long terme lors de thromboembolie artérielle avec l’utilisation de l’anticoagulothérapie étaient respectivement de 0,8 % (IC à 95 %, 0,4-1,4) et de deux événements par 1000 personnes-années (IC à 95 %, 0-4). Le risque d’hémorragie était plus élevé chez les patients qui avaient reçu une anticoagulothérapie (RR 3,22 ; IC à 95 %, 2,82-3,68 ; I2 = 98 % ; P < 0,001 ; deux études). Les estimations d’augmentation du risque absolu à court terme et à long terme des hémorragies avec l’utilisation de l’anticoagulothérapie étaient respectivement de 0,5 % (IC à 95 %, 0,4-0,6) et de 42 événements par 1000 personnes-années (IC à 95 %, 35-51). Conclusions: L’utilisation de l’anticoagulothérapie est associée à une réduction minime du risque de thromboembolie artérielle, mais aussi à une augmentation du risque d’hémorragie. Des essais cliniques à répartition aléatoire sont nécessaires pour aborder cette question.

BackgroundThe role of multidisciplinary clinics for psychosocial care is increasingly recognized for those living with inherited cardiac conditions (ICC). In Canada, access to healthcare providers differ between clinics. Little is known about the relationship between access to specialty care and a patient's ability to cope with, and manage their condition.MethodsWe leveraged the Hearts in Rhythm Organization (HiRO) to conduct a cross-sectional, community-based survey of individuals with ICC and their family members. We aimed to describe access to services, and explore the relationships between participants’ characteristics, cardiac history and self-reported health status and self-efficacy (GSE: General Self-Efficacy Scale) and empowerment (GCOS-24: Genetic Counseling Outcome Scale).ResultsWe collected 235 responses from Canadian participants in 10 provinces and territories. Overall, 63% of participants reported involvement of a genetic counsellor in their care. Access to genetic testing was associated with greater empowerment [mean GCOS-24: 121.14 (SD = 20.53) vs. 105.68 (SD = 21.69); p = 0.004]. Uncertain genetic test results were associated with lower perceived self-efficacy (mean GSE: uncertain = 28.85 vs. positive = 33.16, negative = 34.13; p = 0.01). Low global mental health scores correlated with both lower perceived self-efficacy and empowerment scores, with only 11% of affected participants reporting involvement of psychology services in their care.ConclusionDifferences in resource accessibility, clinical history and self-reported health status impact the perceived self-efficacy and empowerment of patients with ICC. Future research evaluating interventions to improve patient outcomes is recommended.

BACKGROUND: Perioperative atrial fibrillation is associated with an increased risk of stroke, myocardial infarction, and death after noncardiac surgery. Anticoagulation therapy is effective for stroke prevention in nonsurgical atrial fibrillation, but its efficacy and safety in perioperative atrial fibrillation are unknown. METHODS: We searched MEDLINE, EMBASE, and CENTRAL from database inception until January 2022. We included studies comparing anticoagulation versus no anticoagulation use in patients with perioperative atrial fibrillation after noncardiac surgery. Our study outcomes included stroke ± systemic embolism, bleeding, mortality, myocardial infarction, and venous thromboembolism. We pooled studies using fixed-effects models. We reported summary risk ratios (RRs) for studies reporting multivariable-adjusted results. RESULTS: Seven observational studies but no randomised trials were included. Of the 27,822 patients, 29.1% were prescribed therapeutic anticoagulation. Anticoagulation use was associated with a lower risk of stroke ± systemic embolism (RR 0.73; 95% CI, 0.62–0.85; I2 = 81%; 3 studies) but a higher risk of bleeding (RR 1.14; 95% CI, 1.04–1.25; 1 study). There was a lower risk of mortality associated with anticoagulation use (RR 0.45; 95% CI, 0.40–0.51; I2 = 80%; 2 studies). There was no difference in the risk of myocardial infarction (RR 2.19; 95% CI, 0.97–4.96; 1 study). The certainty of the evidence was very low across all outcomes. CONCLUSION: Anticoagulation is associated with a reduced risk of stroke and death but an increased risk of bleeding. The quality of the evidence is very poor. Randomised trials are needed to better determine the effects of anticoagulation use in this population.

Background: Perioperative atrial fibrillation (POAF) after cardiac surgery has been associated with an increased risk of stroke in some studies. However, the exact magnitude of this association during short-term and long-term follow-up remains unclear. Methods: We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) for the time period from database inception to October 2020. We included observational studies with ≥ 100 patients that reported data on short-term or long-term stroke risk in patients with and without POAF after cardiac surgery. Data were pooled using random-effects models. We reported summary risk ratios (RRs) for studies reporting multivariable adjusted results and calculated absolute risk differences (ARDs) with 95% confidence intervals (CIs). Results: A total of 55 studies with 540,209 patients were included. POAF was associated with both an increased relative risk (RR 1.69; 95% CI, 1.41-2.03; I2 = 82%; 9 studies) and absolute risk of short-term stroke (4.5% vs 2.5%; ARD 2.0%; 95% CI, 1.28-2.89). POAF was associated with an increased relative risk (RR 1.20; 95% CI, 1.12-1.29; I2 = 16%; 10 studies) and absolute risk of long-term stroke (1.06 vs 0.88 per 100 patient-years; ARD 0.18 per 100 patient-years; 95% CI, 0.07-0.26). Sensitivity analyses of high-quality studies and studies reporting either ischemic or embolic strokes yielded similar findings. Conclusions: POAF after cardiac surgery was associated with an increased risk of both short-term and long-term stroke. However, the long-term stroke ARD was small, and whether these patients will benefit from long-term oral anticoagulation therapy is unclear. Résumé: Contexte: La fibrillation auriculaire périopératoire (FAPO) après une chirurgie cardiaque a été associée à un risque accru d’accident vasculaire cérébral (AVC) dans certaines études. Cependant, l’ampleur exacte de cette association durant le suivi à court et à long terme reste incertaine. Méthodologie: Nous avons effectué des recherches dans les bases de données PubMed, Embase et CENTRAL (Cochrane Central Register of Controlled Trials) pour la période allant de la création de ces bases à octobre 2020. Nous avons inclus des études d’observation comptant ≥ 100 patients et rapportant des données sur le risque d’AVC à court ou à long terme chez les patients ayant présenté ou non une FAPO après une chirurgie cardiaque. Les données ont été regroupées à l’aide de modèles à effets aléatoires. Nous avons consigné les rapports de risque (RR) sommaires pour les études rapportant des résultats corrigés multivariables et calculé les différences de risque absolu (DRA) avec des intervalles de confiance (IC) à 95 %. Résultats: Au total, 55 études portant sur 540 209 patients ont été incluses. La FAPO était associée à une augmentation tant du risque relatif (RR : 1,69; IC à 95 % : 1,41 à 2,03; I2 = 82 %; 9 études) que du risque absolu d’AVC à court terme (4,5 % vs 2,5 %; DRA : 2,0 %; IC à 95 % : 1,28 à 2,89). La FAPO était également associée à une augmentation du risque relatif (RR : 1,20; IC à 95 % : 1,12 à 1,29; I2 = 16 %; 10 études) et du risque absolu d’AVC à long terme (1,06 vs 0,88 par 100 années-patients; DRA : 0,18 par 100 années-patients; IC à 95 % : 0,07 à 0,26). Les analyses de sensibilité des études de haute qualité et des études rapportant des AVC ischémiques ou emboliques ont donné des résultats similaires. Conclusions: La FAPO après une chirurgie cardiaque a été associée à un risque accru d’AVC à court et à long terme. Cependant, comme la différence de risque absolu d’AVC à long terme était faible, la possibilité qu’une anticoagulothérapie orale à long terme soit bénéfique pour ces patients est incertaine.

Background: Heart failure (HF) is a frequent cause of hospitalization and death in patients with atrial fibrillation (AF). Identifying AF patients at risk of HF hospitalization could help select individuals for intensive follow-up and treatment. Methods: We pooled data from 3 randomized trials (ACTIVE-A, RE-LY, AVERROES) of AF patients, for derivation and internal validation of a risk score for first HF hospitalization. Secondary endpoints were cardiovascular death and a composite of HF hospitalizations and cardiovascular death. Results: In 23,503 patients, the mean age was 71.3 years, and 62% were male. Over a mean follow-up of 2.0 years, 875 patients (3.7%) experienced their first HF hospitalization, and 1037 patients (4.4%) died from cardiovascular causes. Incidence rates per 100 patient-years were 1.85 for HF hospitalizations, 2.15 for cardiovascular death, and 3.71 for the composite. Independent predictors for HF hospitalizations included the following: increased age, weight, heart rate and serum creatinine level, lower height and systolic blood pressure, diabetes, vascular disease, valvular disease, heart rhythm, left ventricular hypertrophy, and intraventricular conduction delay. The C-statistic (95% confidence intervals by bootstrap simulations) was 0.717 (0.705-0.732). At 2 years of follow-up, the incidence rate of the primary outcome increased across risk-score quintiles: 0.49, 0.87, 1.29, 2.44, and 4.51 per 100 patient-years, respectively. Patients in the highest quintile had an absolute risk of 6.8% for the primary endpoint at 2 years. Conclusions: In a large AF population, new-onset HF was common. A combination of characteristics can identify high-risk patients for whom strategies to prevent HF should be considered. Résumé: Introduction: L’insuffisance cardiaque (IC) est une cause fréquente d’hospitalisation et de décès chez les patients atteints de fibrillation auriculaire (FA). Le repérage des patients atteints de FA exposés au risque d’hospitalisation liée à l’IC pourrait faciliter la sélection des individus pour un suivi et un traitement intensifs. Méthodes: Nous avons regroupé les données de trois essais contrôlés (ACTIVE-A, RE-LY, AVERROES) de patients atteints de FA pour obtenir la dérivation et la validation interne d’un score de risque lors de la première hospitalisation liée à l’IC. Les critères secondaires étaient les décès dus aux maladies cardiovasculaires et le critère composite d’hospitalisations liées à l’IC et de décès dus aux maladies cardiovasculaires. Résultats: L’âge moyen des 23 503 patients, dont 62 % étaient des hommes, était de 71,3 ans. Durant un suivi moyen de 2,0 ans, 875 patients (3,7 %) ont subi leur première hospitalisation liée à l’IC, et 1 037 patients (4,4 %) sont morts de maladies cardiovasculaires. Les taux d’incidence par 100 patients-années étaient de 1,85 pour les hospitalisations liées à l’IC, de 2,15 pour les décès dus aux maladies cardiovasculaires et de 3,71 pour le critère composite. Les prédicteurs indépendants des hospitalisations liées à l’IC étaient les suivants : l’âge avancé, le poids, la fréquence cardiaque et la concentration sérique de la créatinine, la taille inférieure et la pression artérielle systolique, le diabète, les maladies vasculaires, la valvulopathie, le rythme cardiaque, l’hypertrophie ventriculaire gauche et le retard de conduction intraventriculaire. La statistique C (intervalles de confiance à 95 % obtenus par simulations d’auto-amorçage) était de 0,717 (0,705-0,732). Après deux ans de suivi, le taux d’incidence du critère d’évaluation principal augmentait de façon respective dans tous les quintiles de scores de risque : 0,49, 0,87, 1,29, 2,44 et 4,51 par 100 patients-années. Les patients dans le quintile supérieur avaient un risque absolu du critère d’évaluation principal de 6,8 % après deux ans. Conclusions: Dans une vaste population atteinte de FA, l’IC d’apparition récente était fréquente. La combinaison des caractéristiques peut permettre de déterminer les patients exposés à un risque élevé chez lesquels des stratégies de prévention de l’IC devraient être envisagées.

Abstract Background Catheter ablation is an established therapy for atrial fibrillation but is limited by recurrence; efforts have been made to identify biomarkers that predict recurrence. We investigated the effect of baseline NT-proBNP on AF recurrence following catheter ablation in patients randomized to aggressive ( 3 months post-ablation. Results Of the 173 patients, 88 were randomized to the aggressive cohort, and 85 into the standard group. The primary outcome occurred in 61.4% of those in the aggressive arm, versus 61.2% in the standard arm. In the aggressive group, logNT-proBNP predicted recurrence (HR 1.28, p = 0.04, adjusted HR 1.43, p = 0.03), while in the standard cohort, it did not (HR 0.94, p = 0.62, adjusted HR 0.83, p = 0.22). NT-proBNP ≥ 280 pg/mL also predicted occurrence in the aggressive (HR 1.98, p = 0.02) but not the standard cohort (HR 1.00, p = 1.00). Conclusion We conclude that pre-ablation NT-proBNP may be useful in predicting recurrence in hypertensive patients and identifying patients who benefit from aggressive blood control and upstream therapies. Trial registration: NCT00438113, registered February 21, 2007.

Background: Women are less likely to receive oral anticoagulation or ablation for treatment of atrial fibrillation (AF). Identification of sex differences in arrhythmia characteristics and symptoms may lead to a better understanding of potential reasons for these differences. Objectives: To determine sex differences in AF with respect to heart rate, duration, burden, and symptoms in patients undergoing mobile cardiac telemetry (MCT) monitoring. Methods: All patients who registered for ≤30-day MCT using PocketECG (MediLynx) in the USA in 2017 were included (n = 27,512, 58 % women). PocketECG records and transmits a three-lead ambulatory electrocardiogram (ECG) with real-time beat-to-beat analysis. Sex-related differences were analyzed with Chi2 and Spearmans rho. Results: Fewer women than men were diagnosed with AF lasting ≥30s (13.7 % versus [vs] 19.0 %, p

Background: Atrial fibrillation (AF) is frequently reported as a complication of noncardiac surgery. It is unknown whether new-onset perioperative AF is associated with an increased risk of stroke and death beyond the perioperative period. We performed a systematic review and meta-analysis to assess the long-term risks of stroke and mortality associated with new-onset perioperative AF after noncardiac surgery. Methods: MEDLINE and EMBASE were searched from inception to March 2020 for studies reporting on the association between perioperative AF and the risk of stroke and death occurring beyond 30 days after noncardiac surgery. Reference screening, study selection, data extraction, and quality assessment were performed in duplicate. Data were pooled using inverse variance-weighted random-effects models and presented as risk ratios (RRs). Results: From 7344 citations, we included 31 studies (3,529,493 patients). The weighted mean incidence of perioperative AF was 0.7%. During a mean follow-up of 28.1 ± 9.4 months, perioperative AF was associated with an increased risk of stroke (1.5 vs 0.9 strokes per 100 patient-years; RR: 2.9, 95% confidence interval [CI]: 2.1-3.9, I2 = 78%). Perioperative AF was also associated with a significantly higher risk of all-cause mortality (21.0 vs 7.6 deaths per 100 patient-years; RR: 1.8, 95% CI: 1.5-2.2, I2 = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I2 = 31%) and 1.5 (95% CI: 1.3-1.7, I2 = 20%), respectively. Conclusions: Patients who had perioperative AF after noncardiac surgery had a higher long-term risk of stroke and mortality compared with patients who did not. Whether this risk is modifiable with oral anticoagulation therapy should be investigated. Résumé: Contexte: La fibrillation atriale (FA) est une arythmie fréquemment attribuée à une complication d’une chirurgie non cardiaque. On ne sait toutefois pas si l’apparition d’une FA périopératoire est associée à un risque accru d’accident vasculaire cérébral et de décès au-delà de la période périopératoire. Nous avons donc procédé à un examen et à une méta-analyse systématiques dans le but d’évaluer les risques à long terme d’accident vasculaire cérébral et de décès associés à l’apparition d’une FA périopératoire à la suite d’une chirurgie non cardiaque. Méthodologie: Des recherches ont été effectuées dans MEDLINE et EMBASE depuis leur création jusqu’à mars 2020 pour y relever les études signalant l’association entre la FA périopératoire et le risque d’accident vasculaire cérébral et de décès survenant au-delà de 30 jours à la suite d’une chirurgie non cardiaque. Le tri des références, la sélection des études, l’extraction des données et l’évaluation de la qualité ont été effectués en double. Les données ont été regroupées à l’aide de modèles à effets aléatoires pondérés par l’inverse de la variance et présentées sous forme de rapports de risques relatifs (RR). Résultats: Parmi 7 344 références, nous avons inclus 31 études (3 529 493 patients). L’incidence moyenne pondérée de FA périopératoire était de 0,7 %. Dans le cadre d’un suivi moyen de 28,1 ± 9,4 mois, la FA périopératoire était associée à un risque accru d’accident vasculaire cérébral (1,5 vs 0,9 accident vasculaire cérébral par 100 années-patients; RR de 2,9; intervalle de confiance [IC] à 95 %; de 2,1 à 3,9; I2 = 78 %). La FA périopératoire était également associée à un risque considérablement plus élevé de décès toutes causes confondues (21,0 vs 7,6 décès par 100 années-patients; RR de 1,8; IC à 95 %; de 1,5 à 2,2; I2 = 94 %). Les rapports de risques instantanés ajustés regroupés d’accident vasculaire cérébral et de décès toutes causes confondues étaient de 1,9 (IC à 95 %; de 1,6 à 2,2; I2 = 31 %) et de 1,5 (IC à 95 %; de 1,3 à 1,7; I2 = 20 %), respectivement. Conclusions: Les patients qui souffraient de FA périopératoire à la suite d’une chirurgie non cardiaque présentaient un risque accru à long terme d’accident vasculaire cérébral et de décès par rapport aux patients qui n’en souffraient pas. Il serait approprié d’examiner la possibilité de modifier ce risque par une anticoagulothérapie orale.

Background: Intracardiac echocardiography and 3D mapping systems allow catheter ablation for atrial fibrillation (AF) to be conducted without fluoroscopy; however, the safety and effectiveness of fluoroless AF ablation are not well defined. Methods: We examined consecutive radiofrequency AF catheter ablations at a large academic teaching hospital from November 2017 to July 2019. Outcomes for fluoroscopy-guided (N = 176) and fluoroless (N = 147) ablations were compared. Cases were designated as fluoroless at the outset of the procedure. Results: Mean age was 59.5 ± 10 years, 66.9% were male, 71.8% had paroxysmal AF, and the mean CHA2DS2-VASc score was 1.7 ± 1.4. There were no differences in patient baseline characteristics. In the fluoroless group, minimal fluoroscopy was used in 17 patients (median, 3 seconds; interquartile range, 1.2-4.8). Mean procedure time, fluoroscopy time, and radiation dose (± standard deviation) were greater in the fluoroscopy group compared with the fluoroless group (194 ± 56 vs 176 ± 46 minutes, P = 0.0021; 10.7 ± 6.6 vs 0.008 ± 0.03 minutes, P < 0.0001; 2759.2 ± 1911 vs 5.4 ± 24 μGy m2, P < 0.0001). In multivariable linear regression models, fluoroless AF ablation was independently associated with reduced procedure times (ß = −16.5 minutes, P = 0.01). Acute procedural success (95.5% vs 98.6%, P = 0.1), complication rates (4.5% vs 2.0%, P = 0.24), and 1-year AF recurrence rates (28.7% vs 27.1%, log-rank P = 0.69) were similar between fluoroscopy and fluoroless groups. Excluding the 17 patients receiving fluoroscopy in the fluoroless group did not impact our results (P = 0.013). After exclusion of redo cases, fluoroless AF ablation was no longer associated with reduced procedure times (ß = −11.4 minutes, P = 0.106). Conclusions: Fluoroless radiofrequency AF ablation had similar effectiveness and safety compared with conventional fluoroscopy-guided AF ablation. Résumé: Contexte: L'échocardiographie intracardiaque et les systèmes de cartographie 3D permettent l'ablation par cathéter de la fibrillation auriculaire (FA) sans fluoroscopie; l'innocuité et l'efficacité d'une telle approche ne sont toutefois pas bien connues. Méthodologie: Nous avons examiné les résultats d'ablations par cathéter de la FA par radiofréquences menées de façon consécutive dans un hôpital universitaire d’envergure entre novembre 2017 et juillet 2019. Les résultats des ablations par fluoroscopie (n = 176) et des ablations sans fluoroscopie (n = 147) ont été comparés. Les cas étaient désignés comme n'ayant pas utilisé la fluoroscopie à la fin de l'intervention, le cas échéant. Résultats: L'âge moyen était de 59,5 ± 10 ans, 66,9 % des patients étaient des hommes, 71,8 % étaient atteints de FA paroxystique, et le score CHA2DS2-VASc moyen était de 1,7 ± 1,4. Il n'y avait pas de différences entre les caractéristiques des patients au départ. Dans le groupe ayant subi une ablation sans fluoroscopie, une fluoroscopie minimale a été utilisée chez 17 patients (médiane : 3 secondes; intervalle interquartile : 1,2-4,8). La durée moyenne de l'intervention, la durée de la fluoroscopie, et la dose de rayonnements (± écart type) ont été plus élevées dans le groupe avec fluoroscopie que dans le groupe sans fluoroscopie (194 ± 56 vs 176 ± 46 minutes, p = 0,0021; 10,7 ± 6,6 vs 0,008 ± 0,03 minute, p < 0,0001; 2759,2 ± 1911 vs 5,4 ± 24 μGy m2, p < 0,0001). Dans des modèles de régression linéaire multivariables, l'ablation de la FA sans fluoroscopie a été associée de façon indépendante à des interventions de plus courte durée (ß = −16,5 minutes, p = 0,01). Le succès immédiat de l'intervention (95,5 % vs 98,6 %, p = 0,1), le taux de complications (4,5 % vs 2,0 %, p = 0,24), et le taux de récidive de la FA après 1 an (28,7 % vs 27,1 %, p (test du log-rank = 0,69) ont été comparables dans les groupes avec et sans fluoroscopie. L'exclusion des 17 patients chez qui la fluoroscopie avait été utilisée dans le groupe sans fluoroscopie n'a pas modifié ces résultats (p = 0,013). Après l'exclusion des cas où l'intervention était une reprise, l'ablation de la FA sans fluoroscopie n'était plus associée à une réduction des durées d'intervention (ß = −11,4 minutes, p = 0,106). Conclusions: L'ablation de la FA par radiofréquences sans fluoroscopie est associée à une efficacité et à une innocuité comparables à celles de l'ablation de la FA classique guidée par fluoroscopie.

Background: The number of implantable cardioverter defibrillator (ICD) infections is increasing due to an increased number of ICD implants, higher-risk patients, and more frequent replacement procedures, which carry a higher risk of infection. Reducing the morbidity, mortality, and cost of ICD-related infections requires an understanding of the current rate of this complication and its predictors. Methods: The Shock Implant Evaluation Trial (SIMPLE) trial randomized 2500 ICD recipients to defibrillation testing or not. Over an average of 3.1 years, patients were seen every 6 months and examined for evidence of ICD infection, which was defined as requiring device removal and/or intravenous antibiotics. Results: Within 24 months, 21 patients (0.8%) developed infection. Fourteen patients (67%) with infection presented within 30 days, 20 patients by 12 months, and only 1 patient beyond 12 months. Univariate analysis demonstrated that patients with primary electrical disorders (3 patients, P = 0.009) and those with a secondary prevention indication (13 patients, P = 0.0009) were more likely to develop infection. Among the 2.2% of patients who developed an ICD wound hematoma, 10.4% developed an infection. Among the 8.3% of patients requiring an ICD reintervention, 1.9% developed an infection. Conclusions: This cohort of ICD recipients at high-volume centres have a low risk of device-related infection. However; strategies to reduce wound hematoma and the need for ICD reintervention could further reduce the rate of infection. Résumé: Contexte: L’incidence des cas d’infection du défibrillateur cardioverteur implantable (DCI) augmente en raison du nombre accru d’implantations, de l’emploi de ces dispositifs chez des patients exposés à un risque très élevé et de l’augmentation de la fréquence des interventions de remplacement, qui sont associées à un plus grand risque d’infections. Pour parvenir à réduire la morbidité, la mortalité et les coûts associés aux infections liées à un DCI, il faut connaître la fréquence de cette complication et les facteurs qui permettent de la prédire. Méthodologie: Lors de l’essai Shock Implant Evaluation Trial (SIMPLE), 2 500 patients ayant reçu un DCI ont été répartis aléatoirement en deux groupes, l’un subissant des tests de défibrillation et l’autre, non. Sur une période de 3,1 ans en moyenne, les patients ont été vus en consultation tous les 6 mois et examinés à la recherche de signes d’infection du DCI, définie comme étant une infection exigeant le retrait du dispositif et/ou l’administration d’antibiotiques par voie intraveineuse. Résultats: Au total, 21 patients (0,8 %) ont présenté une infection dans les 24 mois suivant l’implantation. Quatorze patients (67 %) ont présenté une infection dans les 30 jours suivant l’intervention; à 12 mois, 20 patients avaient présenté une infection. Un seul patient a présenté une infection plus de 12 mois après l’intervention. Les résultats d’une analyse univariée ont démontré qu’une infection était plus probable chez les patients qui présentaient un trouble électrique primaire (3 patients, p = 0,009) et chez ceux qui avaient reçu un dispositif en prévention secondaire (13 patients, p = 0,0009). Parmi les patients qui présentaient un hématome après l’implantation du DCI (2,2 %), 10,4 % ont présenté une infection. Parmi les patients qui ont eu besoin d’une nouvelle intervention relative au DCI (8,3 %), 1,9 % ont présenté une infection. Conclusions: Les patients de cette cohorte ayant reçu un DCI dans des établissements à haut volume étaient exposés à un faible risque d’infection du défibrillateur. Des stratégies visant à réduire les hématomes et la nécessité d’une nouvelle intervention sur les DCI pourraient toutefois contribuer à réduire encore plus la fréquence des infections.

Background: Catheter ablation (CA) is performed in patients with atrial fibrillation (AF) to reduce symptoms and improve health-related quality of life (HRQL). Methods: This systematic review and meta-analysis of randomized controlled trials (RCTs) evaluated CA of any energy modality compared with antiarrhythmic drugs (AADs) using inverse-variance random-effects models. We searched for RCTs reporting HRQL and AF-related symptoms at 3, 6, 12, 24, 48, and 60 months after treatment as well as the number of repeat ablations. Results: Of 15,878 records, we included 13 RCTs of CA vs AADs for the analyses of HRQL, 7 RCTs for the analyses of AF-related symptoms, and 13 RCTs for the number of repeat ablations. For the HRQL analyses at 3 months, there were significant increases in both the Physical Component Summary score (3 months’ standardized mean difference = 0.58 [0.39-0.78]; P < 0.00001, I2 = 6%, 3 trials, n = 443) and the Mental Component Summary score (3 months’ standardized mean difference = 0.57 [0.37-0.77]; P < 0.00001, I2 = 0%, 3 trials, n = 443), favouring CA over AADs. These differences were sustained at 12 months but not >24 months after randomization. Similar results were seen for AF-related symptoms. The number of repeat ablations and success rates after procedure varied considerably across trials. Conclusions: Evidence from few trials suggests that CA improves physical and mental health and AF-related symptoms in the short term, but these benefits decrease with time. More trials, reporting both HRQL and AF-related symptoms, at consistent time points are needed to assess the effectiveness of CA for the treatment of AF. Résumé: Contexte: L’ablation par cathéter (AC) est réalisée chez les patients atteints de fibrillation auriculaire (FA) afin d’atténuer les symptômes et d’améliorer la qualité de vie liée à la santé (QVLS). Méthodologie: Cette revue systématique et méta-analyse d’essais contrôlés à répartition aléatoire (ECRA) a permis d’évaluer l’AC, toutes modalités énergétiques confondues, comparativement aux agents antiarythmiques (AA) à l’aide de modèles à effets aléatoires à variance inverse. Nous avons recherché les ECRA qui faisaient état de la QVLS et des symptômes liés à la FA à 3, 6, 12, 24, 48 et 60 mois après le traitement et qui précisaient le nombre d’ablations répétées. Résultats: À partir de 15 878 entrées, nous avons retenu 13 ECRA comparant l’AC à des AA pour l’analyse de la QVLS, 7 autres pour l’analyse des symptômes liés à la FA et 13 de plus aux fins de calcul du nombre d’ablations répétées. L’analyse de la QVLS à 3 mois indique une augmentation significative du score sommaire de la composante physique (différence moyenne normalisée à 3 mois = 0,58 [0,39-0,78]; p < 0,00001, I2 = 6 %, 3 essais, n = 443) et du score sommaire de la composante mentale (différence moyenne normalisée à 3 mois = 0,57 [0,37-0,77]; p < 0,00001, I2 = 0 %, 3 essais, n = 443), faisant pencher la balance en faveur de l’AC plutôt que des AA. Ces différences persistaient à 12 mois après la répartition aléatoire, mais pas aux moments d’évaluation ultérieurs (24, 48 et 60 mois). Des résultats similaires ont été observés au chapitre des symptômes liés à la FA. Le nombre d’ablations répétées et le taux de réussite postopératoire variaient considérablement d’un essai à l’autre. Conclusions: Les données probantes de quelques essais donnent à penser que l’AC améliore la santé physique et mentale ainsi que les symptômes liés à la FA à court terme, mais que ces bienfaits s’atténuent avec le temps. D’autres essais faisant état de la QVLS et des symptômes liés à la FA, à des moments d’évaluation constants, devront être réalisés pour évaluer l’efficacité réelle de l’AC dans le traitement de la FA.

Background Sodium‐glucose co‐transporter (SGLT) inhibitors reduce cardiovascular outcomes including mortality in several populations; however, their effect on atrial fibrillation/flutter (AF) remains unclear. Our objective was to determine whether SGLT inhibitors reduce AF and whether a history of AF modifies the effect of SGLT inhibitors on the composite of heart failure hospitalization or cardiovascular death. Methods and Results We searched MEDLINE, Embase, and CENTRAL to March 2021. Pairs of reviewers identified randomized controlled trials that compared an SGLT inhibitor with placebo or no therapy. We pooled data using RevMan 5.4.1, assessed risk of bias using the Cochrane tool, and determined the overall quality of evidence using Grades of Recommendation, Assessment, Development and Evaluation. Thirty‐one eligible trials reported on AF events (75 279 participants, mean age 62 years, 35.0% women). Moderate quality evidence supported a lower risk of serious AF events with SGLT inhibitors (1.1% versus 1.5%; risk ratio 0.75 [95% CI, 0.66–0.86]; I2=0%). A similar reduction in total AF events was also noted with SGLT inhibitors. Three trials reported on heart failure hospitalization/cardiovascular death stratified by a baseline history of AF (18 832 participants, mean age 66 years, 38.1% women); in patients with a history of AF, SGLT inhibitors resulted in a lower risk in the composite of heart failure hospitalization or cardiovascular death (hazard ratio, 0.70 [95% CI, 0.57–0.85]; I2=0%)—similar to the effect estimate for patients without AF, P value for interaction: 1.00. Conclusions SGLT inhibitors may reduce AF events and likely reduce heart failure hospitalization/cardiovascular death to a similar extent in patients with and without AF.

Background Heart failure (HF) is a common complication to atrial fibrillation (AF), leading to rehospitalization and death. Early identification of patients with AF at risk for HF might improve outcomes. We aimed to derive a score to predict 1‐year risk of new‐onset HF after an emergency department (ED) visit with AF. Methods and Results The RE‐LY AF (Randomized Evaluation of Long‐Term Anticoagulant Therapy) registry enrolled patients with AF presenting to an ED in 47 countries, and followed them for a year. The end point was HF hospitalization and/or HF death. Among 15 400 ED patients, 9765 had no prior HF (mean age, 64.9±14.9 years). Within 1 year, new‐onset HF developed in 6.8% of patients, of whom 21% died of HF. Independent predictors of HF included left ventricular hypertrophy (odds ratio [OR], 1.47; 95% CI, 1.19–1.82), valvular heart disease (OR, 1.55; 95% CI, 1.18–2.04), smoking (OR, 1.42; 95% CI, 1.12–1.78), height (OR, 0.93; 95% CI, 0.90–0.95 per 3 cm), age (OR, 1.11; 95% CI, 1.07–1.15 per 5 years), rheumatic heart disease (OR, 1.77, 95% CI, 1.24–2.51), prior myocardial infarction (OR, 1.85; 95% CI, 1.45–2.36), remaining in AF at ED discharge (OR, 1.86; 95% CI, 1.46–2.36), and diabetes (OR, 1.33; 95% CI, 1.09–1.64). A continuous risk prediction score (LVS‐HARMED [left ventricular, valvular heart disease, smoking or other tobacco use, height, age, rheumatic heart disease, myocardial infarction, emergency department discharge rhythm, and diabetes]) had good discrimination (C statistic, 0.735; 95% CI, 0.716–0.755). Validation was conducted internally using bootstrapping (optimism‐corrected C statistic, 0.705) and externally (C statistic, 0.699). The 1‐year incidence of HF hospitalization and/or HF death across quartile groups of the score was 1.1%, 4.5%, 6.9%, and 14.4%, respectively. LVS‐HARMED also predicted incident stroke (C statistic, 0.753; 95% CI, 0.728–0.778). Conclusions The LVS‐HARMED score predicts new‐onset HF after an ED visit for AF. Preventative strategies should be considered in patients with high LVS‐HARMED HF risk.

Aims: Guidelines endorse long-term oral anticoagulation (OAC) for stroke prophylaxis in patients with atrial fibrillation (AF) and additional stroke risk factors. However, diverse estimates of guideline based OAC treatment are reported. The objective was to provide insight into the variability seen in estimates of OAC treatment uptake and treatment gaps in clinical practice. Methods and results: A systematic review was conducted following Cochrane methodology, using comprehensive search terms for AF and anticoagulation. MEDLINE and EMBASE databases (January 2006–2016) were searched, and prospective and retrospective observational studies reporting OAC use included. Study data and patient characteristics were extracted, OAC rates pooled by study factors, and meta-regression analysis conducted to identify factors associated with OAC uptake.Of 8861 records screened, 155 eligible datasets from 147 studies were identified [median (25th, 75th percentiles) 2259 (595, 10,240) patients, mean age 73.8 ± 7.1 years]. The majority of studies included AF patients with CHA2DS2-VASc >1 [median proportion (25th, 75th percentile) 0.92 (0.83, 1.00)]. OAC use varied across studies [median proportion (25th, 75th percentile) 51.2% (36.7%, 64.7%)] with high heterogeneity (I2 = 100.0%). In the meta-regression analysis [coefficient, p], prospective study design (0.093, p = 0.008), general practitioner treating physician (0.105, p = 0.001) and data collection after 2013 (0.072, p = 0.070) were associated with higher OAC use. Consecutive enrollment (−0.075, p = 0.008) and Asian region (−0.181, p

Background Perioperative atrial fibrillation (POAF) is common in patients undergoing cardiac surgery. Conflicting evidence exists whether patients with POAF after cardiac surgery have an increased long‐term risk of stroke and other adverse events. Methods and Results We prospectively followed for up to 5 years 4624 patients without prior atrial fibrillation who underwent coronary artery bypass grafting in an international study. POAF was defined as atrial fibrillation that occurred during the initial hospitalization for surgery, lasted for ≥5 minutes, and required treatment. Outcomes assessed were a composite of death, nonfatal myocardial infarction or nonfatal stroke, and its individual components. Median age was 67 years, and 778 (16.8%) had an episode of POAF. The incidence of the composite outcome was 6.84 and 4.10 per 100 patient‐years in patients with and without POAF, and the incidence of stroke was 0.75 versus 0.45, respectively. The adjusted hazard ratios (aHRs) were 1.36 (95% CI, 1.16–1.59) for the composite outcome; 1.33 (95% CI, 1.10–1.61) for death; 1.58 (95% CI, 1.23–2.02) for myocardial infarction, and 1.27 (95% CI, 0.81–2.00) for stroke. In a landmark analysis excluding events of the initial hospital admission, the aHRs were 1.26 (95% CI, 1.03–1.54) for the composite outcome, 1.28 (95% CI, 1.03–1.59) for death, 1.70 (95% CI, 0.86–3.36) for myocardial infarction, and 1.07 (95% CI, 0.59–1.93) for stroke. At hospital discharge, 10.7% and 1.4% of patients with and without POAF received oral anticoagulation, respectively. Conclusions Patients with POAF after cardiac surgery had an increased long‐term risk of adverse outcomes, mainly death and myocardial infarction. The risk of stroke was low and not increased in patients with POAF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00463294.

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

Objective:. To estimate the incidence of new-onset atrial fibrillation in critically ill patients. Design:. Prospective cohort. Setting:. Medical-surgical ICU. Subjects:. Consecutive patients without a history of atrial fibrillation but with atrial fibrillation risk factors. Interventions:. Electrocardiogram patch monitor until discharge from hospital or up to 14 days. Measurements and Main Results:. A total of 249 participants (median age of 71 yr [interquartile range] 64–78 yr; 35% female) completed the study protocol of which 158 (64%) were admitted to ICU for medical illness, 78 (31%) following noncardiac surgery, and 13 (5%) with trauma. Median Acute Physiology and Chronic Health Evaluation II score was 16 (interquartile range, 12–22). Median duration of patch electrocardiogram monitoring, ICU, and hospital lengths of stay were 6 (interquartile range, 3–12), 4 (interquartile range, 2–8), and 11 days (interquartile range, 5–23 d), respectively. Atrial fibrillation ≥ 30 seconds was detected by the patch in 44 participants (17.7%), and three participants (1.2%) had atrial fibrillation detected clinically after patch removal, resulting in an overall atrial fibrillation incidence of 18.9% (95% CI, 14.2–24.3%). Total duration of atrial fibrillation ranged from 53 seconds to the entire monitoring time. The proportion of participants with ≥1 episode(s) of ≥6 minute, ≥1 hour, ≥12 hour and ≥24 hour duration was 14.8%, 13.2%, 7.0%, and 5.3%, respectively. The clinical team recognized only 70% of atrial fibrillation cases that were detected by the electrocardiogram patch. Conclusions:. Among patients admitted to an ICU, the incidence of new-onset atrial fibrillation is approximately one in five, although approximately one-third of cases are not recognized by the clinical team.

Background Patients with persistent atrial fibrillation (AF) undergoing catheter‐based AF ablation have lower success rates than those with paroxysmal AF. We compared healthcare use and clinical outcomes between patients according to their AF subtypes. Methods and Results Consecutive patients undergoing AF ablation were prospectively identified from a population‐based registry in Ontario, Canada. Via linkage with administrative databases, we performed a retrospective analysis comparing the following outcomes between patients with persistent and paroxysmal AF: healthcare use (defined as AF‐related hospitalizations/emergency room visits), periprocedural complications, and mortality. Multivariable Poisson modeling was performed to compare the rates of AF‐related and all‐cause hospitalizations/emergency room visits in the year before versus after ablation. Between April 2012 and March 2016, there were 3768 consecutive patients who underwent first‐time AF ablation, of whom 1040 (27.6%) had persistent AF. The mean follow‐up was 1329 days. Patients with persistent AF had higher risk of AF‐related hospitalization/emergency room visits (hazard ratio [HR], 1.21; 95% CI, 1.09–1.34), mortality (HR, 1.74; 95% CI, 1.15–2.63), and periprocedural complications (odds ratio, 1.36; 95% CI, 1.02–1.75) than those with paroxysmal AF. In the overall cohort, there was a 48% reduction in the rate of AF‐related hospitalization/emergency room visits in the year after versus before ablation (rate ratio [RR], 0.52; 95% CI, 0.48–0.56). This reduction was observed for patients with paroxysmal (RR, 0.45; 95% CI, 0.41–0.50) and persistent (RR, 0.74; 95% CI, 0.63–0.87) AF. Conclusions Although patients with persistent AF had higher risk of adverse outcomes than those with paroxysmal AF, ablation was associated with a favorable reduction in downstream AF‐related healthcare use, irrespective of AF type.

Background Recent data have suggested a substantial incidence of atrial arrhythmias (AAs) in cardiac sarcoidosis (CS). Our study aims were to first assess how often AAs are the presenting feature of previously undiagnosed CS. Second, we used prospective follow‐up data from implanted devices to investigate AA incidence, burden, predictors, and response to immunosuppression. Methods and Results This project is a substudy of the CHASM‐CS (Cardiac Sarcoidosis Multicenter Prospective Cohort Study; NCT01477359). Inclusion criteria were presentation with clinically manifest cardiac sarcoidosis, treatment‐naive status, and implanted with a device that reported accurate AA burden. Data were collected at each device interrogation visit for all patients and all potential episodes of AA were adjudicated. For each intervisit period, the total AA burden was obtained. A total of 33 patients met the inclusion criteria (aged 56.1±7.7 years, 45.5% women). Only 1 patient had important AAs as a part of the initial CS presentation. During a median follow‐up of 49.1 months, 11 of 33 patients (33.3%) had device‐detected AAs, and only 2 (6.1%) had a clinically significant AA burden. Both patients had reduced burden after CS was successfully treated and there was no residual fluorodeoxyglucose uptake on positron emission tomography scan. Conclusions First, we found that AAs are a rare presenting feature of clinically manifest cardiac sarcoidosis. Second, AAs occurred in a minority of patients at follow‐up; the burden was very low in most patients. Only 2 patients had clinically significant AA burden, and both had a reduction after CS was treated. Registration URL: https://www.clini​caltr​ials.gov; unique identifier NCT01477359.

Background Atrial fibrillation (AF) is a major, often undetected, cardiac cause of stroke. Markers of atrial cardiopathy, including left atrial enlargement (LAE) or excessive atrial ectopy (EAE) increase the risk of AF and have shown associations with stroke. We sought to determine whether these markers improve stroke risk prediction beyond traditional vascular risk factors (eg CHA2DS2‐VASc score). Methods and Results Retrospective longitudinal cohort of 32 454 consecutive community‐dwelling adults aged ≥65 years referred for outpatient echocardiogram or Holter in Ontario, Canada (2010–2017). Moderate‐severe LAE was defined as men >47 mm and women >43 mm, and EAE was defined as >30 APBs per hour. Cause‐specific competing risks Cox proportional hazards used to estimate risk of ischemic stroke (primary), incident AF, and death (secondary). C‐statistics, incremental discrimination improvement and net reclassification were used to compare CHA2DS2‐VASc with LAE and EAE to CHA2DS2‐VASc alone. Each 10 mm increase in left atrial diameter increased 2‐ and 5‐year adjusted cause‐specific stroke hazard almost 2‐fold (LAE: 2‐year hazard ratio (HR), 1.72; P=0.007; 5‐year HR, 1.87; P

Abstract A significant proportion of patients’ experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random‐effects meta‐analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow‐up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10‐0.37; P

Abstract Background Patient decision aids (PtDA) support quality decision-making. The aim of this research was to evaluate the feasibility of conducting a randomized controlled trial delivering an implantable cardioverter defibrillator (ICD)-specific PtDA to new ICD candidates and examining preliminary estimates of differences in outcomes. Methods Prior to recruitment, ICD candidacy was determined. Consented patients were randomized to (1) usual care or (2) PtDA intervention. Feasibility outcomes included referral and recruitment rates, successful PtDA delivery, and completion of measures. The PtDA intervention was administered prior to specialist consultation and baseline demographics, and measures of decision quality including decisional conflict (DCS), SURE test (Sure of myself, Understand information, Risk-benefit ratio, Encouragement), patient’s ICD specific values, ICD knowledge, and health-related quality of life were recorded. Post-consultation, participant’s DCS was repeated and decisions to proceed, decline, or defer ICD implantation were collected. Feasibility data was determined using descriptive statistics (continuous and categorical). Preliminary estimates of differences in outcomes were assessed using mean differences. Concordance between values and decision choice was assessed using logistic regression of the intervention group. Results We identified 135 eligible patients. Eighty-two consented to the trial randomizing patients to usual care (n = 41) or PtDA intervention (n = 41). Feasibility outcome results were (1) referral rate at approximately 20/month, (2) recruitment rate 61%, and (3) successful delivery of PtDA and study management. Pre-consultation, PtDA patients scored lower on the DCS scale (mean, standard deviation [SD] 27.3 (18.4) compared to usual care, 49.4 (18.6); the between-group difference in means [95% confidence interval (CI)] was − 22.1[− 30.23, − 13.97]. A difference remained post-implantation 21.2 (11.7), PtDA intervention 29.9 (13.3), and usual care − 8.7 [− 14.61, − 2.86]. SURE test results supported DCS differences. The PtDA group scored higher on the ICD-related knowledge questions, with 47.50% scoring greater than 3/5 of the knowledge questions correct, compared to 23.09% receiving usual care. The mean [SD] number of correct knowledge responses out of 5 was 3.33(1.19) in the PtDA group and 2.62 (1.16) in usual care pre-implant. Concordance between values and decision choice found a strong association between predicted and actual ICD implant status in the intervention group. Conclusion Our results suggest that a future definitive trial is feasible. The ICD-specific PtDA shows promise with respect to preliminary estimates of differences in outcomes. Trial registration NCT01876173 .

Background: Nonvalvular atrial fibrillation (NVAF) is an independent risk factor for ischemic stroke and is common in chronic kidney disease (CKD) and dialysis patients. The use of oral anticoagulation to prevent stroke and systemic embolism in the setting of kidney disease is controversial. Novel alternatives to vitamin K antagonists include left atrial appendage occlusion devices (LAAOD) and apixaban. Objective: We sought to elicit Canadian nephrologist views regarding stroke and systemic embolism prevention therapies in CKD and dialysis patients with NVAF. Design: Survey. Setting: Online via https://www.surveymonkey.com . Participants: Canadian Society of Nephrology members actively treating adult dialysis patients with NVAF. Measurements: Management questions were asked with response options consisting of a Likert scale ranging from 1 to 8 (with 1 being definitely would not and 8 being definitely would ). Methods: We randomly allocated each respondent to 2 of 4 cases that varied by stroke and bleeding risks (using varying CHADS2 and HASBLED scores, respectively). Results: There were 91 responses (36.3% response rate) from mostly university (83.5%) and also community with university affiliation (12.1%) and community (4.4%) nephrologists. Warfarin was more likely to be recommended in individuals at high stroke risk and low bleeding risk (mean = 5.47, 95% confidence interval = 4.87-6.07) and less likely to be recommended in individuals at moderate stroke risk and high bleeding risk (mean = 2.89, 95% confidence interval = 2.37-3.41). The likelihood of recommending LAAOD did not vary by stroke or bleeding risks (means ranging from 3.92-4.90). Apixaban was not likely to be recommended in any case (means ranging from 2.60-3.50). However, nephrologists felt there was equipoise regarding anticoagulation strategies allowing participation in appropriate randomized controlled trials (RCTs). Limitations: The survey only involved nephrologists and only 4 cases with dichotomized risk categories were presented instead of complete range of stroke and bleeding risk combinations. As with any survey, there was the potential for responder bias and treatment decisions are not anchored directly to patient management. Conclusions: Nephrologists caring for patients with kidney disease appear willing to include patients in clinical trials examining alternatives to warfarin for stroke and systemic embolism prevention for NVAF in the setting of kidney disease.

BackgroundEarly life risk factors are associated with cardiometabolic disease, but have not been fully studied in atrial fibrillation (AF). There are discordant results from existing studies of birth weight and AF, and the impact of maternal body size, gestational age, placental size, and birth length is unknown. Methods and ResultsThe Helsinki Birth Cohort Study includes 13 345 people born as singletons in Helsinki in the years 1934–1944. Follow‐up was through national registries, and ended on December 31, 2013, with 907 incident cases. Cox regression analyses stratified on year of birth were constructed for perinatal variables and incident AF, adjusting for offspring sex, gestational age, and socioeconomic status at birth. There was a significant U‐shaped association between birth weight and AF (P for quadratic term=0.01). The lowest risk of AF was found among those with a birth weight of 3.4 kg (3.8 kg for women [85th percentile] and 3.0 kg for men [17th percentile]). High maternal body mass index (≥30 kg/m2) predicted offspring AF; hazard ratio 1.36 (95% CI 1.07–1.74, P=0.01) compared with normal body mass index (

The twiddler syndrome results in retraction and coiling of the lead in the pacemaker pocket with subsequent pacemaker malfunction. If the lead׳s parameters are not affected, then the problem can be corrected by lead repositioning. We describe the first reported case of a dramatic pacemaker lead coiling with a double level of lead compromise, with one of them being intra-cardiac. This condition affected our treatment strategy, as the repositioning of the lead was unfeasible.

Objective. The objective of this study is to evaluate the cost-effectiveness of catheter ablation for rhythm control compared to antiarrhythmic drug (AAD) therapy in patients with atrial fibrillation (AF) who have previously failed on an AAD. Methods. An economic model was developed to compare (1) catheter ablation and (2) AAD (amiodarone 200 mg/day). At the end of the initial 12 month phase of the model, patients are classified as being in normal sinus rhythm or with AF, based on data from a meta-analysis. In the 5-year Markov phase of the model, patients are at risk of ischemic stroke each 3-month model cycle. Results. The model estimated that, compared to the AAD strategy, ablation had $8,539 higher costs, 0.033 fewer strokes, and 0.144 more QALYS over the 5-year time horizon. The incremental cost per QALY of ablation compared to AAD was estimated to be $59,194. The probability of ablation being cost-effective for willingness to pay thresholds of $50,000 and $100,000 was estimated to be 0.89 and 0.90, respectively. Conclusion. Based on current evidence, pulmonary vein ablation for treatment of AF is cost-effective if decision makers willingness to pay for a QALY is $59,194 or higher.