Single femoral artery access is safe and feasible during transcatheter aortic valve replacement: a propensity score matched analysis.

Background: Transcatheter aortic valve replacement (TAVR) potentially may be significantly simplified by using the single artery access (SA) technique, which does not require a secondary artery access. Nevertheless, the safety and efficacy of this technique remains unclear. Our goal was to determine if single artery access TAVR (without upgrading the sheath size) is a feasible, minimally invasive procedure. Methods: Patients with symptomatic severe aortic stenosis who underwent TAVR via the femoral artery were consecutively enrolled in this study. Eligible individuals were divided into 2 groups: the SA group and the dual artery access (DA) group. The primary end point was device success (defined by the valve academic research consortium 3, VARC 3). A 6-month follow-up and propensity score matching analyses were performed. Results: After propensity score matching analysis, a total of 130 patients were included: 65 in the SA group and 65 in the DA group. The SA procedure achieved similar device success (95.4% vs. 87.7%; P = 0.115) compared with the DA procedure. The SA procedure shortened the operating time (102 min vs. 125 min; P = 0.001) but did not increase the x-ray time or dose. Both a 20 Fr and a 22 Fr sheath (without upgrading the sheath size) could be used for the SA procedure. There was no major vascular complication occurred in both groups. The incidence of minor main vascular and access complications in the SA group was comparable to those of the DA procedure (0.0% vs. 3.1%; P = 0.156). Conclusions: The SA access procedure is a promising minimally invasive TAVR technique with a low incidence of vascular complications and a high incidence of device success. It is safe and possibly applicable in all TAVR procedures.

Feasibility study of temporary permanent pacemaker in patients with conduction block after TAVR.

Background: Limited data exist on the use of temporary permanent pacemaker (TPPM) to reduce unnecessary PPM in patients with high-degree atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR). Objectives: This study aims to determine the feasibility of TPPM in patients with HAVB after TAVR to provide prolonged pacing as a bridge. Materials and methods: One hundred and eleven consecutive patients undergoing TAVR were screened from August 2021 to June 2022. Patients with HAVB eligible for PPM were included. TPPM were used in these patients instead of conventional temporary pacing or early PPM. Patients were followed up for 1 month. Holter and pacemaker interrogation were used to determine whether to implant PPM. Results: Twenty one patients met the inclusion criteria for TPPM, of which 14 patients were third-degree AVB, 1 patient was second-degree AVB, 6 patients were first degree AVB with PR interval > 240 ms and LBBB with QRS duration > 150 ms. TPPM were placed on the 21 patients for 35 ± 7 days. Among 15 patients with HAVB, 26.7% of them (n = 4) recovered to sinus rhythm; 46.7% (n = 7) recovered to sinus rhythm with bundle branch block. The remains of 26.7% patients (n = 4) still had third-degree AVB and received PPM. For patients with first-degree AVB and LBBB, PR interval shortened to < 200 ms in all 6 patients and LBBB recovered in 2 patients. TPPM were successfully removed from all patients and no procedure-related adverse events occurred. Conclusion: TPPM is reliable and safe in the small sample of patients with conduction block after TAVR to provide certain buffer time to distinguish whether a PPM is necessary. Future studies with larger sample are needed for further validation of the current results.

Impact of Low-density Lipoprotein Cholesterol Levels on Outcomes in Nonvalvular Atrial Fibrillation: Results from the China Atrial Fibrillation Registry Study.

BACKGROUND Low-density lipoprotein cholesterol (LDL-C) reduction improves cardiovascular outcomes. This study investigates the relationship between lipid levels and outcomes in patients with nonvalvular atrial fibrillation by LDL-C quarters. MATERIAL AND METHODS Patients with atrial fibrillation were enrolled from 31 typical hospitals in China. Of 19 515 patients, 6775 with nonvalvular atrial fibrillation (NVAF) were followed for 5 years or until an event occurred. RESULTS Hyperlipidemia was not an independent risk factor for stroke/thromboembolism and cardiovascular mortality among patients with NVAF (hazard ratio 0.82, 95% CI 0.7-0.96, P=0.82). When patients were divided into quartiles according to LDL-C levels at the time of enrollment (Q1, <1.95; Q2, 1.95-2.51; Q3, 2.52-3.09; and Q4, >3.09 mmol/L), as LDL-C increased, events tapered off according to Kaplan-Meier curves for patients who were without oral anticoagulants and off statins (non-OAC; log-rank=8.3494, P=0.0393) and for those with oral anticoagulants (OAC; log-rank=6.7668 P=0.0797). This relationship was stronger for patients who were without OAC treatment and off statins than for those with OAC treatment. The relationship was not significant in patients with or without OAC and on statins (log-rank=2.5080, P=0.4738). This relationship also existed in patients with CHA2DS2-VASc scores <2 (log-rank=5.893, P=0.1167). For those with CHA2DS2-VASc scores ≥2 (log-rank=6.6163, P=0.0852), the relationship was stronger. CONCLUSIONS In patients with NVAF using standard or no lipid-lowering medication, low plasma LDL-C levels were related to an increased risk of stroke/thromboembolism and cardiovascular mortality.

Sex-Related Characteristics, Quality of Care, and Short-Term Mortality Rates in Patients With Chronic Heart Failure.

BACKGROUND: The association of female sex with quality of care and short-term mortality rates in patients with chronic heart failure (CHF) remains controversial. METHOD: We performed a retrospective study using data from 2,663 patients with CHF from nine hospitals in Beijing between January 2014 and December 2015. Multivariable logistic regression analyses were performed to investigate whether female sex was independently associated with quality of care and short-term mortality rates in Chinese patients with CHF. RESULTS: Compared to male patients, female patients (48%) were older and had a higher prevalence of comorbidities. Performance measures, including angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, aldosterone receptor antagonists, and beta blocker use in patients with heart failure with reduced ejection fraction, warfarin therapy in those with atrial fibrillation, documentation of B-type natriuretic peptide/N-terminal pro-B-type natriuretic peptide, and left ventricular ejection fraction, showed no sex difference in multivariable analysis. Adjusted in-hospital mortality (1.7% vs 2.1%; adjusted odds ratio, 0.908; 95% confidence interval [CI], 0.448-1.842; p=0.789) and 30-day mortality (4.2% vs. 4.4%; adjusted hazard ratio, 0.908; 95% CI, 0.567-1.454; p=0.689) were comparable between the sexes. CONCLUSION: Chinese female patients with CHF receive a similar quality of care and have similar short-term mortality rates as male patients.

Use of oral anticoagulants and its associated factors among nonvalvular atrial fibrillation patients with new-onset acute ischemic stroke: A report from the China Atrial Fibrillation Registry study.

BACKGROUND: The adherence of oral anticoagulant (OAC) therapy among nonvalvular atrial fibrillation (NVAF) patients with acute ischemic stroke (AIS) in China during recent years was unclear, and the possible factors that influenced the initiation and persistent use of OAC were needed to be explored. METHODS: A total of 1085 NVAF patients, who experienced new-onset and nonfatal AIS from August 2011 to December 2020 during follow-ups in the China Atrial Fibrillation Registry (China-AF), were enrolled. Information including patients' demographic characteristics, medical history, medication usage, which were collected before and after the index stroke, were used in the analysis. RESULTS: OAC was initiated in 40% (434/1085) NVAF patients within 3 months after new-onset AIS. High-reimbursement-rate insurance coverage (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.03-2.22, p = .036), 3-month-peri-stroke AF episodes (OR: 2.63, 95% CI: 1.88-3.69, p < .001), and pre-stroke OAC usage (OR: 8.92, 95% CI: 6.01-13.23, p < .001), were positively associated with initiation of OAC within 3 months after new-onset AIS, while age (OR: 0.98, 95% CI: 0.96-1.00, p = .024), female (OR: 0.63, 95% CI: 0.44-0.90, p = .012) and higher modified HASBLED score (OR: 0.45, 95% CI: 0.37-0.55, p < .001) were negatively associated with it. Among 3-month-post-stroke OAC users, history of radiofrequency ablation (hazard ratio: 1.65, 95% CI: 1.16-2.35; p = .006) was positively associated with non-persistence of OAC usage. CONCLUSIONS: In China, the proportion of NVAF patients who initiated OAC therapy since new-onset AIS was still low. More efforts are needed on improving patients' adherence to anticoagulant therapy.

Association Between Left Ventricular Global Function Index and Outcomes in Patients With Dilated Cardiomyopathy.

Purpose: Left ventricular global function index (LVGFI) assessed using cardiac magnetic resonance (CMR) seems promising in the prediction of clinical outcomes. However, the role of the LVGFI is uncertain in patients with heart failure (HF) with dilated cardiomyopathy (DCM). To describe the association of LVGFI and outcomes in patients with DCM, it was hypothesized that LVGFI is associated with decreased major adverse cardiac events (MACEs) in patients with DCM. Materials and Methods: This prospective cohort study was conducted from January 2015 to April 2020 in consecutive patients with DCM who underwent CMR. The association between outcomes and LVGFI was assessed using a multivariable model adjusted with confounders. LVGFI was the primary exposure variable. The long-term outcome was a composite endpoint, including death or heart transplantation. Results: A total of 334 patients (mean age: 55 years) were included in this study. The average of CMR-LVGFI was 16.53%. Over a median follow-up of 565 days, 43 patients reached the composite endpoint. Kaplan-Meier analysis revealed that patients with LVGFI lower than the cutoff values (15.73%) had a higher estimated cumulative incidence of the endpoint compared to those with LVGFI higher than the cutoff values (P = 0.0021). The hazard of MACEs decreased by 38% for each 1 SD increase in LVGFI (hazard ratio 0.62[95%CI 0.43-0.91]) and after adjustment by 46% (HR 0.54 [95%CI 0.32-0.89]). The association was consistent across subgroup analyses. Conclusion: In this study, an increase in CMR-LVGFI was associated with decreasing the long-term risk of MACEs with DCM after adjustment for traditional confounders.

Left ventricular strain-curve morphology to distinguish between constrictive pericarditis and restrictive cardiomyopathy.

AIMS: To distinguish between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM) using cardiac magnetic resonance feature tracking (CMR-FT) left ventricle (LV) diastolic time-strain curve patterns and myocardial strain. METHODS AND RESULTS: A total of 32 CP patients, 27 RCM patients, and 25 control subjects were examined by CMR-FT and analysed for global strain, segmental strain, and LV time-strain curve patterns in the longitudinal, circumferential, and radial directions. Speckle tracking echocardiography (STE) strain imaging was performed in some cases. The peak global longitudinal strain (GLS) and global circumferential strain (GCS) of the RCM group were lower than those of the CP group. GLS [median (interquartile range) CP vs. RCM: -11.15 (-12.85, -9.35) vs. -6.5 (-8.75, -4.85), P < 0.001] and GCS (CP vs. RCM: -16.89 ± 5.11 vs. -13.37 ± 5.79, P < 0.001). In circumferential and radial directions, the strain ratios of the LV lateral/septal wall (LW/SW) of the CP group were significantly lower than those of the RCM group at the basal and mid segments. The CS ratio of LW/SW at the basal segment [CP vs. RCM: 0.95 (0.85, 1.25) vs. 1.43 (1.18, 1.89), P < 0.001] and mid segment [CP vs. RCM: 1.05 (0.92, 1.15) vs. 1.18 (1.06, 1.49), P = 0.026]. The RS ratio of LW/SW at the basal segment [CP vs. RCM: 0.97 (0.76, 1.37) vs. 1.55 (1.08, 2.31), P = 0.006] and mid segment [CP vs. RCM: 0.95 (0.70, 1.28) vs. 1.79 (1.32, 2.92), P < 0.001]. In the longitudinal and circumferential directions, the characteristic 'plateau' pattern of time-strain curves could be seen in the CP but not in the RCM during the diastole. The GCS ratio of 0-50%/50-75% diastolic period of the CP was higher than that of the RCM [CP vs. RCM: 17.01 (8.67, 23.75) vs. 5.38 (1.93, 11.24), P = 0.001], while the GCS ratio of 50-75%/75-100% diastolic period was lower than that of the RCM [CP vs. RCM: 0.36 (0.15, 1.67) vs. 1.12 (0.70, 5.58), P < 0.001]. The peak GLS (sensitivity, 85%; specificity, 78%) and the GCS ratio of 0-50%/50-75% diastolic period (sensitivity, 88%; specificity, 73%) had higher differential diagnosis value. CONCLUSIONS: The CMR-FT could distinctly differentiate CP from RCM based on LV myocardial strain and LV time-strain curve patterns. The characteristic 'plateau' pattern of the time-strain curve is specific for CP and not RCM and this curve can also be duplicated by STE.

Evaluation of medical quality and treatment trends of nonvalvular atrial fibrillation in Beijing inpatients.

BACKGROUND: The quality of care presented to AF cases in tertiary and non-tertiary hospitals in China remains obscure and needs further investigation. Therefore, we examined the compliance with quality measures (QMs) and clinical performance measures (PMs) that were proposed by the ACC/AHA in 2016 in a Chinese adult population with nonvalvular atrial fibrillation (AF). We also investigated the changes in patients' characteristics, treatment plans, and quality of provided care at different time-points [2011-2016]. METHODS: We used the datasets from two registry-based studies in Beijing, including the Chinese Atrial Fibrillation Registry (CHINA-AF) investigation. From August 2011 to July 2016, an overall number of 13,439 nonvalvular AF cases were included. Our primary outcome was to determine the compliance rate with two PMs [oral anticoagulant (OAC) use and prothrombin time international normalized ratio (INR)] and six QMs (beta-blocker, ACEI-ARB, and the inappropriate prescription of antiarrhythmic drugs, Sotalol, antiplatelet and OAC, and non-dihydropyridine calcium channel antagonist) over a period of 5 years [2011-2016]. Also, the difference in compliance between tertiary and non-tertiary hospitals was investigated. RESULTS: The compliance with PMs and QMs was variable between tertiary and non-tertiary hospitals. In tertiary hospitals, the total number of inpatient beds was >500, and each bed was equipped with >1.03 health technical personnel and >0.4 nurses. In non-tertiary hospitals, the available beds capacity was <500, and each bed corresponded with 0.7-0.88 health technical personnel and >0.4 nurses. The compliance rates with OAC use steadily increased from 2011-2015 in tertiary hospitals (35%, 35.9%, 37.9%, 45%, and 49%, P<0.001). In non-tertiary hospitals, INR follow-up of warfarin use increased significantly over the years, with rates of 36.2%, 60.5%, 71.6%, 64.3%, and 81.5% (P=0.04), respectively. In terms of QMs, the compliance with the six measure sets was quite similar among tertiary and non-tertiary hospitals avoiding any significant difference over the years (P>0.05). CONCLUSIONS: We noted an improvement in medical quality regarding the use of OAC, especially in tertiary hospitals. Meanwhile, the compliance rates of INR follow-up improved in non-tertiary hospitals. However, the compliance rates of other performance and QMs are still low, which are in need of improvement.

Association between right ventricular strain and outcomes in patients with dilated cardiomyopathy.

OBJECTIVE: To explore the association between three-dimensional (3D) cardiac magnetic resonance (CMR) feature tracking (FT) right ventricular peak global longitudinal strain (RVpGLS) and major adverse cardiovascular events (MACEs) in patients with stage C or D heart failure (HF) with non-ischaemic dilated cardiomyopathy (NIDCM) but without atrial fibrillation (AF). METHODS: Patients with dilated cardiomyopathy were enrolled in this prospective cohort study. Comprehensive clinical and biochemical analysis and CMR imaging were performed. All patients were followed up for MACEs. RESULTS: A total of 192 patients (age 53±14 years) were eligible for this study. A combination of cardiovascular death and cardiac transplantation occurred in 18 subjects during the median follow-up of 567 (311, 920) days. Brain natriuretic peptide, creatinine, left ventricular (LV) end-diastolic volume, LV end-systolic volume, right ventricular (RV) end-diastolic volume and RVpGLS from CMR were associated with the outcomes. The multivariate Cox regression model adjusting for traditional risk factors and CMR variables detected a significant association between RVpGLS and MACEs in patients with stage C or D HF with NIDCM without AF. Kaplan-Meier analysis based on RVpGLS cut-off value revealed that patients with RVpGLS <-8.5% showed more favourable clinical outcomes than those with RVpGLS ≥-8.5% (p=0.0037). Subanalysis found that this association remained unchanged. CONCLUSIONS: RVpGLS-derived from 3D CMR FT is associated with a significant prognostic impact in patients with NIDCM with stage C or D HF and without AF.

Differentiation between left bundle branch block (LBBB) preceded dilated cardiomyopathy and dilated cardiomyopathy preceded LBBB by cardiac magnetic resonance imaging.

BACKGROUND: Dilated cardiomyopathy (DCM) may be a result of or the cause of left bundle branch block (LBBB) in patients with DCM and LBBB. It is almost impossible from the history alone to know which came first in clinical work. METHODS: Patients with LBBB and DCM who had cardiac magnetic resonance (CMR) examination were analyzed. Occurrence sequence of DCM and LBBB was determined by chart reviewing. Diastolic lateral/septal wall thickness ratio (DLSWTR) and lateral wall thickening (LWT) were compared between patients with different time sequences. Response to CRT was analyzed according to medical history and CMR manifestation. RESULTS: Sixty-three patients were divided into two groups by cluster analysis. DLSWTR and LWT were significantly higher in group 1 (preserved lateral wall thickness and function), compared to those in group 2 (reduced lateral wall thickness and function) (1.06 ± 0.13 vs. 0.8 ± 0.12, 34.57 ± 11.48% vs. 11.18 ± 5.56%, respectively, both P < .001). Occurrence sequence was clear in 14 patients and further analyzed. In group 1, seven patients were clearly having no evidence of DCM when LBBB was first diagnosed (defined as LBBB-precede-DCM) and in group 2, seven patients did not have LBBB when DCM was diagnosed (defined as DCM-precede-LBBB). Among 10 patients who received CRT therapy, all seven patients in group 1 responded well whereas none of three patients in group 2 responded well. CONCLUSIONS: Occurrence sequence of DCM and LBBB can be discriminated by CMR. Preserved lateral wall morphology and function in CMR suggested LBBB preceded to DCM. Such features may be predictors of good response to CRT.

Physical activity and atrial tachyarrhythmia recurrence in atrial fibrillation patients after catheter ablation.

BACKGROUND: The association between physical activity (PA) and atrial tachyarrhythmia (AT) recurrence after ablation for atrial fibrillation (AF) remains unclear. METHODS: We consecutively enrolled 496 patients treated with AF ablation therapy in Beijing Anzhen Hospital. After excluding six patients with valvular heart disease, seven patients with congenital heart disease, 33 patients lost to follow-up, and 14 patients who did not provide PA level during follow-ups, 436 patients had their PA level assessed by the International Physical Activity Questionnaire-Short Form before ablation and each time of follow-up. The association between PA level (measured at the time closest to AT recurrence, or the end of 12-month follow-up if no AT recurrence), as well as active PA during follow-up, and postablation AT recurrence was tested by multivariate logistic regression. RESULTS: Of the enrolled patients, 134 (30.7%) patients experienced AT recurrence in the first 12 months postablation. Compared to patients with low PA, patients with moderate or high PA had a lower risk of AT recurrence (odds ratio [OR] = .44; 95% confidence interval [CI], .25-.80; P = .01 for patients with moderate PA; and OR = .43 [95% CI, .21-.85], P = .02 for patients with high PA). Compared to patients without active PA, patients with active PA had a lower risk of AT recurrence (OR = .44 [95% CI, .27-.70], P < .01). CONCLUSIONS: Moderate and high PA are associated with a lower risk of AT recurrence after AF ablation. Active PA during follow-up is also associated with a significantly lower risk of AT recurrence in the postablation AF population.

Effectiveness and safety of atrial fibrillation ablation in females.

BACKGROUND: Existing data on the effectiveness and safety of atrial fibrillation (AF) ablation in females are limited to studies of small sample size, lacking longer term follow-up or adjustment for potential confounders. METHODS: A total of 6421 patients (2072 females) undergoing a first AF ablation procedure after enrollment in the Chinese Atrial Fibrillation Registry (China-AF) study between August 2011 and December 2017 were analyzed. We evaluated the effectiveness (recurrence of documented [symptomatic or not] atrial tachyarrhythmia (AT)) and the safety (incidence of procedure-related complications) of AF ablation in female patients compared to male patients. Sensitivity analyses based on routine data were also utilized to avoid potential sex differences in reporting of AF symptoms. RESULTS: Females were about 5 years older than males at the time of ablation (mean age 63.4 ± 9.5 vs 58.3 ± 10.8, P < .0001). A higher proportion of female patients had paroxysmal AF (74.3% vs 56.7%, P < .0001), hypertension (69.7% vs 61.3%, P < .0001), and hyperlipidemia (57.2% vs 52.9%, P = .001). Female sex was found to be an independent risk factor of AT recurrence in multivariate analyses (HR = 1.26, 95% CI 1.15-1.38, P < .0001). These findings were confirmed in sensitivity analyses using only Holter data. Female sex was also associated with a higher risk of periprocedural complications after adjustment for baseline variables (OR = 1.41, 95% CI 1.03-1.94, P = .03). CONCLUSIONS: Female sex is an independent risk factor of AT recurrence and periprocedural complications after AF ablation.

The safety of discontinuation of oral anticoagulation therapy after apparently successful atrial fibrillation ablation: a report from the Chinese Atrial Fibrillation Registry study.

AIMS: We aimed to investigate the safety of discontinuing oral anticoagulation (OAC) therapy after apparently successful atrial fibrillation (AF) ablation, using data from the Chinese Atrial Fibrillation Registry study. METHODS AND RESULTS: We identified 4512 consecutive patients who underwent successful AF ablation between August 2011 and December 2017. Of them, 3149 discontinued OAC 3 months post-ablation (Off-OAC group) and 1363 continued OAC beyond this period (On-OAC group). Regular follow-up examinations were undertaken to detect AF recurrence, monitor OAC therapy, and measure clinical outcomes. Primary outcomes included thromboembolic and major bleeding (MB) events experienced beyond 3 months after ablation. Low thromboembolic and MB event rates were noted in the on-treatment analysis. The incidence rates for thromboembolism were 0.54 [95% confidence interval (CI) 0.39-0.76] and 0.86 (95% CI 0.56-1.30) per 100 patient-years, and that for MB events were 0.19 (95% CI 0.11-0.34) and 0.35 (95% CI 0.18-0.67) per 100 patient-years, for the Off-OAC and On-OAC groups over mean follow-up periods of 24.2 ± 14.7 and 23.0 ± 13.6 months, respectively. Similar results were observed in the intention-to-treat analysis. Previous history of ischaemic stroke (IS)/transient ischaemic attack (TIA)/systemic embolism (SE) [hazard ratio (HR) 3.40, 95% CI 1.92-6.02; P < 0.01] and diabetes mellitus (HR 2.06, 95% CI 1.20-3.55, P = 0.01) were independently associated with thromboembolic events, while OAC discontinuation (HR 0.71, 95% CI 0.41-1.23, P = 0.21) remained insignificant in multivariable analysis. CONCLUSIONS: This study suggests that it may be safe to discontinue OAC in post-ablation patients under diligent monitoring, in the absence of AF recurrence, history of IS/TIA/SE, and diabetes mellitus. However, further large-scale randomized trials are required to confirm this. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR-OCH-13003729. URL: http://www.chictr.org.cn/showproj.aspx?proj=5831.

Ablation Versus Medical Therapy for Atrial Fibrillation in the Elderly: A Propensity Score-Matched Comparison.

BACKGROUND Whether ablation therapy reduces the risk of death and embolic events in elderly patients with atrial fibrillation (AF) remains unclear. MATERIAL AND METHODS AF patients ≥65 years old receiving either catheter ablation or non-ablation therapy at 2 tertiary and 2 non-tertiary hospitals in Beijing from November 2009 to December 2012 were enrolled. Patients were followed up every 6 months for information on treatment and clinical event occurrence. A propensity score matching algorithm produced comparable 2 groups of patients treated with ablation or non-ablation. Rates of a composite of all-cause death, non-fatal stroke, and peripheral embolism were the primary outcomes. Each composite component and major bleeding were the secondary outcomes. RESULTS There were 596 ablated patients and 1144 patients with non-ablation therapy enrolled. Propensity score algorithm matched 347 comparable pairs of patients. Patient characteristics variables were well balanced. During 523.5 and 497.5 patient-years follow-up, respectively, ablation therapy was associated with a significant lower risk of experiencing the primary composite outcome (hazard ratio [HR]=0.40; 95% confidence interval [CI]: 0.19-0.85), all-cause death (HR=0.13 95% CI: 0.04-0.43), and major bleeding (HR=0.23; 95% CI: 0.12-0.67), without apparent heterogeneity by age, sex, and AF type, and for risk score subgroups. CONCLUSIONS In this propensity-matched elderly sample, ablation therapy was associated with lower risk of composite outcome consisting of all-cause death, non-fatal stroke, and peripheral embolism, and therefore might be an alternative to conservative therapy.

Sex Differences in Presentation, Quality of Life, and Treatment in Chinese Atrial Fibrillation Patients: Insights from the China Atrial Fibrillation Registry Study.

BACKGROUND There is a growing recognition of sex-related disparities in atrial fibrillation (AF). However, limited data is available in Chinese AF patients. MATERIAL AND METHODS We compared symptoms, quality of life (QoL), and treatment of AF according to sex from the China AF Registry study. RESULTS We studied 14 723 patients with non-valvular AF, of whom 5645 patients (38.3%) were female. Women were older than men (67.5±10.6 vs. 62.2±12.2). Compared to men, women had more comorbidities and a higher proportion of CHA2DS2-VASC score ≥2. Women with AF experienced more severe or disabling symptoms than men (33.7% vs. 22.9% in age <75 group; 40.3% vs. 28.7% in age ≥75 group; both P<0.0001). After multivariate analysis, women with AF still had lower QoL (OR 0.69; 95%CI, 0.63-0.76; P<0.0001). Women tended to have lower rates of ablation and rhythm-control drug use in those aged <75 years. Oral anticoagulant use was low and had no sex difference in AF patients with a CHA2DS2-VASC score ≥2. CONCLUSIONS In Chinese AF patients, women were older and more symptomatic, and had worse QoL. Despite all these differences, women tended to receive less rhythm-control treatment in those aged <75 years. Oral anticoagulant was substantially underused in high stroke risk patients, regardless of sex.

Prevalence of modifiable risk factors and relation to stroke and death in patients with atrial fibrillation: A report from the China atrial fibrillation registry study.

BACKGROUND: Lifestyle and risk factor management may improve outcomes in patients with atrial fibrillation (AF). We aim to evaluate the prevalence of modifiable risk factors and how these factors impact clinical outcomes in patients with AF. METHODS AND RESULTS: Data on 17 898 AF cohort patients with AF enrolled between 2011 and 2016 was analyzed. A healthy lifestyle was defined as not smoking, not drinking, a healthy body mass index (BMI), untreated total cholesterol less than 200 mg/dL, untreated blood pressure (BP) less than 120/80 mm Hg, and untreated fasting plasma glucose (FPG) less than 100 mg/dL. The association between risk factors and risk of the composite endpoint of all-cause mortality and nonfatal ischemic stroke were assessed using Cox proportional hazards regression model. Only 4.0% of patients achieved a healthy lifestyle. In multivariate analysis, current smoking, a low BMI, not well-controlled FPG were independently and significantly associated with higher risk of all-cause mortality and nonfatal ischemic stroke, with corresponding hazard ratio (HR) estimates 1.22 (95% confidence interval [CI], 1.00-1.47), HR = 1.72 (95% CI, 1.34-2.20), and HR = 1.25 (95% CI, 1.06-1.46), respectively. High BP was also associated with higher risk with the outcomes (HR = 1.15, 95% CI, 1.00-1.34). Compared with patients with no risk factor, those who failed to maintained or achieved optimal risk factor control had a progressively higher risk of death and nonfatal ischemic stroke (HR for 1 risk factor = 1.44; 95% CI, 1.07-1.92; and more than 2 risk factors = 1.75; 95% CI, 0.99-3.09). CONCLUSIONS: Maintenance of well-controlled risk factors may substantially lower the risk of death and ischemic stroke in patients with AF.

Effect of Mental Health Status on Arrhythmia Recurrence After Catheter Ablation of Atrial Fibrillation.

BACKGROUND: Patients diagnosed with atrial fibrillation suffer more from anxiety and depression than the general population. This study sought to evaluate the association between mental health status and recurrence of atrial tachyarrhythmia (AT) after catheter ablation. METHODS: A total of 448 patients who underwent catheter ablation for atrial fibrillation were enrolled in this single-centre prospective cohort study. Mental Health Inventory-5 (MHI-5) was used to assess the mental health status at the end of the blanking period after ablation and lower scores indicated poorer mental health status. Patients with no early recurrence of AT during the blanking period were included for analyses. Multivariate logistic regression was used to examine the association between mental health status and risk of arrhythmia recurrence in the following 3 months. RESULTS: Among 335 patients without early recurrence during the blanking period, 36 patients (10.7%) experienced AT recurrence in the 3 months after the mental health status evaluation. Recurrence rates were 35.7%, 13.5%, 10.6%, and 4.6% in patients with an MHI-5 score of 0-52, 53-75, 76-85, and 86-100, respectively (overall P = 0.004). A significant association between low MHI-5 scores and AT recurrence was observed after multivariate adjustment (odds ratio: 8.81 [1.93-40.22], P = 0.005 for the MHI-5 score of 0-52 and 3.61 [1.05-12.35], P = 0.041 for the MHI-5 score of 53-75, compared with an MHI-5 score of 86-100). CONCLUSIONS: A poorer mental health status is associated with AT recurrence after catheter ablation. Intervention studies are warranted to evaluate the efficacy of counselling and psychological support after ablation in improving success rates in these patients.

Association Between Digoxin Use and Adverse Outcomes Among Patients in the Chinese Atrial Fibrillation Registry.

INTRODUCTION: Digoxin is widely used in patients with atrial fibrillation (AF), but its association with adverse outcomes remains controversial. OBJECTIVE: We aimed to assess the association between digoxin and adverse outcomes in Chinese patients with AF. METHODS: We used data from the Chinese Atrial Fibrillation Registry, a prospective, multicenter, hospital-based registry study involving 31 hospitals. In total, 10,472 eligible patients with AF, enrolled from August 2011 to December 2016, were included in this study. The association between digoxin use and all-cause mortality, cardiovascular death, and cardiovascular hospitalization were investigated using Cox proportional hazards models. RESULTS: In total, 1152 (11%) patients were treated with digoxin at baseline. Patients receiving digoxin were older (mean age 69.7 vs. 66.5 years) and had a higher heart rate (92.4 vs. 79.7 beats/min). A higher proportion of patients receiving digoxin therapy had a history of heart failure (62.5 vs. 15.6%), diabetes mellitus (34.4 vs. 24.4%), and persistent AF (67.9 vs. 38.4%). Digoxin use was independently associated with increased all-cause mortality (adjusted hazard ratio (aHR) 1.21; 95% confidence interval (CI) 1.02-1.43; p = 0.031), cardiovascular death (aHR 1.25; 95% CI 1.01-1.55; p = 0.043), and cardiovascular hospitalization (aHR 1.21; 95% CI 1.05-1.39; p = 0.007). The associations were also homogeneous across various subgroups except in patients with and without renal dysfunction (p value for interaction = 0.029). DISCUSSION: In this Chinese AF cohort, for patients who had not undergone ablation, digoxin use was associated with a significant increase in adverse outcomes. Although residual confounders may exist, and serum concentrations of digoxin were unavailable, digoxin should be used with caution in clinical practice, and its effects need to be critically evaluated in randomized trials. CLINICAL TRIAL REGISTRATION: URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729.

Long-Term Persistence with Newly-Initiated Warfarin or Non-VKA Oral Anticoagulant (NOAC) in Patients with Non-Valvular Atrial Fibrillation: Insights from the Prospective China-AF Registry.

BACKGROUND Oral anticoagulants (OACs) such as warfarin and non-VKA oral anticoagulants (NOACs) have been recommended for patients with atrial fibrillation (AF) who are at risk for stroke. Whether NOACs have a higher persistence than warfarin is still unclear. This is especially true in China. MATERIAL AND METHODS Data from a large hospital-based cohort in China (China-AF Registry) from 2011 to 2017 were used for this study. Non-valvular AF patients with newly initiated OACs were included. A time-to-event approach was used to analyze patient persistence. The survival distributions of persistence were compared using the log-rank test. A multivariable Cox regression model was used to explore predictors of warfarin and NOACs non-persistence. RESULTS Patients with newly initiated warfarin (n=4845) or NOACs (n=854) were included in this study. Persistence rates at 1, 2, and 3 years were 93.2%, 89.4%, and 87.2% in the warfarin group and 88.8%, 84.3%, and 81.3% in the NOAC group respectively. Non-persistence was significantly higher with NOACs than with warfarin. On multivariate analysis, age <75 years old, outpatient clinic visits, asymptomatic AF, paroxysmal AF, duration of AF <3 years, history of peptic ulcer, and no previous TIA, stroke or thromboembolism were strong predictors of warfarin non-persistence, while in the NOACs group, age <75 years old, outpatient clinic visits, lower education status and no history of congestive heart failure were predictors. CONCLUSIONS Treatment persistence of NOACs was lower than that of warfarin among Chinese patients with AF. Patients with characteristics of non-persistence predictors need special attention to maintain their therapy.

Female Sex as a Risk Factor for Ischemic Stroke and Systemic Embolism in Chinese Patients With Atrial Fibrillation: A Report From the China-AF Study.

Background Previous studies have provided conflicting results as to whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation ( AF ). We investigated whether women with AF were at higher risk of ischemic stroke in the China-AF (China Atrial Fibrillation Registry) Study. Methods and Results A total of 19 515 patients were prospectively enrolled between August 2011 and December 2016 in the China- AF Study. After exclusion of patients receiving anticoagulation or ablation therapy, 6239 patients (2574 women) with results from at least 6 months of follow-up were used for the analysis. Cox proportional hazards models were performed to evaluate whether female sex was an independent risk factor for thromboembolism after multivariate adjustment. The primary outcome was the time to the first occurrence of ischemic stroke or systemic embolism. After a mean follow-up of 2.81±1.46 years, 152 female patients reached the primary outcome, as compared with 172 male patients. Crude incidence rates of thromboembolism between women and men were of borderline statistical significance (2.08 versus 1.68 per 100 patient-years, P=0.058). After multivariable analysis, female sex was not independently associated with an increased thromboembolism risk (hazard ratio 1.09, 95% confidence interval 0.86-1.39). There was no significant difference in thromboembolism risk by sex stratified by age and presence or absence of risk factors ( P for interaction all >0.1). Conclusions Although crude incidence rates of thromboembolism were higher in Chinese female patients with AF compared with male patients, female sex did not emerge as an independent risk factor for thromboembolism on multivariate analysis. Clinical Trial Registration URL : http://www.chictr.org.cn/ . Unique identifier: Chi CTR - OCH -13003729.