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MedRxiv : the Preprint Server For... Jun 2024Atrial fibrillation (AF) is often asymptomatic and thus under-observed. Given the high risks of stroke and heart failure among patients with AF, early prediction and...
BACKGROUND
Atrial fibrillation (AF) is often asymptomatic and thus under-observed. Given the high risks of stroke and heart failure among patients with AF, early prediction and effective management are crucial. Importantly, obstructive sleep apnea is highly prevalent among AF patients (60-90%); therefore, electrocardiogram (ECG) analysis from polysomnography (PSG), a standard diagnostic tool for subjects with suspected sleep apnea, presents a unique opportunity for the early prediction of AF. Our goal is to identify individuals at a high risk of developing AF in the future from a single-lead ECG recorded during standard PSGs.
METHODS
We analyzed 18,782 single-lead ECG recordings from 13,609 subjects at Massachusetts General Hospital, identifying AF presence using ICD-9/10 codes in medical records. Our dataset comprises 15,913 recordings without a medical record for AF and 2,056 recordings from patients who were first diagnosed with AF between 1 day to 15 years after the PSG recording. The PSG data were partitioned into training, validation, and test cohorts. In the first phase, a signal quality index (SQI) was calculated in 30-second windows and those with SQI 0.95 were removed. From each remaining window, 150 hand-crafted features were extracted from time, frequency, time-frequency domains, and phase-space reconstructions of the ECG. A compilation of 12 statistical features summarized these window-specific features per recording, resulting in 1,800 features. We then updated a pre-trained deep neural network and data from the PhysioNet Challenge 2021 using transfer-learning to discriminate between recordings with and without AF using the same Challenge data. The model was applied to the PSG ECGs in 16-second windows to generate the probability of AF for each window. From the resultant probability sequence, 13 statistical features were extracted. Subsequently, we trained a shallow neural network to predict future AF using the extracted ECG and probability features.
RESULTS
On the test set, our model demonstrated a sensitivity of 0.67, specificity of 0.81, and precision of 0.3 for predicting AF. Further, survival analysis for AF outcomes, using the log-rank test, revealed a hazard ratio of 8.36 (p-value of 1.93 × 10 ).
CONCLUSIONS
Our proposed ECG analysis method, utilizing overnight PSG data, shows promise in AF prediction despite a modest precision indicating the presence of false positive cases. This approach could potentially enable low-cost screening and proactive treatment for high-risk patients. Ongoing refinement, such as integrating additional physiological parameters could significantly reduce false positives, enhancing its clinical utility and accuracy.
PubMed: 38883765
DOI: 10.1101/2024.06.04.24308444 -
MedRxiv : the Preprint Server For... May 2024One-time screening trials for atrial fibrillation (AF) have produced mixed results; however, it is unclear if there is a subset of individuals for whom screening would...
BACKGROUND
One-time screening trials for atrial fibrillation (AF) have produced mixed results; however, it is unclear if there is a subset of individuals for whom screening would be effective. Identifying such a subgroup would support targeted screening.
METHODS
We conducted a secondary analysis of VITAL-AF, a randomized trial of one-time, single-lead ECG screening during primary care visits. We tested two approaches to identify heterogeneous screening effects. First, we developed an effect-based model for heterogeneous screening effects using a potential outcomes framework. Specifically, we predicted the likelihood of AF diagnosis under both screening and usual care conditions using LASSO, a penalized regression method. The difference between these probabilities was the predicted screening effect. Second, we used the CHARGE-AF score, a validated AF risk model, to test for a heterogeneous screening effect. We used interaction testing to determine if observed AF diagnosis rates in the screening and control groups differed when stratified by decile of the predicted screening effect and predicted AF risk.
RESULTS
Baseline characteristics were similar between the screening (n=15187) and usual care (n=15078) groups (mean age 74 years, 59% female). On average, screening did not significantly increase the AF diagnosis rate (2.55 vs. 2.30 per 100 person-years, rate difference 0.24, 95%CI -0.18 to 0.67). In the effect-based analysis, in the highest decile of predicted screening efficacy (n=3026), AF diagnosis rates were higher in the screening group (6.5 vs. 3.06 per 100 person-years, rate difference 3.45, 95%CI 1.62 to 5.28, interaction p-value 0.003). In this group, the mean age was 84 years, 68% were female, and 55% had vascular disease. The risk-based analysis did not identify a subgroup where screening was more effective. Predicted screening effectiveness and predicted baseline AF risk were poorly correlated and demonstrated a U-shaped relationship (Spearman coefficient 0.13).
CONCLUSIONS
In a secondary analysis of the VITAL-AF trial, we identified a small subgroup where one-time screening was associated with increased AF diagnoses using an effect-based approach. In this study, predicted AF risk was a poor proxy for predicted screening efficacy. These data caution against the assumption that high AF risk is necessarily correlated with high screening efficacy.
PubMed: 38883753
DOI: 10.1101/2024.05.17.24307559 -
Journal of Thoracic Disease May 2024Atrial fibrillation (AF) is a prevalent clinical arrhythmia with a high incidence of disability and mortality. Autonomic nervous system (ANS) plays a crucial role in the... (Review)
Review
BACKGROUND AND OBJECTIVE
Atrial fibrillation (AF) is a prevalent clinical arrhythmia with a high incidence of disability and mortality. Autonomic nervous system (ANS) plays a crucial role in the onset and persistence of AF, and can lead to electrophysiological changes and alterations in atrial structure. Both animal models and clinical findings suggest that parasympathetic and sympathetic activity within the cardiac ANS could induce atrial remodeling and AF. Remodeling of the cardiac autonomic nerves is a significant structural basis for promoting AF. Given the challenges faced by conventional pharmacological and atrial ablation techniques in the treatment of AF, increasing attention has been paid to autonomic intervention strategies for AF. Current research has demonstrated that the frequency and severity of AF episodes can be significantly reduced by modulating the activity of ANS. ANS neuromodulation is expected to lead more effective and personalized treatment options for patients with AF. The objective of this review is to provide a broader perspective for future related studies by reviewing preclinical and clinical studies of neuromodulation methods for the treatment of AF, searching for relevant approaches to treat AF, as well as identifying the strengths and weaknesses demonstrated by current relevant studies, and providing researchers with a broader overview of the latest neurological treatments for AF.
METHODS
A narrative review was conducted on the literature on PubMed, WanFang data, and Google Scholar, including all relevant studies published until November 2023.
KEY CONTENT AND FINDINGS
In this review, we delve into the innervation of cardiac autonomic nerves, the role of the ANS in the development and maintenance of AF, and the current neuromodulation methods for AF treatment. These methods include stellate ganglion (SG) resection or ablation, vagus nerve stimulation (VNS), thoracic subcutaneous nerve stimulation (ScNS), renal denervation (RDN) therapy, ganglionated plexus (GP) ablation, and epicardial botulinum toxin or CaCl injection. More and more research suggests that neuromodulation methods for the treatment of AF have broad prospects.
CONCLUSIONS
ANS plays a crucial role in AF development and maintenance through cardiac autonomic nerve remodeling. Modulating ANS activity can significantly reduce AF frequency and severity, offering more personalized treatment options. Current research on autonomic interventions for AF shows promise for more effective and personalized treatments.
PubMed: 38883655
DOI: 10.21037/jtd-23-1981 -
Journal of Thoracic Disease May 2024Atrial fibrillation (AF) is one of the most common arrhythmias in clinical practice, which leads to cardiac decompensation, cardiovascular and cerebrovascular... (Review)
Review
BACKGROUND AND OBJECTIVE
Atrial fibrillation (AF) is one of the most common arrhythmias in clinical practice, which leads to cardiac decompensation, cardiovascular and cerebrovascular infarction, and other thromboembolic diseases. AF is one of the most common comorbidities of valvular heart disease, especially in mitral valve disease. At the time of their mitral valve surgery, 20-42% of patients have AF. It is beneficial to maintain postoperative sinus rhythm and minimize complications when AF surgery is performed concurrently with mitral valve surgery. This review describes the surgical management of AF in mitral valve surgery, including AF surgical route, surgical ablation technology and surgical approaches. The aim of this review is to enable more patients with AF to receive more appropriate and individualised treatment.
METHODS
A narrative review was conducted on the literature on PubMed, Embase including all relevant studies published until November 2023.
KEY CONTENT AND FINDINGS
This review focuses on the surgical management of AF during mitral valve surgery, including AF surgical route, surgical ablation technology and surgical approaches.
CONCLUSIONS
Mitral valve surgery combined with AF surgery facilitates the maintenance of postoperative sinus rhythm in patients, reduces the risk of postoperative stroke, and improves survival. Advances in ablation technology have reduced the difficulty of the procedure, making it possible for more patients to undergo surgical ablation. In the future, it will be possible to tailor specific lesion sets and ablation modalities for individual patients. This would make surgical treatment of AF more effective and applicable to a larger population of patients with AF and mitral valve disease.
PubMed: 38883625
DOI: 10.21037/jtd-23-1984 -
Clinical and Applied... 2024NCT02950168, NCT02951039. (Clinical Trial)
Clinical Trial
NCT02950168, NCT02951039.
Topics: Humans; Pyridines; Thiazoles; Female; Male; Aged; Venous Thromboembolism; Treatment Outcome; Atrial Fibrillation; Factor Xa Inhibitors; Aged, 80 and over; Cardiac Catheterization
PubMed: 38881370
DOI: 10.1177/10760296241260728 -
Journal of the American Heart... Jun 2024A lower serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio (EPA/AA) level correlates with cardiovascular events. Nevertheless, elevated serum EPA levels...
BACKGROUND
A lower serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio (EPA/AA) level correlates with cardiovascular events. Nevertheless, elevated serum EPA levels increase the risk of new-onset atrial fibrillation (AF) in older patients. The relationship between the EPA/AA and outcomes post-AF ablation remains unclear. This study investigated the impact of the EPA/AA on AF recurrence and cardiovascular events after AF ablation in older patients.
METHODS AND RESULTS
This retrospective cohort study examined consecutive patients with AF aged ≥65 years who underwent a first-time AF ablation. We compared the 3-year AF recurrence and 5-year major adverse cardiovascular event (MACE) rates between patients divided into high and low EPA/AA levels defined as above and below the median EPA/AA value before ablation. MACE was defined as heart failure hospitalizations, strokes, coronary artery disease, major bleeding, and cardiovascular death. Among the 673 included patients, the median EPA/AA value was 0.35. Compared with the low EPA/AA group, the high EPA/AA group had a significantly higher cumulative incidence of AF recurrence (39.3% versus 27.6%; log-rank =0.004) and lower cumulative incidence of MACE (13.8% versus 25.5%, log-rank =0.021). A high EPA/AA level was determined as an independent predictor of AF recurrence (hazard ratio [HR], 1.75 95% CI, 1.24-2.49; =0.002) and MACE (HR, 0.60 [95% CI, 0.36-0.99]; =0.046).
CONCLUSIONS
The EPA/AA was associated with AF recurrence and MACE after ablation in patients with AF aged ≥65 years.
PubMed: 38879457
DOI: 10.1161/JAHA.123.033969 -
Clinica Chimica Acta; International... Jun 2024Postoperative atrial fibrillation (POAF) represents the most common complication following cardiac surgery. Approximately one-third of patients experiencing POAF...
BACKGROUND
Postoperative atrial fibrillation (POAF) represents the most common complication following cardiac surgery. Approximately one-third of patients experiencing POAF transition to atrial fibrillation within a year, challenging the notion of POAF as merely a transient event. Soluble ST2 (sST2) is an established biomarker regarding fibrosis and myocardial stretch, however, its role in predicting the onset of POAF remains unclear.
METHODS
Preoperative sST2 levels have been assessed in 496 individuals with no prior history of AF who underwent elective cardiac surgery, including valve, coronary artery bypass graft surgery, or a combined procedure.
RESULTS
The average age was 70 years, and 29.4 % were female. Overall, 42.3 % developed POAF. sST2 levels were found to be significantly higher in patients with POAF. Interestingly, sST2 was only predictive of POAF in females with an adjusted OR of 1.894 (95 %CI:1.103-3.253; p = 0.021) and not males (OR:1.091; 95 %CI:0.849-1.402; p = 0.495). Furthermore, within a linear regression model it was observed that for every 1 ng/mL increase in sST2 levels, the average POAF duration extended by 39.5 min (95 %CI:15.8-63.4 min; p = 0.001).
CONCLUSION
sST2 predicts the onset of POAF in women but not men undergoing cardiac surgery. Furthermore, sST2 levels were associated with the subsequent burden of POAF. Thus, assessment of sST2 in addition to clinical risk factors could improve risk stratification for development of POAF following elective cardiac surgery.
PubMed: 38879062
DOI: 10.1016/j.cca.2024.119815 -
Indian Heart Journal Jun 2024To evaluate paroxysmal atrial fibrillation (AF) prevalence in Indian adults who completed 24-Hour Holter monitoring.
OBJECTIVE
To evaluate paroxysmal atrial fibrillation (AF) prevalence in Indian adults who completed 24-Hour Holter monitoring.
METHODS
A total of 23,847 patients (36.9% women) were analyzed for AF duration using using a software algorithm.
RESULTS
AF was diagnosed in 4,153 (17.4%) patients with a median AF duration of 13 minutes and 55 seconds.
CONCLUSION
AF prevalence was high and largely untreated. The short duration of AF episodes indicates a low likelihood of detection during clinical visits, highlighting its potential underestimation in Indian healthcare.
PubMed: 38878964
DOI: 10.1016/j.ihj.2024.06.012 -
International Journal of Cardiology Jun 2024
Corrigendum to "The effect of antiarrhythmic medications on the risk of cardiovascular outcomes in patients with atrial fibrillation and coronary artery disease" [International Journal of Cardiology 409 (2024) 132198].
PubMed: 38878528
DOI: 10.1016/j.ijcard.2024.132257 -
JACC. Heart Failure May 2024Mineralocorticoid receptor antagonists (MRAs) improve outcomes in patients with heart failure and reduced ejection fraction (HFrEF). However, MRAs are often underused...
BACKGROUND
Mineralocorticoid receptor antagonists (MRAs) improve outcomes in patients with heart failure and reduced ejection fraction (HFrEF). However, MRAs are often underused because of hyperkalemia concerns.
OBJECTIVES
The purpose of this study was to assess whether sodium zirconium cyclosilicate (SZC), a nonabsorbed crystal that traps and rapidly lowers potassium, enables MRA use in patients with HFrEF and prevalent hyperkalemia (or at high risk).
METHODS
REALIZE-K is a prospective, double-blind, placebo-controlled trial in patients with HFrEF (NYHA functional class II-IV; left ventricular ejection fraction ≤40%), optimal therapy (except MRA), and prevalent hyperkalemia (or at high risk). During the open-label run-in, all participants underwent protocol-mandated spironolactone titration (target: 50 mg daily); those with prevalent (cohort 1) or incident (cohort 2) hyperkalemia during titration started SZC. Participants achieving normokalemia while on spironolactone ≥25 mg daily were randomized to continuing SZC or matching placebo for 6 months. The primary composite endpoint was proportion of participants with optimal response (normokalemia, on spironolactone ≥25 mg daily, no rescue for hyperkalemia [months 1-6]).
RESULTS
Of 365 patients (run-in), 202 were randomized. Baseline characteristics included mean age 70 years, prevalent comorbidities (78% estimated glomerular filtration rate <60 mL/min/1.73 m, 38% atrial fibrillation/flutter), high N-terminal pro B-type natriuretic peptide (median 1,136 pg/mL), and high HFrEF therapy use (64% sacubitril/valsartan, 96% beta-blocker, 42% sodium glucose co-transporter 2 inhibitor). At randomization, 78% were receiving spironolactone 50 mg daily.
CONCLUSIONS
REALIZE-K is the first trial to evaluate whether SZC can enable rapid and safe MRA optimization and long-term continuation in patients with HFrEF and prevalent/high risk of hyperkalemia. (Study to Assess Efficacy and Safety of SZC for the Management of High Potassium in Patients with Symptomatic HFrEF Receiving Spironolactone; NCT04676646).
PubMed: 38878009
DOI: 10.1016/j.jchf.2024.05.003