Europace最新文献

Aims: Electronic healthcare records (EHR) are at the forefront of advances in epidemiological research emerging from large-scale population biobanks and clinical studies. Hospital admissions, diagnoses, and procedures (HADP) data are often used to identify disease cases. However, this may result in incomplete ascertainment of chronic conditions such as atrial fibrillation (AF), which are principally managed in primary care (PC). We examined the relevance of EHR sources for AF ascertainment, and the implications for risk factor associations, patient management, and outcomes in UK Biobank.

Methods and results: UK Biobank is a prospective study, with HADP and PC records available for 230 000 participants (to 2016). AF cases were ascertained in three groups: from PC records only (PC-only), HADP only (HADP-only), or both (PC + HADP). Conventional statistical methods were used to describe differences between groups in terms of characteristics, risk factor associations, ascertainment timing, rates of anticoagulation, and post-AF stroke and death. A total of 7136 incident AF cases were identified during 7 years median follow-up (PC-only: 22%, PC + HADP: 49%, HADP-only: 29%). There was a median lag of 1.3 years between cases ascertained in PC and subsequently in HADP. AF cases in each of the ascertainment groups had comparable baseline demographic characteristics. However, AF cases identified in hospital data alone had a higher prevalence of cardiometabolic comorbidities and lower rates of subsequent anticoagulation (PC-only: 44%, PC + HADP: 48%, HADP-only: 10%, P < 0.0001) than other groups. HADP-only cases also had higher rates of death [PC-only: 9.3 (6.8, 12.7), PC + HADP: 23.4 (20.5, 26.6), HADP-only: 81.2 (73.8, 89.2) events per 1000 person-years, P < 0.0001] compared to other groups.

Conclusion: Integration of data from primary care with that from hospital records has a substantial impact on AF ascertainment, identifying a third more cases than hospital records alone. However, about a third of AF cases recorded in hospital were not present in the primary care records, and these cases had lower rates of anticoagulation, as well as higher mortality from both cardiovascular and non-cardiovascular causes. Initiatives aimed at enhancing information exchange of clinically confirmed AF between healthcare settings have the potential to benefit patient management and AF-related outcomes at an individual and population level. This research underscores the importance of access and integration of de-identified comprehensive EHR data for a definitive understanding of patient trajectories, and for robust epidemiological and translational research into AF.

Aims: Early rhythm control therapy in atrial fibrillation (AF) results in higher freedom from atrial arrhythmia (AA) recurrence and improved cardiovascular outcomes. The optimal timing of cryoballoon ablation (CBA) is unknown.

Methods and results: We evaluated AA recurrence and procedure-related complications of early vs. late CBA (≤12 vs. >12 months from diagnosis) in patients enrolled in the prospective Cryo Global Registry (121 centres in 37 countries, NCT02752737). A total of 3447 subjects were followed through 12 months and 1220 through 24 months. In summary, 1573 patients (46%) had early ablation at a median (IQR) of 0.3 (0.1-0.6) years from AF diagnosis (age 62 ± 12 years., 35.8% female, 71.4% paroxysmal), and 1874 (54%) had late ablation at a median of 3.4 (1.9-6.7) years after diagnosis (age 61 ± 11 years, 36.2% female, 75.0% paroxysmal). Early ablation patients were less hypertensive (53.5% vs. 57.9%, P = 0.01) and less symptomatic (1.5 ± 1.1 vs. 1.8 ± 1.1 symptoms/patient, P < 0.01) and had smaller left atrial diameters (41 ± 7 mm vs. 42 ± 7 mm, P < 0.01). Freedom from AA recurrence was 81.5% (95% CI: 78.7-83.9%) in the early vs. 71.7% (95% CI: 68.9-74.3%) in the late ablation group at 24 months (P < 0.01). The risk of cardioversion was 41% lower in the early ablation group [HRAdj: 0.59 (0.42-0.83), P < 0.01]. Serious procedure-related adverse events occurred in 2.4 and 3.5% of patients in the early and late ablation groups (P = 0.045), respectively.

Conclusion: CBA within 12 months from AF diagnosis resulted in higher freedom from AA recurrence and is associated with fewer safety events in a real-world evaluation.

Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT02752737.

Background: Initial clinical studies of pulsed field ablation (PFA) to treat atrial fibrillation (AF) indicated a >90% durability rate of pulmonary vein isolation (PVI). However, these studies were largely conducted in single centers and involved a limited number of operators. The electrophysiological findings and outcomes in patients undergoing repeat ablation after an initial PF ablation for AF are incompletely understood.

Methods: In the MANIFEST-REDO study, we investigated patients who underwent repeat ablation due to clinical recurrence - AF or atrial tachycardia (AT) - following first-ever PVI with a pentaspline PFA catheter (Farawave; Boston Scientific Inc).

Results: At 22 centers, 427 patients (age 64±11 years; 37% female) were included. Of note, the recurrent arrhythmia leading to the repeat ablation was paroxysmal AF (51%), persistent AF (30%), or AT (19%). At the repeat procedure, the PV reconnection rates were: 30% (LSPV), 28% (LIPV), 33% (RSPV) and 32% (RIPV). In 45% of patients all PVs were durably isolated at the beginning of the repeat procedure, with the previous use of any imaging or mapping modality being univariately associated with durable PVI. After a post-redo follow-up period of 284 [90-366] days, the primary effectiveness endpoint (freedom from documented AF/AT lasting ≥30s after 3-month blanking without class I/III antiarrhythmic drugs or symptoms) was achieved in 65% of patients, with significant differences between groups (PAF 65% vs. PersAF 56% vs. AT 76%; p=0.04). Persistent AF as recurrent arrhythmia after the initial PFA ablation predicted AT/AF recurrence after repeat ablation (HR 1.241 (95% CI 1.534-1.005 CI); p=0.045). The procedural complication rate was 2.8%.

Conclusion: In repeat procedures for AF/AT performed after an index procedure with PFA for AF, PV reconnections are not uncommon. Repeat procedures can be performed safely and with an acceptable subsequent success rate.

Aims: The aim of this study was to examine differences in incidence rates of all-cause mortality (ACM) and sudden cardiac death (SCD) in persons of differing socioeconomic position (SEP).

Methods: All deaths in Denmark from 01-01-2010 to 31-12-2010 (1 year) were included. Autopsy reports, death certificates, discharge summaries and nationwide health registries were reviewed to identify cases of SCD. SEP was measured as either household income or highest achieved educational level and analysed separately. Hazard rates were calculated using univariate and multivariable Cox regression model adjusting for age, sex, and selected comorbidities.

Results: A total of 53452 deaths were included of which 6820 were classified as SCDs. Incidence rates of ACM and SCD increased with age and were higher in the lower SEP groups. The greatest difference in SCD incidence was found between the low and high education level groups with an incidence rate ratio of 5.1 (95% CI 3.8-6.8). The hazard ratios for ACM and SCD were significantly higher for low SEP groups independently of comorbidities. Compared with the highest income group, the low-income group had adjusted hazard ratios of ACM and SCD that were 2.17 (2.01-2.34) and 1.72 (1.67-1.76) respectively.

Conclusion: We observed an inverse association between both income and education level and the risk of ACM and SCD in the general population, which persisted independently of baseline comorbidities. Our results indicate a need for further research into the mechanisms behind socioeconomic disparities in healthcare and targeted preventative strategies.

Background: Orthostatic hypotension (OH) is an important differential diagnosis in unexplained syncope. Neurogenic OH (nOH) has been postulated to differ from non-neurogenic OH (non-nOH), yet pathophysiological differences are largely unexplored. We aimed to investigate etiology and tilt table test (TTT)-induced hemodynamic responses in symptomatic OH patients.

Methods: We performed a retrospective study analyzing patients referred for unexplained syncope or highly symptomatic orthostatic intolerance with TTT-verified classical OH (cOH). Medical records were analyzed for the presumptive etiology of cOH. Fifty-two patients (mean age 73±9 years, 46% women) with good quality TTT recordings were divided into three groups on clinical grounds: nOH, non-nOH, and mixed OH. The log-ratio (LR) method was applied to compare the decrease in mean arterial pressure (MAPLR) and corresponding contributions of heart rate (HRLR), stroke volume (SVLR) and total peripheral resistance (TPRLR) during the upright phase of TTT.

Results: The prevalence of cOH was 12 (23%) nOH, 14 (27%) non-nOH and 26 (50%) mixed OH. No difference in MAPLR was observed among the three groups during the 4th upright minute of TTT (nOH: -0.10±0.04 vs. non-nOH: -0.07±0.05 and vs. mixed OH: -0.06±0.05, p=0.10). The contributions of HRLR, SVLR and TPRLR to the drop in MAPLR did not differ between groups (all p>0.05).

Conclusions: One-half of highly symptomatic OH patients had mixed OH, whereas one-quarter had either pure neurogenic, or non-neurogenic OH, respectively. Different forms of OH were indifferentiable based on hemodynamic responses during TTT, questioning the clinical utility of such classification. Larger studies are needed to confirm these findings.

Background: Loss of bipolar electrograms immediately after pulsed field ablation (PFA) makes lesion durability assessment challenging.

Objective: The aim of this trial (NCT06700226) was to evaluate a novel ablation system that can optically predict lesion durability by detecting structural changes in the tissue during ablation.

Methods: Patients with paroxysmal atrial fibrillation underwent pulmonary vein isolation (PVI) using PFA (AblaView®, MedLumics). Using polarization sensitive optical coherence reflectometry (PS-OCR), reflective characteristics of myocardial tissue and visualization of real-time contrast between healthy tissue and ablated tissue using a drop in tissue birefringence (BiR) was assessed. Wide antral PVI was performed using single point irrigated PFA (unipolar, 1800V, 3 trains, 21sec). Remapping was performed at 3 months. Primary efficacy outcome was the ability of PS-OCR to predict lesion durability at 3-month remapping. Serious adverse events were recorded.

Results: Ten patients were included. In total, 38/40 PVs could be isolated with the system. The mean drop of BiR was 17.3±11.5%. Dragging across the ablation lines showed a persistent drop in BiR. During the remap procedures (9/10 patients), 15 PVs (41.7%) were found to be electrically reconnected. The mean loss of BiR during the index ablation for durable lesions was 20.9%, while only 10.1% BiR loss was observed during the index ablation for reconnected areas (p<0.001). None of the points with ≥17% loss of birefringence was found to be reconnected.

Conclusions: This first in human study supports the use of real-time drop in tissue BiR for lesion assessment during PFA delivery and its procedural safety.

Background and aims: Atrial fibrillation (AF) or atrial flutter (AFL) after cardiac surgery are common and associated with adverse outcomes. The increased risk related to AF or AFL may extend beyond discharge. This study aims to determine whether photoplethysmography (PPG)-based smartphone monitoring to detect AF or AFL after hospital discharge following cardiac surgery improves AF management.

Methods: The intervention group performed one-minute rhythm checks three times daily using a smartphone-based PPG application during six weeks after hospitalization for cardiac surgery. The primary outcome involved AF management interventions by independent physicians, including initiation of oral anticoagulation (OAC), direct cardioversion and up-titration or initiation of antiarrhythmic drugs.

Results: The study included 450 patients (mean [SD] age, 64.1 [9.2] years; 96 women [21.3%]; 130 patients with AF history [28.9%]; median [IQR] CHA2DS2-VASc score, 2 [1-3]), of whom 238 were randomized to PPG-based monitoring and 212 to usual care. AF/AFL was detected with PPG or electrocardiography in 44 patients (18.5%) in the monitoring group and 4 patients (1.9%) in the usual care group (OR 11.8; 95%CI, 4.2-33.3; P<.001), these were new detections in respectively 22 patients (9.2%) and 1 patient (0.5%) (OR 21.3; 95%CI, 2.9-166.7; P=.003). AF management interventions occurred in 24 patients (10.1%) in the monitoring group compared to 5 patients (2.4%) in the usual care group (odds ratio [OR]), 5.1; 95%CI, 1.8-14.4; P=.002).

Conclusions: In unselected patients discharged home following cardiac surgery, PPG-based smartphone monitoring revealed significantly more AF/AFL which led to significantly more optimization of AF management.

Background and aims: Studies have shown correlations between early recurrence (ER) and late recurrence (LR) of atrial arrhythmia after ablation with thermal technologies. This admIRE trial (NCT05293639) subanalysis aims to analyze ER versus LR in patients with paroxysmal atrial fibrillation (PAF) undergoing pulsed field ablation (PFA).

Methods: Patients with symptomatic paroxysmal atrial fibrillation and ≥1 transtelephonic monitoring transmission during the blanking period were included (n=169). ER was defined as documented recurrence in the blanking period (days 1-90), and LR as recurrence in the evaluation period (days 91-365). Freedom from 12-month recurrence was estimated using Kaplan-Meier method. A Cox proportional-hazards regression model, with ER as the primary factor, and adjusted for age, sex, and body mass index, was used to estimate hazard ratios (HRs) and 95% CI.

Results: ER was observed in 20.1% (31/169) of patients (66.1±7.1 years, 35.5% female, 46.6±48.4-month PAF history). Time to first documented ER was 49 (37-61) days. Occurrence of LR was 16.7% (23/138) in patients without ER, 71.0% (22/31) in those with ER, and 87.0% (20/23) in patients whose ER onset occurred within the first 2 months. Twelve-month freedom from documented recurrence was significantly lower in patients with ER at 29.0% (95% CI, 13.1%-45.0%), versus 82.5% (95% CI, 75.9-89.1%) in those without ER (adjusted HR, 7.9; 95% CI, 4.1-15.1; P<0.001).

Conclusion: This admIRE subanalysis demonstrated that PAF patients who experience ER after PFA are at a substantially higher risk for LR. The optimal duration of the blanking period post PFA need further assessments.