When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a ...follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities.
This study hypothesized that the “Delta CHA2DS2-VASc score,” which reflects the change in score between baseline and follow-up, would be more predictive of ischemic stroke compared with the baseline CHA2DS2-VASc score.
A total of 31,039 patients with AF who did not receive antiplatelet agents or oral anticoagulants, and who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc scores were defined as the differences between the baseline and follow-up CHA2DS2-VASc scores. During 171,956 person-years, 4,103 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analyzed and compared.
The mean baseline CHA2DS2-VASc score was 1.29, which increased to 2.31 during the follow-up, with a mean Delta CHA2DS2-VASc score of 1.02. The CHA2DS2-VASc score remained unchanged in only 40.8% of patients. Among 4,103 patients who experienced ischemic stroke, 89.4% had a Delta CHA2DS2-VASc score ≥1 compared with only 54.6% in patients without ischemic stroke, and 2,643 (64.4%) patients had ≥1 new-onset comorbidity, the most common being hypertension. The Delta CHA2DS2-VASc score was a significant predictor of ischemic stroke that performed better than baseline or follow-up CHA2DS2-VASc scores, as assessed by the C-index and the net reclassification index.
In this AF cohort, the authors demonstrated that the CHA2DS2-VASc score was not static, and that most patients with AF developed ≥1 new stroke risk factor before presentation with ischemic stroke. The Delta CHA2DS2-VASc score, reflecting the change in score between baseline and follow-up, was strongly predictive of ischemic stroke, reflecting how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities.
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Background
Atrial fibrillation (AF) prevalence increases with age. Aging affects the substrate properties of the left atrium (LA) and the outcomes of catheter ablation for treating AF. We ...investigated the AF trigger distribution and catheter ablation outcomes in patients of different ages with AF.
Methods
1585 patients with AF (1181 paroxysmal and 404 non‐ paroxysmal AF) who had undergone catheter ablation were enrolled. The patients were divided into young (20–40 year‐old, n = 175), middle‐aged (41–64 year‐old, n = 1134), and old (≥ 65 year‐old, n = 276) groups. Electrophysiological characteristics and AF trigger sites were recorded.
Result
The incidence of AF with only non‐pulmonary vein (non‐PV) foci was higher in the young group than in the other groups (8.6% vs. 3.6% vs. 3.3%, p < 0.01). Non‐PV foci were more commonly located in the superior vena cava (SVC) in the young group than in the other groups (13.1% vs. 7.8% vs. 6.5%, p = 0.03). The left atrium (LA) mean voltage was higher and the incidence of very late recurrence after AF ablation was lower in the young group than in the other groups. However, the final AF recurrence rate after multiple procedures and complication rates were similar among all the groups at a mean follow‐up of 5.6 years.
Conclusion
The young patients with AF had a higher incidence of only non‐PV foci, mostly located in SVC, than the middle‐aged and old patients. Our study highlights the importance of identifying the non‐PV foci in catheter ablation of young patients with AF.
Current American and European guidelines emphasize the importance of rate-control treatments in treating atrial fibrillation with a Class I recommendation, although data on the survival benefits of ...rate control are lacking. The goal of the present study was to investigate whether patients receiving rate-control drugs had a better prognosis compared with those without rate-control treatment.
This study used the National Health Insurance Research Database in Taiwan. There were 43 879, 18 466, and 38 898 patients with atrial fibrillation enrolled in the groups receiving β-blockers, calcium channel blockers, and digoxin, respectively. The reference group consisted of 168 678 subjects who did not receive any rate-control drug. The clinical end point was all-cause mortality. During a follow-up of 4.9±3.7 years, mortality occurred in 88 263 patients (32.7%). After adjustment for baseline differences, the risk of mortality was lower in patients receiving β-blockers (adjusted hazard ratio=0.76; 95% confidence interval=0.74-0.78) and calcium channel blockers (adjusted hazard ratio=0.93; 95% confidence interval=0.90-0.96) compared with those who did not receive rate-control medications. On the contrary, the digoxin group had a higher risk of mortality with an adjusted hazard ratio of 1.12 (95% confidence interval=1.10-1.14). The results were observed consistently in subgroup analyses and among the cohorts after propensity matching.
In this nationwide atrial fibrillation cohort, the risk of mortality was lower for patients receiving rate-control treatment with β-blockers or calcium channel blockers, and the use of β-blockers was associated with the largest risk reduction. Digoxin use was associated with greater mortality. Prospective, randomized trials are necessary to confirm these findings.
Influenza infection could activate systemic inflammatory responses and increase the sympathetic tone that plays an important role in the pathogenesis of atrial fibrillation (AF).
The goal of the ...present study was to investigate whether influenza infection was a risk factor for AF. We also aimed to study whether influenza vaccination could decrease the risk of AF.
From 2000 to 2010, a total of 11,374 patients with newly diagnosed AF were identified from the Taiwan National Health Insurance Research Database. On the same date of enrollment, 4 control patients (without AF) with matched age and sex were selected to be the control group for each study patient. The relationship between AF and influenza infection or vaccination 1 year before the enrollment was analyzed.
Compared with patients without influenza infection or vaccination (reference group; n = 38,353), patients with influenza infection without vaccination (n = 1369) were associated with a significantly higher risk of AF with an odds ratio of 1.182 (P = .032) after adjustment for baseline differences. The risk of AF was lower in patients receiving influenza vaccination without influenza infection (n = 16,452) with an odds ratio of 0.881 (P < .001). In patients who have received influenza vaccination and experienced influenza infection (n = 696), the risk of AF was similar to that in the reference group (odds ratio 1.136; P = .214). The lower risk of AF with vaccination was consistently observed in subgroup analyses.
Influenza infection was significantly associated with the development of AF, with an 18% increase in the risk, which could be reduced through influenza vaccination.
Instruction
We hypothesized that real‐time simultaneous amplitude frequency electrogram transform (SAFE‐T) during sinus rhythm (SR) is able to identify and characterize the drivers of atrial ...fibrillation (AF) in nonparoxysmal (NP) AF.
Methods
Twenty‐one NPAF patients (85.71% males, mean age 52 years old) underwent substrate mapping during SR (SAFE‐T and voltage) and during AF (complex fractionated atrial electrograms CFAE and similarity index SI). After pulmonary veins isolation, extensive substrate ablation was performed with the endpoint of procedural termination or elimination of all SI sites (>63% similarities). Sites with procedural termination and non‐termination sites were tagged for postablation SR analysis using SAFE‐T.
Results
In 74 CFAE sites identified (average of 3 ± 2 sites per person), 28 (37.84%) were identified as termination sites demonstrating a high SI compared with the non‐termination sites (80.11 ± 9.57% vs. 45.96 ± 13.38%, p < .001) during AF. During SR, these termination sites have high SAFE‐T values and harbor a highly resonant, localized, repetitive high frequency components superimposed in the low frequency components compared with non‐termination sites (5.70 ± 3.04 vs. 1.49 ± 1.66 Hz·mV, p < .001). In the multivariate analysis, the termination sites have higher SAFE‐T and SI value (p < .001).
Conclusion
AF procedural termination sites harbored signal characteristics of repetitive, high frequency component of individualized electrogram during SR, which can be masked by the low frequency fractionated electrogram and are difficult to see from the bipolar electrogram. Thus, SAFE‐T mapping is feasible in identifying and characterizing sites of AF drivers.
Introduction
Carina breakthrough (CB) at the right pulmonary vein (RPV) can occur after circumferential pulmonary vein isolation (PVI) due to epicardial bridging or transient tissue edema. High‐power ...short‐duration (HPSD) ablation may increase the incidence of RPV CB. Currently, the surrogate of ablation parameters to predict RPV CB is not well established. This study investigated predictors of RPV CB in patients undergoing ablation index (AI)‐guided PVI with HPSD.
Methods
The study included 62 patients with symptomatic atrial fibrillation (AF) who underwent AI‐guided PVI using HPSD. Patients were categorized into two groups based on the presence or absence of RPV CB. Lesions adjacent to the RPV carina were assessed, and CB was confirmed through residual voltage, low voltage along the ablation lesions, and activation wavefront propagation.
Results
Out of the 62 patients, 21 (33.87%) experienced RPV CB (Group 1), while 41 (66.13%) achieved first‐pass RPV isolation (Group 2). Despite similar AI and HPSD, patients with RPV CB had lower contact force (CF) at lesions adjacent to the RPV carina. Receiver operating characteristic (ROC) curve analysis identified CF < 10.5 g as a predictor of RPV CB, with 75.7% sensitivity and 56.2% specificity (area under the curve: 0.714).
Conclusion
In patients undergoing AI‐guided PVI with HPSD, lower CF adjacent to the carina was associated with a higher risk of RPV CB. These findings suggest that maintaining higher CF during ablation in this region may reduce the occurrence of RPV CB.
Patients with liver cirrhosis have been excluded from randomized clinical trials of oral anticoagulation therapy for stroke prevention in atrial fibrillation. We hypothesized that patients with liver ...cirrhosis would have a positive net clinical benefit for oral anticoagulation when used for stroke prevention in atrial fibrillation.
This study used the National Health Insurance Research Database in Taiwan. Among 289 559 atrial fibrillation patients aged ≥20 years, there were 10 336 with liver cirrhosis, and 9056 of them having a CHA
DS
-VASc score ≥2 were divided into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Patients with liver cirrhosis had a higher risk of ischemic stroke (hazard ratio=1.10,
=0.046) and intracranial hemorrhage (hazard ratio=1.20,
=0.043) compared with those without. Among patients with liver cirrhosis, patients taking antiplatelet therapy had a similar risk of ischemic stroke (hazard ratio=1.02, 95%CI=0.88-1.18) compared to those without antithrombotic therapies, but the risk was significantly lowered among warfarin users (hazard ratio=0.76, 95%CI=0.58-0.99). For intracranial hemorrhage, there were no significant differences between those untreated and those taking antiplatelet therapy or warfarin. The use of warfarin was associated with a positive net clinical benefit compared with being untreated or receiving only antiplatelet therapy.
For atrial fibrillation patients with liver cirrhosis in the current analysis of an observational study, warfarin use was associated with a lower risk of ischemic stroke and a positive net clinical benefit compared with nontreatment, and thus, thromboprophylaxis should be considered for such patients.
Introduction
Despite undergoing an index ablation, some patients progress from paroxysmal atrial fibrillation (PAF) to persistent AF (PersAF), and the mechanism behind this is unclear. The aim of ...this study was to investigate the predictors of progression to PersAF after catheter ablation in patients with PAF.
Methods
This study included 400 PAF patients who underwent an index ablation between 2015 and 2019. The patients were classified into three groups based on their outcomes: Group 1 (PAF to sinus rhythm, n = 226), Group 2 (PAF to PAF, n = 146), and Group 3 (PAF to PersAF, n = 28). Baseline and procedural characteristics were collected, and predictors for AF recurrence and progression were evaluated.
Results
The mean age of the patients was 58.4 ± 11.1 years, with 272 males. After 3 years of follow‐up, 7% of the PAF cases recurred and progressed to PersAF despite undergoing an index catheter ablation. In the multivariable analysis, a larger left atrial (LA) diameter and the presence of non‐pulmonary vein (PV) triggers during the index procedure independently predicted recurrence. Moreover, a larger LA diameter, the presence of non‐PV triggers, and a history of thyroid disease independently predicted AF progression.
Conclusion
The progression from PAF to PersAF after catheter ablation is associated with a larger LA diameter, history of thyroid disease, and the presence of non‐PV triggers. Meticulous preprocedural evaluation, patient selection, and comprehensive provocation tests during catheter ablation are recommended.
The study investigated the outcomes of 400 patients with PAF who underwent an index ablation procedure, while also identifying the predictors associated with recurrence and progression to PersAF.
CI, confidence interval; OR, odd ratio; PAF, paroxysmal atrial fibrillation; PersAF, persistent atrial fibrillation; SR, sinus rhythm.
Introduction
We aimed to clarify the effect of vein of Marshall (VOM) ethanol infusion for treating VOM triggers and/or mitral flutter after first‐attempt endocardial ablation in patients with ...nonparoxysmal atrial fibrillation (AF).
Methods and Results
Of the 254 consecutive patients (age, 56 ± 10 years; 221 male) undergoing catheter ablation for drug‐refractory nonparoxysmal AF, 32 (12.6%) received VOM ethanol infusion. The patients were stratified into group 1 (pulmonary vein isolation PVI, substrate modification, VOM ethanol infusion), group 2 (PVI, substrate modification), and group 3 (PVI alone). Propensity‐matched analysis (N = 128) of long‐term outcomes (3.9 ± 0.5 years) revealed a higher AF recurrence risk in group 2 (hazard ratio HR, 4.17; 95% confidence interval 95% CI, 1.63‐10.69; P = .003) and group 3 (HR, 1.82; 95% CI, 1.09‐3.04; P = .021) than in group 1, as well as a higher atrial arrhythmia recurrence risk in group 2 than in group 1 (HR, 2.42; 95% CI, 1.16‐5.03; P = .018). A higher procedural termination rate was observed in group 1 than groups 2 and 3 (41.7% vs 17.2% vs 18.8%; P = .042). On multivariate analysis, VOM ethanol injection was an independent predictor of freedom from recurrence of AF (HR, 0.20; 95% CI, 0.08‐0.52; P = .001) and atrial arrhythmia (HR, 0.35; 95% CI, 0.17‐0.74; P = .005), whereas a left atrial diameter >45 mm and hypertension were independent risk factors for recurrence. Periprocedural complications rates were comparable among the groups.
Conclusion
Adjunctive VOM ethanol infusion is effective and safe for treating nonparoxysmal AF in patients with VOM triggers and/or refractory mitral flutter, providing good long‐term freedom from AF and atrial arrhythmia.
Background Although several risk schemes have been proposed to predict new-onset atrial fibrillation (AF), clinical prediction models specific for Asian patients were limited. In the present study, ...we aimed to develop a clinical risk score (Taiwan AF score) for AF prediction using the whole Taiwan population database with a long-term follow-up. Methods and Results Among 7 220 654 individuals aged ≥40 years without a past history of cardiac arrhythmia identified from the Taiwan Health Insurance Research Database, 438 930 incident AFs occurred after a 16-year follow-up. Clinical risk factors of AF were identified using Cox regression analysis and then combined into a clinical risk score (Taiwan AF score). The Taiwan AF score included age, male sex, and important comorbidities (hypertension, heart failure, coronary artery disease, end-stage renal disease, and alcoholism) and ranged from -2 to 15. The area under the receiver operating characteristic curve of the Taiwan AF scores in the predictions of AF are 0.857 for the 1-year follow-up, 0.825 for the 5-year follow-up, 0.797 for the 10-year follow-up, and 0.756 for the 16-year follow-up. The annual risks of incident AF were 0.21%/year, 1.31%/year, and 3.37%/year for the low-risk (score -2 to 3), intermediate-risk (score 4 to 9), and high-risk (score ≥10) groups, respectively. Compared with low-risk patients, the hazard ratios of incident AF were 5.78 (95% CI, 3.76-7.75) for the intermediate-risk group and 8.94 (95% CI, 6.47-10.80) for the high-risk group. Conclusions We developed a clinical AF prediction model, the Taiwan AF score, among a large-scale Asian cohort. The new score could help physicians to identify Asian patients at high risk of AF in whom more aggressive and frequent detections and screenings may be considered.
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