Publications by authors named "Jeff S Healey"

279 Publications

A clinical dilemma: the longer the higher the risk?-Authors' reply.

Europace 2022 May 16. Epub 2022 May 16.

Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada.

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http://dx.doi.org/10.1093/europace/euac065DOI Listing
May 2022

Association of Eligibility for a Sodium-Glucose Co-transporter 2 Inhibitor and Cardiovascular Events in Patients with Atrial Fibrillation.

Can J Cardiol 2022 May 10. Epub 2022 May 10.

Population Health Research Institute; Division of Cardiology, Department of Medicine, McMaster University. Electronic address:

Background: Sodium-glucose co-transporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i-eligibility and cardiovascular events in AF patients to evaluate the potential utility of SGLT2is for AF management.

Methods: We pooled data from two randomized controlled trials (RCT) of AF patients (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least one of the phase 3 SGLT2i RCTs were classified as "SGLT2i-eligible" and the remainder as "SGLT2i-ineligible". The primary outcome was the composite of HF hospitalization or cardiovascular death.

Results: A total of 21,484 AF patients (mean age: 71.2±8.8, 36.1% women, median CHADS-VASc Score=3) were included. The proportion of AF patients eligible for an SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death/hospitalization for HF (5.8 vs. 3.2/100 person-years, P<0.001), cardiovascular death (3.9 vs. 1.5/100 person-years, P<0.001), and hospitalization for HF (2.5 vs. 1.9/100 person-years, P<0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death/hospitalization for HF (HR 1.97, 95% CI 1.79-2.17; P<0.001), cardiovascular death (HR 2.75, 95% CI 2.41-3.13, P<0.001), and hospitalization for HF (HR 1.41, 95% CI 1.23-1.62, P<0.001) than ineligible patients.

Conclusions: Most patients with AF do not currently have an indication for SGLT2is, but still have a substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in AF patients.
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http://dx.doi.org/10.1016/j.cjca.2022.05.004DOI Listing
May 2022

Comparison of Anticoagulation with Left Atrial Appendage Closure after AF Ablation: Rationale and Design of the OPTION randomized trial.

Am Heart J 2022 May 5. Epub 2022 May 5.

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, NY.

Background: For patients with symptomatic atrial fibrillation (AF), physicians typically offer AF ablation for symptom relief; however, patients often anticipate/expect a life free from anticoagulation. This belief puts patients at increased risk of stroke due to the potential for asymptomatic AF post-ablation if anticoagulation is ceased contrary to clinical guidelines. Although the WATCHMAN device has been FDA-approved to decrease the risk of thromboembolism from the left atrial appendage (LAA) in patients with an appropriate rationale to avoid oral anticoagulation, it has not been well-studied following AF ablation. Additionally, there are limited data comparing the WATCHMAN device to direct oral anticoagulants. The OPTION study will investigate whether LAA closure with the WATCHMAN FLX device is a reasonable alternative to oral anticoagulation following percutaneous catheter ablation for nonvalvular AF.

Trial Design: OPTION is a multinational, multicenter, prospective randomized clinical trial. Patients with a CHADS-VASc of ≥2 in men or ≥3 in women and who underwent a AF catheter ablation procedure between 90 and 180 days prior to randomization (sequential) or are planning to have catheter ablation within 10 days of randomization (concomitant) will be randomized in a 1:1 allocation of WATCHMAN FLX versus control. Control patients will start or continue market-approved oral anticoagulation for the duration of the trial. A total of 1600 patients were randomized from 130 global investigational sites. Follow-up for both device and control patients will occur at 3, 12, 24, and 36 months. The primary effectiveness non-inferiority endpoint is stroke (ischemic or hemorrhagic), all-cause death, or systemic embolism at 36 months. The primary safety superiority endpoint is non-procedural bleeding through 36 months (International Society on Thrombosis and Haemostasis [ISTH] major bleeding or clinically relevant non-major bleeding). The secondary non-inferiority endpoint is ISTH major bleeding through 36 months (including procedural bleeding).

Conclusions: This trial will assess the safety and efficacy of WATCHMAN FLX in a post-ablation contemporary clinical AF patient population at risk of stroke.

Clinicaltrials: gov Identifier: NCT03795298.
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http://dx.doi.org/10.1016/j.ahj.2022.05.003DOI Listing
May 2022

Previous history of hyperthyroidism in emergency department patients with atrial fibrillation does not increase the risk of thromboembolism and death.

Ann Acad Med Singap 2022 04;51(4):250-252

Department of Emergency Medicine, Singapore General Hospital, Singapore.

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April 2022

New-Onset Atrial Fibrillation After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

JACC Cardiovasc Interv 2022 03;15(6):603-613

Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada. Electronic address:

Objectives: The authors aimed to identify risk factors and outcomes associated with new-onset atrial fibrillation (NOAF) after transcatheter aortic valve replacement (TAVR).

Background: NOAF is a common complication after TAVR, although estimates of the precise occurrence are variable. This study sought to quantify the occurrence of NOAF after TAVR and to explore the outcomes and predictors associated with this complication.

Methods: We searched Medline, EMBASE, and the Cochrane database from 2016 to 2020 for articles that reported NOAF after TAVR. We extracted data for studies published before 2016 from a previous systematic review. We pooled data using a random effects model.

Results: We identified 179 studies with 241,712 total participants (55,271 participants with pre-existing atrial fibrillation (AF) were excluded) that reported NOAF from 2008 to 2020. The pooled occurrence of NOAF after TAVR was 9.9% (95% CI: 8.1%-12%). NOAF after TAVR was associated with a longer index hospitalization (mean difference = 2.66 days; 95% CI: 1.05-4.27), a higher risk of stroke in the first 30 days (risk ratio [RR]: 2.35; 95% CI: 2.12-2.61), 30-day mortality (RR: 1.76; 95% CI: 1.12-2.76), major or life-threatening bleeding (RR: 1.60; 95% CI: 1.39-1.84), and permanent pacemaker implantation (RR: 1.12; 95% CI: 1.05-1.18). Risk factors for the development of NOAF after TAVR included higher Society of Thoracic Surgeons score, transapical access, pulmonary hypertension, chronic kidney disease, peripheral vascular disease, and severe mitral regurgitation, suggesting that the risk for NOAF is highest in more comorbid TAVR patients.

Conclusions: NOAF is common after TAVR. Whether AF after TAVR is a causal factor or a marker of sicker patients remains unclear.
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http://dx.doi.org/10.1016/j.jcin.2022.01.018DOI Listing
March 2022

In Memoriam: George Wyse (1941-2022).

Can J Cardiol 2022 Apr 8;38(4):412-413. Epub 2022 Mar 8.

Population Health Research Institute, Hamilton, Ontario, Canada.

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http://dx.doi.org/10.1016/j.cjca.2022.02.016DOI Listing
April 2022

Prospective long-term follow-up of silicone-polyurethane-insulated implantable cardioverter-defibrillator leads.

Heart Rhythm O2 2022 Feb 1;3(1):57-64. Epub 2021 Dec 1.

Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada.

Background: St Jude Medical (now Abbott) Optim-insulated implantable cardioverter-defibrillator (ICD) leads were expected to overcome problems with insulation abrasion and externalized conductors in earlier models. Long-term follow-up is essential to the evaluation of lead performance.

Objective: To determine, in a prospective cohort of Optim-insulated ICD leads, the rates of all-cause mechanical failure and its subtypes (conductor fracture, insulation abrasion, externalized conductors, and other mechanical failures) and electrical dysfunction adjudicated as nonmechanical failure.

Methods: Abbott established 3 prospective registries, enrolling 11,155 leads among 10,872 patients beginning in 2006. There was standardized baseline documentation, 6-monthly follow-up, adverse events reporting, and documentation of lead revision or inactivation, study withdrawal, and death or transplant. The Population Health Institute (McMaster University) reviewed database functions, adjudicated all potential mechanical lead failures, and conducted independent data analyses.

Results: During a median follow-up of 4.6 years, there were 171 mechanical failures (1.53%, 95.4% freedom from failure by 12 years). There were no significant differences in survival among Durata DF4 and DF1 and Riata ST Optim leads. The year-to-year rate of failure of leads increased over time. There were 69 electrical dysfunctions (0.62%, 98.8% freedom from failure by 12 years) adjudicated as nonmechanical failure.

Conclusion: During follow-up as long as 12 years (median 4.6 years), Optim-insulated leads had low rates of mechanical failure and electrical dysfunction. Independent analyses provide reliable data on the long-term outcomes essential to analyzing ICD lead performance.
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http://dx.doi.org/10.1016/j.hroo.2021.11.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8859782PMC
February 2022

Short-term and Long-term Risk of Stroke in Patients With Perioperative Atrial Fibrillation After Cardiac Surgery: Systematic Review and Meta-analysis.

CJC Open 2022 Jan 16;4(1):85-96. Epub 2021 Sep 16.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

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; I = 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; I = 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.
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http://dx.doi.org/10.1016/j.cjco.2021.09.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8767142PMC
January 2022

Estimated incidence of previously undetected atrial fibrillation on a 14-day continuous electrocardiographic monitor and associated risk of stroke.

Europace 2022 Jan 21. Epub 2022 Jan 21.

Population Health Research Institute, 237 Barton St E C3-109, Hamilton, ON L8L 2X2, Canada.

Aims: There is uncertainty about whether and how to perform screening for atrial fibrillation (AF). To estimate the incidence of previously undetected AF that would be captured using a continuous 14-day ECG monitor and the associated risk of stroke.

Methods And Results: We analysed data from a cohort of patients >65 years old with hypertension and a pacemaker, but without known AF. For each participant, we simulated 1000 ECG monitors by randomly selecting 14-day windows in the 6 months following enrolment and calculated the average AF burden (total time in AF). We used Cox proportional hazards models adjusted for CHA2DS2-VASc score to estimate the risk of subsequent ischaemic stroke or systemic embolism (SSE) associated with burdens of AF > and <6 min. Among 2470 participants, the median CHA2DS2-VASc score was 4.0, and 44 patients experienced SSE after 6 months following enrolment. The proportion of participants with an AF burden >6 min was 3.10% (95% CI 2.53-3.72). This was consistent across strata of age and CHA2DS2-VASc scores. Over a mean follow-up of 2.4 years, the rate of SSE among patients with <6 min of AF was 0.70%/year, compared to 2.18%/year (adjusted HR 3.02; 95% CI 1.39-6.56) in those with >6 min of AF.

Conclusions: Approximately 3% of individuals aged >65 years with hypertension may have more than 6 min of AF detected by a 14-day ECG monitor. This is associated with a stroke risk of over 2% per year. Whether oral anticoagulation will reduce stroke in these patients is unknown.
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http://dx.doi.org/10.1093/europace/euab324DOI Listing
January 2022

Ventricular tachycardia characteristics and outcomes with catheter ablation vs. antiarrhythmic therapy: insights from the VANISH trial.

Europace 2022 Jan 14. Epub 2022 Jan 14.

Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.

Aims: Catheter ablation is superior to escalated antiarrhythmic drugs among patients with ventricular tachycardia (VT) and prior myocardial infarction (MI). However, it is uncertain whether clinical VT characteristics, should influence choice of therapy. The purpose of this study was to evaluate whether presentation with electrical storm and the clinical VT cycle length predicted response to ablation vs. escalated antiarrhythmic therapy.

Methods And Results: All patients enrolled in the Ventricular Tachycardia Ablation vs. Escalated Antiarrhythmic Drug Therapy in Ischaemic Heart Disease (VANISH) trial were included. The association between VT cycle length and presentation with electrical storm and the primary outcome of death, subsequent VT storm or appropriate ICD shock was evaluated. Among the study population of 259 patients, escalated antiarrhythmic drug therapy had worse outcomes for those presenting with a VT cycle length >400 ms [<150 b.p.m., 89/259, hazard ratio (HR) 1.7 (1.02-3.13)]. This effect was more pronounced among those taking amiodarone at baseline [HR of 2.22 (1.19-4.16)]. Presentation with VT storm (32/259) did not affect the primary outcome between groups. However, those presenting with VT storm on amiodarone had a trend towards worse outcomes with escalated antiarrhythmic therapy [HR 4.31 (0.55-33.93)].

Conclusion: The VT cycle length can influence response to either ablation or escalated drug therapy in patients with VT and prior MI. Those with slow VT had improved outcomes with ablation. Patients presenting with electrical storm demonstrated similar outcomes to the overall trial population, with a trend to benefit of catheter ablation, particularly in those on amiodarone.
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http://dx.doi.org/10.1093/europace/euab328DOI Listing
January 2022

Incidence and Predictors of Heart Failure in Patients With Atrial Fibrillation.

CJC Open 2021 Dec 8;3(12):1482-1489. Epub 2021 Aug 8.

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.

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.
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http://dx.doi.org/10.1016/j.cjco.2021.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8712577PMC
December 2021

Sex-Specific Clinical Outcomes of the PACT-HF Randomized Trial.

Circ Heart Fail 2021 11 29;14(11):e008548. Epub 2021 Oct 29.

Department of Health Research Methods, Evidence, and Impact (H.G.C.V., S.F.L., J.S.H., L.T., S.J.C.), McMasterUniversity, Hamilton, Ontario, Canada.

Background: Transitional care may have different effects in males and females hospitalized for heart failure. We assessed the sex-specific effects of a transitional care model on clinical outcomes following hospitalization for heart failure.

Methods: In this stepped-wedge cluster randomized trial of adults hospitalized for heart failure in Ontario, Canada, 10 hospitals were randomized to a group of transitional care services or usual care. Outcomes in this exploratory analysis were composite all-cause readmission, emergency department visit, or death at 6 months; and composite all-cause readmission or emergency department visit at 6 months. Models were adjusted for stepped-wedge design and patient age.

Results: Among 2494 adults, mean (SD) age was 77.7 (12.1) years, and 1258 (50.4%) were female. The first composite outcome occurred in 371 (66.3%) versus 433 (64.1%) males (hazard ratio [HR], 1.04 [95% CI, 0.86-1.26]; =0.67) and in 326 (59.9%) versus 463 (64.8%) females (HR, 0.83 [95% CI, 0.69-1.01]; =0.06) in the intervention and usual care groups, respectively (=0.012 for sex interaction). The second composite outcome occurred in 357 (63.8%) versus 417 (61.7%) males (HR, 1.03 [95% CI, 0.85-1.24]; =0.76) and 314 (57.7%) versus 450 (63.0%) females (HR, 0.81 [95% CI, 0.67-0.99]; =0.037) in the intervention and usual care groups, respectively (=0.024 for sex interaction). The sex differences were driven by a reduction in all-cause emergency department visits among females (HR, 0.66 [95% CI, 0.51-0.87]; =0.003), but not males (HR, 1.10 [95% CI, 0.85-1.43]; =0.46), receiving the intervention (<0.001 for sex interaction).

Conclusions: A transitional care model offered a reduction in all-cause emergency department visits among females but not males following hospitalization for heart failure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02112227.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.121.008548DOI Listing
November 2021

Canadian Heart Rhythm Society Task Force Report on Physician Training and Maintenance of Competency for Cardiovascular Implantable Electronic Device Therapies: Executive Summary.

Can J Cardiol 2021 11 25;37(11):1857-1860. Epub 2021 Sep 25.

St. Mary's Regional Cardiac Care Centre, Kitchener, Ontario, Canada.

Physicians engaged in cardiovascular implantable electronic device (CIED)-related practice come from diverse training backgrounds with variable degrees of CIED implant training. The objective of the Canadian Heart Rhythm Society Task Force on CIED Implant Training was to establish a common structure and content for training programs in CIED implantation, related activities and maintenance of competency. This executive summary presents the essence of the report with key recommendations included, with the complete version made available in a linked supplement. The goals are to ensure that future generations of CIED implanters are better prepared for continuously evolving CIED practice and quality care for all Canadians.
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http://dx.doi.org/10.1016/j.cjca.2021.09.017DOI Listing
November 2021

The role of brain natriuretic peptide in atrial fibrillation: a substudy of the Substrate Modification with Aggressive Blood Pressure Control for Atrial Fibrillation (SMAC-AF) trial.

BMC Cardiovasc Disord 2021 09 16;21(1):445. Epub 2021 Sep 16.

Dalhousie University, 1796 Summer Street, Rm 2501-D, Halifax Infirmary, Halifax, NS, B3H 3A7, Canada.

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 (< 120/80 mmHg) or standard blood pressure management (< 140/90 mmHg) in the Substrate Modification with Aggressive Blood Pressure Control trial (SMAC-AF).

Methods: The SMAC-AF study included 173 patients resistant or intolerant to at least one class I or III antiarrhythmic drug. We studied the effect of baseline NT-proBNP on the primary outcome of AF recurrence > 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.
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http://dx.doi.org/10.1186/s12872-021-02254-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8447763PMC
September 2021

LVS-HARMED Risk Score for Incident Heart Failure in Patients With Atrial Fibrillation Who Present to the Emergency Department: Data from a World-Wide Registry.

J Am Heart Assoc 2021 09 13;10(18):e017735. Epub 2021 Sep 13.

Population Health Research Institute McMaster University Hamilton Onatrio Canada.

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.
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http://dx.doi.org/10.1161/JAHA.120.017735DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649506PMC
September 2021

Sodium-Glucose Co-Transporter Inhibitors and Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

J Am Heart Assoc 2021 09 28;10(17):e022222. Epub 2021 Aug 28.

Department of Health Research Methods, Evidence and Impact McMaster University Hamilton Ontario Canada.

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]; I=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]; I=0%)-similar to the effect estimate for patients without AF, 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.
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http://dx.doi.org/10.1161/JAHA.121.022222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649253PMC
September 2021

OCEAN trial update.

Am Heart J 2022 Jun 19;248:169. Epub 2021 Aug 19.

University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

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http://dx.doi.org/10.1016/j.ahj.2021.08.005DOI Listing
June 2022

Oral anticoagulation for patients with atrial fibrillation in the ED: RE-LY AF registry analysis.

J Thromb Thrombolysis 2022 Jan 2;53(1):74-82. Epub 2021 Aug 2.

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.

Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF). We sought to determine predictors of OAC initiation in AF patients presenting to the emergency department (ED). Secondary analysis of the RE-LY AF registry which enrolled individuals from 47 countries between 2007 and 2011 who presented to an ED with AF and followed them for 1 year. A total of 4149 patients with AF as their primary diagnosis who were not already taking OAC and had a CHADS-VASc ≥ 1 for men or ≥ 2 for women were included in this analysis. Of these individuals, 26.8% were started on OAC (99.2% vitamin K antagonists) in the ED and 29.8% were using OAC one year later. Factors associated with initiating OAC in the ED included: specialist consultation (relative risk [RR] 1.84, 95%CI 1.44-2.36), rheumatic heart disease (RR 1.60, 95%CI 1.29-1.99), persistence of AF at ED discharge (RR 1.33, 95%CI 1.18-1.50), diabetes mellitus (RR 1.32, 95%CI 1.19-1.47), and hospital admission (RR 1.30, 95%CI 1.14-1.47). Heart failure (RR 0.83, 95%CI 0.74-0.94), antiplatelet agents (RR 0.77, 95%CI 0.69-0.84), and dementia (RR 0.61, 95%CI 0.40-0.94) were inversely associated with OAC initiation. Patients taking OAC when they left the ED were more likely using OAC at 1-year (RR 2.81, 95%CI 2.55-3.09) and had lower rates of death (RR 0.55, 95%CI 0.38-0.79) and stroke (RR 0.59, 95%CI 0.37-0.96). In patients with AF presenting to the ED, prompt initiation of OAC and specialist involvement are associated with a greater use of OAC 1 year later and may result in improved clinical outcomes.
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http://dx.doi.org/10.1007/s11239-021-02530-3DOI Listing
January 2022

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update.

Glob Heart 2021 05 27;16(1):41. Epub 2021 May 27.

Universidad de Buenos Aires, AR.

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.
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http://dx.doi.org/10.5334/gh.1023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162289PMC
May 2021

Device-detected atrial high rate episodes and the risk of stroke/thrombo-embolism and atrial fibrillation incidence: a systematic review and meta-analysis.

Eur J Intern Med 2021 10 19;92:100-106. Epub 2021 Jun 19.

Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.. Electronic address:

Background: Atrial High Rate Episodes (AHRE) are asymptomatic atrial tachy-arrhythmias detected through continuous monitoring with a cardiac implantable electronic device. The risks of stroke/Thromboembolic (TE) events and incident clinical Atrial Fibrillation (AF) associated with AHRE varies markedly.

Objectives: To assess the relationship between AHRE and TE events, and between AHRE and incident clinical AF.

Methods: This systematic review and meta-analysis was conducted following the PRISMA recommendations. PubMed, Scopus, and Google Scholar were searched from inception to 18/02/2021 for studies reporting TE events and incident clinical AF in patients with AHRE, as compared with patients without.

Results: Ten out of 8081 records fulfilled the inclusion criteria, for a total of 37 266 patients. Seven out of ten studies excluded patients with prior history of clinical AF (4961 patients), embracing the most recent definition of AHRE. The risk ratio (RR) for TE events in AHRE patients was 2.13 (95% CI: 1.53-2.95, I: 0%). The incidence of clinical AF was reported in four studies excluding patients with a history of clinical AF (3574 patients). The RR for incident clinical AF was 3.34 (95%CI: 1.89-5.90, I: 73%).

Conclusions: AHRE are significantly associated with systemic thromboembolism and incident clinical AF. Further studies are needed to improve patients' risk stratification and management.
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http://dx.doi.org/10.1016/j.ejim.2021.05.038DOI Listing
October 2021

Antiplatelet Therapy in Patients with Atrial Fibrillation: A Systematic Review and Metaanalysis of Randomized Trials.

Eur Heart J Cardiovasc Pharmacother 2021 Jun 17. Epub 2021 Jun 17.

Population Health Research Institute, McMaster University, Hamilton, Canada.

Aims: To systematically assess the effects of antiplatelets on clinical outcomes in patients with atrial fibrillation (AF), treated and not treated with oral anticoagulation.

Methods And Results: We searched MEDLINE, Embase and CENTRAL from inception until September 2020. From 5,446 citations, we selected randomized trials allocating patients with AF to antiplatelet therapy vs. control. We applied random-effects models for meta-analysis and assessed potential effect modification with background anticoagulation use. Eighteen trials including 21,518 participants met our prespecified eligibility criteria. In 10 studies without background anticoagulation, antiplatelets reduced all-cause stroke (486/6,165 [events/patients] vs. 621/6,061; risk ratio [RR] 0.77, 95% confidence interval [CI] 0.69-0.86, I2=0%). In 8 studies with background anticoagulation, there was a signal for an increase in all-cause stroke with antiplatelets (97/4,608 vs. 72/4,684; RR 1.33, 95% CI 0.98-1.79, I2=0%), p-value for interaction < 0.001. A similar pattern emerged for ischaemic stroke. Irrespective of background anticoagulation use, antiplatelets increased major bleeding (509/10,402 vs. 328/10,496; RR 1.54, 95% CI 1.35-1.77, I2=0%) and intracranial Haemorrhage (107/10,221 vs. 65/10,232; RR 1.64, 95% CI 1.20-2.24, I2=0%), and reduced myocardial infarction (201/9,679 vs. 260/9,751; RR 0.79, 95% CI 0.65-0.94, I2=0%), all p-values for interaction ≥ 0.36. Antiplatelets did not affect mortality (1,221/10,299 vs. 1,211/10,287; RR 1.02, 95% CI 0.89-1.17, I2=29%), p-value for interaction = 0.23.

Conclusions: In patients with AF not receiving oral anticoagulation, antiplatelet therapy modestly reduced stroke. There was a corresponding signal for harm when used on top of anticoagulation. Irrespective of background anticoagulation use, antiplatelet therapy significantly increased bleeding, moderately reduced myocardial infarction and did not affect mortality.
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http://dx.doi.org/10.1093/ehjcvp/pvab044DOI Listing
June 2021

Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation.

J Am Coll Cardiol 2021 06;77(23):2875-2886

Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada. Electronic address:

Background: The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation.

Objectives: The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups.

Methods: EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models.

Results: Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHADS-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001).

Conclusions: LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.
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http://dx.doi.org/10.1016/j.jacc.2021.04.036DOI Listing
June 2021

New-Onset Perioperative Atrial Fibrillation After Coronary Artery Bypass Grafting and Long-Term Risk of Adverse Events: An Analysis From the CORONARY Trial.

J Am Heart Assoc 2021 06 29;10(12):e020426. Epub 2021 May 29.

Population Health Research Institute McMaster University Hamilton Canada.

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.
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http://dx.doi.org/10.1161/JAHA.120.020426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8477852PMC
June 2021

Association Between Perioperative Atrial Fibrillation and Long-term Risks of Stroke and Death in Noncardiac Surgery: Systematic Review and Meta-analysis.

CJC Open 2021 May 12;3(5):666-674. Epub 2021 Jan 12.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

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, I = 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, I = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I = 31%) and 1.5 (95% CI: 1.3-1.7, I = 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.
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http://dx.doi.org/10.1016/j.cjco.2020.12.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134907PMC
May 2021

Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke.

N Engl J Med 2021 06 15;384(22):2081-2091. Epub 2021 May 15.

From McMaster University (R.P.W., E.P.B.-C., J.S.H., M.S., P.J.D., J.N., K. Balasubramanian, A.L., S.Y., S.J.C.), Hamilton Health Sciences (R.P.W., E.P.B.-C., J.S.H., K. Brady, M.S., P.J.D., J.V., A.L., S.Y., S.J.C.), and the Population Health Research Institute (R.P.W., E.P.B.-C., J.S.H., K. Brady, M.S., P.J.D., J.N., K. Balasubramanian, J.V., A.L., S.Y., S.J.C.), Hamilton, ON, Southlake Regional Health Centre, Newmarket, ON (K.H.T.T.), the University of Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto (C.D.M.), and Quebec Heart and Lung Institute, Quebec, QC (P.V.) - all in Canada; University of Foggia, Foggia (D.P.), Santa Maria Hospital, Gruppo Villa Maria Care and Research, Bari (D.P.), and the University of Pisa, Pisa (A.C.) - all in Italy; Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt (W.R.), and University Hospital Giessen, Giessen (A.B.) - both in Germany; the Institute for Clinical and Experimental Medicine, Prague (P.B.), and the Center of Cardiovascular Surgery and Transplantation, Brno (P.F.) - both in the Czech Republic; "G. Papanikolaou" Hospital (A.J.B.) and Aristotle University of Thessaloniki (G.I.T.) - both in Thessaloniki, Greece; E. Meshalkin National Medical Research Center, Novosibirsk, Russia (A.B.-P.); the University of Louisville, Louisville, KY (M.S.S.); the University of Melbourne and Royal Melbourne Hospital, Melbourne, VIC, Australia (A.G.R.); Auckland City Hospital, Auckland, New Zealand (S.M.); Amphia Ziekenhuis, Breda (M.A.), and Medical Center Leeuwarden, Leeuwarden (R.J.F.) - both in the Netherlands; the National Heart and Lung Institute, Imperial College London, London (P.P.P.); and the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (Á.A.).

Background: Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons.

Methods: We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHADS-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments.

Results: The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHADS-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P = 0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups.

Conclusions: Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it. (Funded by the Canadian Institutes of Health Research and others; LAAOS III ClinicalTrials.gov number, NCT01561651.).
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http://dx.doi.org/10.1056/NEJMoa2101897DOI Listing
June 2021

Detection of atrial fibrillation in asymptomatic at-risk individuals.

Int J Cardiol 2021 Jul 28;334:55-57. Epub 2021 Apr 28.

Bristol Myers Squibb, Montréal, Canada. Electronic address:

Background: Undiagnosed atrial fibrillation (AF) exposes unsuspecting patients to elevated stroke risks. The optimal algorithm for identifying patients who should be screened for AF remains undetermined. The objective of this study is to determine the AF burden in an asymptomatic, at-risk population. We also sought to investigate potential predictors of undiagnosed AF.

Methods: This registry is a prospective observational study assessing continuous ECG monitoring in screening for AF using a wearable single lead 7-day continuous monitoring device. Patients included were asymptomatic individuals, at risk for AF as determined by either 1) ≥65 years of age with ≥1 high risk factor or; 2) ≥75 years of age and ≥2 moderate risk factors. A multivariable logistic regression was used to explore the predictive value of certain patient characteristics in identifying patients susceptible to have undiagnosed AF.

Results: Among the 942 patients included, 25 patients (2.7%) had evidence of AF detected. Only 8 patients had AF duration ≥24 h. History of perioperative AF (OR: 3.25, 95%CI: 1.08-9.79, p = 0.036), age over 85 (OR: 4.71, 95%CI: 1.31-16.92, p = 0.017) and absence of cardiovascular disease (CVD) (OR: 0.27, 95%CI: 0.10-0.76, p = 0.013) were found to be predictive of undiagnosed AF.

Conclusion: This study demonstrates the feasibility of office-based AF screening in at-risk population. The low rate of AF detection suggests that the optimal algorithm for identifying asymptomatic patients who would benefit from continuous screening remains unclear. Advanced age, history of perioperative AF and absence of CVD are variables that could be explored further.
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http://dx.doi.org/10.1016/j.ijcard.2021.04.048DOI Listing
July 2021

Antidiabetic drugs for preventing atrial fibrillation: A new revolution?

Heart Rhythm 2021 07 8;18(7):1097. Epub 2021 Apr 8.

McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.hrthm.2021.03.046DOI Listing
July 2021

Outcomes and Safety of Fluoroless Catheter Ablation for Atrial Fibrillation.

CJC Open 2021 Mar 13;3(3):303-310. Epub 2020 Nov 13.

Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.

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 CHADS-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,  = 0.0021; 10.7 ± 6.6 vs 0.008 ± 0.03 minutes, < 0.0001; 2759.2 ± 1911 vs 5.4 ± 24 μGy m, < 0.0001). In multivariable linear regression models, fluoroless AF ablation was independently associated with reduced procedure times (ß = -16.5 minutes,  = 0.01). Acute procedural success (95.5% vs 98.6%,  = 0.1), complication rates (4.5% vs 2.0%,  = 0.24), and 1-year AF recurrence rates (28.7% vs 27.1%, log-rank  = 0.69) were similar between fluoroscopy and fluoroless groups. Excluding the 17 patients receiving fluoroscopy in the fluoroless group did not impact our results ( = 0.013). After exclusion of redo cases, fluoroless AF ablation was no longer associated with reduced procedure times (ß = -11.4 minutes,  = 0.106).

Conclusions: Fluoroless radiofrequency AF ablation had similar effectiveness and safety compared with conventional fluoroscopy-guided AF ablation.
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http://dx.doi.org/10.1016/j.cjco.2020.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984996PMC
March 2021
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