A pilot study of longitudinal changes in neurocognition, white matter hyperintensities, and cortical thickness in atrial fibrillation patients following catheter ablation vs medical management.

Background: Cerebral microembolization and atrophy complicate atrial fibrillation (AF). Objectives: We aimed to compare changes in neuroimaging findings between AF patients treated with catheter ablation and those treated with medical therapy. Methods: In this pilot study, we evaluated differences in the change in regional white matter hyperintensity burden (WMHb) and cognitive function from baseline to 6 weeks and 1 year in patients treated with AF ablation (n = 12) and patients treated with medical management alone (n = 11). Change in cortical thickness over time in Alzheimer's disease (AD) risk, aging-associated, and shared AD risk/aging regions was also compared between groups. Results: The mean age was 69.7 ± 5.0 years, 78% of patients were male, 39% had persistent AF, and all received oral anticoagulation. There were no significant differences between groups in the change in cognitive function. At 6 weeks, there were no significant differences in periventricular WMHb changes between groups (0.00 vs 0.04, P = .12), but changes in attention/concentration were inversely correlated with periventricular (P = .01) and total (P = .03) WMHb. Medical management patients demonstrated significantly greater cortical thinning in AD risk regions from baseline to 1 year (P = .003). Conclusions: AF patients who underwent ablation demonstrated less cortical thinning in regions associated with AD risk than patients treated with medical therapy. Larger, prospective studies are needed to better understand the relationship between AF therapies and the development of cognitive decline.

Evaluation of organized atrial arrhythmias after cryptogenic stroke.

Background: Long-term rhythm monitoring to detect atrial fibrillation (AF) following a cryptogenic stroke (CS) is well established. However, the burden of organized atrial arrhythmias in this population is not well defined. Objective: The purpose of this study was to assess the incidence and risk factors for organized atrial arrhythmias in patients with CS. Methods: We evaluated all patients with CS who received an insertable cardiac monitor (ICM) between October 2014 and April 2020. All ICM transmissions categorized as AF, tachycardia, or bradycardia were reviewed. We evaluated the time to detection of organized AF and the combination of either organized atrial arrhythmia or AF. Results: A total of 195 CS patients with ICMs were included (51% men; mean age 66 ± 12 years; mean CHA2DS2-VASC score 4.6). Over mean follow-up of 18.9 ± 11.2 months, organized atrial arrhythmias lasting ≥30 seconds were detected in 45 patients (23%), of whom 62% did not have AF. Seventeen patients had both organized atrial arrhythmia and AF, and another 21 patients had AF only. Compared to those with normal left atrial size, patients with left atrial enlargement had a higher adjusted risk for development of atrial arrhythmias (mild left atrial enlargement: hazard ratio 1.99; 95% confidence interval 1.06-3.75; moderate/severe left atrial enlargement: hazard ratio 3.06; 95% confidence interval 1.58-5.92). Conclusion: Organized atrial arrhythmias lasting ≥30 seconds are detected in nearly one-fourth of CS patients. Two-thirds of these patients did not have AF. Further studies are required to evaluate the impact of organized atrial arrhythmias on recurrent stroke risk.

Ablation to Reduce Atrial Fibrillation Burden and Improve Outcomes: JACC Review Topic of the Week.

Atrial fibrillation is the most common atrial arrhythmia and accounts for a significant burden of cardiovascular disease globally. With advances in implanted and wearable cardiac monitoring technology, it is now possible to readily and accurately quantify an individual's time spent in atrial fibrillation. This review summarizes the relationship between atrial fibrillation burden and adverse cardiovascular and cerebrovascular outcomes and discusses the role of catheter ablation to mitigate the morbidity and mortality associated with greater burden of atrial fibrillation.

Building a Community Based Mental Health Program for Adolescents in Botswana: Stakeholder Feedback.

BACKGROUND: When planning interventions for adolescents, adult interventions should not be used 'as is' in youth settings. Stakeholder engagement can help understand the overall adolescent mental health ecosystem and adapt existing evidence-based interventions for the youth. OBJECTIVE: To understand the overall mental health needs of adolescents in Botswana and the necessary adaptations required for an adolescent lay counselor based intervention in the country. METHODS: We used the theory of change model and the nominal group technique in five stakeholder meetings. Meetings were held to discuss the mental health needs of youth in Botswana and identify priorities for a lay counsellor based intervention modelled after the Friendship Bench intervention, an existing mental health intervention for adults. RESULTS: The root causes of mental health problems among Botswana's youth identified by stakeholders included limited mental health knowledge among the youth and the community, family problems, poor communication, low self-esteem, the rapid growth of technology, and biological/genetic predisposition. Structurally barriers included: mental illness-related stigma, lack of psychosocial support, incomplete follow up for health services, cultural beliefs about mental illness, and fragmented mental health services. The stakeholders envisage a program that could empower adolescents and youth counselors to address mental health concerns for a healthier community. The group identified and prioritized several key elements of an effective lay counselor intervention. CONCLUSIONS: A diverse group of community stakeholders can illustrate critical mental health needs and elements that countries could use to adapt and contextualize a lay counsellor based mental health intervention for new populations such as the youth.

Acute Cerebrovascular Events in Hospitalized COVID-19 Patients.

BACKGROUND AND PURPOSE: Initial reports suggest a significant risk of thrombotic events, including stroke, in patients hospitalized with coronavirus disease 2019 (COVID-19). However, there is little systematic data on stroke incidence and mechanisms, particularly in racially diverse populations in the United States. METHODS: We performed a retrospective, observational study of stroke incidence and mechanisms in all patients with COVID-19 hospitalized from March 15 to May 3, 2020, at 3 Philadelphia hospitals. RESULTS: We identified 844 hospitalized patients with COVID-19 (mean age 59 years, 52% female, 68% Black); 20 (2.4%) had confirmed ischemic stroke; and 8 (0.9%) had intracranial hemorrhage. Of the ischemic stroke patients, mean age was 64 years, with only one patient (5%) under age 50, and 80% were Black. Conventional vascular risk factors were common, with 95% of patients having a history of hypertension and 60% a history of diabetes mellitus. Median time from onset of COVID symptoms to stroke diagnosis was 21 days. Stroke mechanism was cardioembolism in 40%, small vessel disease in 5%, other determined mechanism in 20%, and cryptogenic in 35%. Of the 11 patients with complete vascular imaging, 3 (27%) had large vessel occlusion. Newly positive antiphospholipid antibodies were present in >75% of tested patients. Of the patients with intracranial hemorrhage, 5/8 (63%) were lobar intraparenchymal hemorrhages, and 3/8 (38%) were subarachnoid hemorrhage; 4/8 (50%) were on extracorporeal membrane oxygenation. CONCLUSIONS: We found a low risk of acute cerebrovascular events in patients hospitalized with COVID-19. Most patients with ischemic stroke had conventional vascular risk factors, and traditional stroke mechanisms were common.