Consumer-Led Screening for Atrial Fibrillation: Frontier Review of the AF-SCREEN International Collaboration.

The technological evolution and widespread availability of wearables and handheld ECG devices capable of screening for atrial fibrillation (AF), and their promotion directly to consumers, has focused attention of health care professionals and patient organizations on consumer-led AF screening. In this Frontiers review, members of the AF-SCREEN International Collaboration provide a critical appraisal of this rapidly evolving field to increase awareness of the complexities and uncertainties surrounding consumer-led AF screening. Although there are numerous commercially available devices directly marketed to consumers for AF monitoring and identification of unrecognized AF, health care professional-led randomized controlled studies using multiple ECG recordings or continuous ECG monitoring to detect AF have failed to demonstrate a significant reduction in stroke. Although it remains uncertain if consumer-led AF screening reduces stroke, it could increase early diagnosis of AF and facilitate an integrated approach, including appropriate anticoagulation, rate or rhythm management, and risk factor modification to reduce complications. Companies marketing AF screening devices should report the accuracy and performance of their products in high- and low-risk populations and avoid claims about clinical outcomes unless improvement is demonstrated in randomized clinical trials. Generally, the diagnostic yield of AF screening increases with the number, duration, and temporal dispersion of screening sessions, but the prognostic importance may be less than for AF detected by single-time point screening, which is largely permanent, persistent, or high-burden paroxysmal AF. Consumer-initiated ECG recordings suggesting possible AF always require confirmation by a health care professional experienced in ECG reading, whereas suspicion of AF on the basis of photoplethysmography must be confirmed with an ECG. Consumer-led AF screening is unlikely to be cost-effective for stroke prevention in the predominantly young, early adopters of this technology. Studies in older people at higher stroke risk are required to demonstrate both effectiveness and cost-effectiveness. The direct interaction between companies and consumers creates new regulatory gaps in relation to data privacy and the registration of consumer apps and devices. Although several barriers for optimal use of consumer-led screening exist, results of large, ongoing trials, powered to detect clinical outcomes, are required before health care professionals should support widespread adoption of consumer-led AF screening.

Evaluation of Huawei smart wearables for detection of atrial fibrillation in patients following ischemic stroke: The Liverpool-Huawei stroke study.

BACKGROUND: Atrial fibrillation (AF) often remains undetected following stroke. Documenting AF is critical to initiate oral anticoagulation, which has proven benefit in reducing recurrent stroke and mortality in patients with AF. The accuracy and acceptability of using smart wearables to detect AF in patients following stroke is unknown. METHODS: The aims of the Liverpool-Huawei Stroke Study are to determine the effectiveness, cost-effectiveness and patient and staff acceptability of using Huawei smart wearables to detect AF following ischemic stroke. The study plans to recruit 1,000 adults aged ≥18 years following ischemic stroke from participating hospitals over 12 months. All participants will be asked to wear a Huawei smart band for 4 weeks postdischarge. If participants do not have access to a compatible smartphone required for the study, they will be provided with a smartphone for the 4-week AF monitoring period. RESULTS: Participants with suspected AF detected by the smart wearables, without previous known AF, will be referred for further evaluation. To determine the effectiveness of the Huawei smart wearables to detect AF, the positive predictive value will be determined. Patient acceptability of using this technology will also be examined. Additional follow-up assessments will be conducted at 6 and 12 months, and clinical outcomes recorded in relation to prevalent and incident AF post-stroke. The study opened for recruitment on May 30, 2022, and is currently open at 4 participating hospitals; the first 106 participants have been recruited. One further hospital is preparing to open for recruitment. CONCLUSIONS: This prospective study will examine the effectiveness and acceptability of the use of smart wearables in patients following ischemic stroke. This could have important implications for detection of AF and therefore, earlier prophylaxis for recurrent stroke. The study is registered on https://www.isrctn.com/ (Identifier ISRCTN30693819).

Mobile health technology integrated care in atrial fibrillation patients with diabetes mellitus in China: A subgroup analysis of the mAFA-II cluster randomized clinical trial.

BACKGROUND: The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) prospective randomized trial showed the efficacy of a mobile health (mHealth) implemented 'Atrial fibrillation Better Care' (ABC) pathway for the integrated care management of patients with atrial fibrillation (AF). In this ancillary analysis, we evaluated the effect of mAFA intervention according to the history of diabetes mellitus (DM). METHODS: The mAFA-II trial enrolled 3324 AF patients across 40 centres in China, between June 2018 and August 2019. In this analysis, we assessed the interaction between history of DM and the effect of mAFA intervention on the risk of the primary composite outcome of stroke, thromboembolism, all-cause death and rehospitalizations. Results were expressed as adjusted hazard ratio (aHR) and 95% confidence intervals (95%CI). The effect of mAFA intervention on exploratory secondary outcomes was also assessed. RESULTS: Overall, 747 (22.5%) patients had DM (mean age: 72.7 ± 12.3, 39.6% females; 381 allocated to mAFA intervention). mAFA intervention was associated with a significant risk reduction for the primary composite outcome both in patients with and without DM (aHR [95%CI]: .36 [.18-.73] and .37 [.23-.61], respectively, p for interaction = .941). A significant interaction was found only for the composite of recurrent AF, heart failure and acute coronary syndromes (pint =.025), with lower effect of mAFA intervention in patients with DM. CONCLUSIONS: A mHealth-technology implemented ABC pathway showed a consistent effect in reducing the risk of the primary composite outcome in AF patients with and without DM. TRIAL REGISTRATION: WHO International Clinical Trials Registry Platform (ICTRP) Registration number: ChiCTR-OOC-17014138.

Natural Language Processing in a Clinical Decision Support System for the Identification of Venous Thromboembolism: Algorithm Development and Validation.

BACKGROUND: It remains unknown whether capturing data from electronic health records (EHRs) using natural language processing (NLP) can improve venous thromboembolism (VTE) detection in different clinical settings. OBJECTIVE: The aim of this study was to validate the NLP algorithm in a clinical decision support system for VTE risk assessment and integrated care (DeVTEcare) to identify VTEs from EHRs. METHODS: All inpatients aged ≥18 years in the Sixth Medical Center of the Chinese People's Liberation Army General Hospital from January 1 to December 31, 2021, were included as the validation cohort. The sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-, respectively), area under the receiver operating characteristic curve (AUC), and F1-scores along with their 95% CIs were used to analyze the performance of the NLP tool, with manual review of medical records as the reference standard for detecting deep vein thrombosis (DVT) and pulmonary embolism (PE). The primary end point was the performance of the NLP approach embedded into the EHR for VTE identification. The secondary end points were the performances to identify VTE among different hospital departments with different VTE risks. Subgroup analyses were performed among age, sex, and the study season. RESULTS: Among 30,152 patients (median age 56 [IQR 41-67] years; 14,247/30,152, 47.3% females), the prevalence of VTE, PE, and DVT was 2.1% (626/30,152), 0.6% (177/30,152), and 1.8% (532/30,152), respectively. The sensitivity, specificity, LR+, LR-, AUC, and F1-score of NLP-facilitated VTE detection were 89.9% (95% CI 87.3%-92.2%), 99.8% (95% CI 99.8%-99.9%), 483 (95% CI 370-629), 0.10 (95% CI 0.08-0.13), 0.95 (95% CI 0.94-0.96), and 0.90 (95% CI 0.90-0.91), respectively. Among departments of surgery, internal medicine, and intensive care units, the highest specificity (100% vs 99.7% vs 98.8%, respectively), LR+ (3202 vs 321 vs 77, respectively), and F1-score (0.95 vs 0.89 vs 0.92, respectively) were in the surgery department (all P<.001). Among low, intermediate, and high VTE risks in hospital departments, the low-risk department had the highest AUC (1.00 vs 0.94 vs 0.96, respectively) and F1-score (0.97 vs 0.90 vs 0.90, respectively) as well as the lowest LR- (0.00 vs 0.13 vs 0.08, respectively) (DeLong test for AUC; all P<.001). Subgroup analysis of the age, sex, and season demonstrated consistently good performance of VTE detection with >87% sensitivity and specificity and >89% AUC and F1-score. The NLP algorithm performed better among patients aged ≤65 years than among those aged >65 years (F1-score 0.93 vs 0.89, respectively; P<.001). CONCLUSIONS: The NLP algorithm in our DeVTEcare identified VTE well across different clinical settings, especially in patients in surgery units, departments with low-risk VTE, and patients aged ≤65 years. This algorithm can help to inform accurate in-hospital VTE rates and enhance risk-classified VTE integrated care in future research.

[Application of photoplethysmography for atrial fibrillation in early warning, diagnosis and integrated management].

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Early diagnosis and effective management are important to reduce atrial fibrillation-related adverse events. Photoplethysmography (PPG) is often used to assist wearables for continuous electrocardiograph monitoring, which shows its unique value. The development of PPG has provided an innovative solution to AF management. Serial studies of mobile health technology for improving screening and optimized integrated care in atrial fibrillation have explored the application of PPG in screening, diagnosing, early warning, and integrated management in patients with AF. This review summarizes the latest progress of PPG analysis based on artificial intelligence technology and mobile health in AF field in recent years, as well as the limitations of current research and the focus of future research.

4S-AF scheme and ABC pathway guided management improves outcomes in atrial fibrillation patients.

BACKGROUND: The 4S-AF scheme and the ABC pathway for integrated care have been proposed to better characterize and treat patients with atrial fibrillation (AF). We aimed to evaluate the assessment of the 4S-AF scheme and ABC pathway in Chinese AF patients. METHODS: The ChiOTEAF is a prospective, observational, multicentre registry. Consecutive AF patients from 44 centres across 20 Chinese provinces with available 1-year follow-up data were included. RESULTS: A total of 6419 patients were included, median age 76 years (interquartile range 67-83; 39.1% female). Of these, 3503 (59.8%) patients were not characterized using the 4S-AF scheme and not management according to the ABC pathway (group 1); 1795 (28.0%) were characterized according to the 4S-AF scheme but ABC pathway non-adherent or vice versa (group 2); and 1121 (17.4%) characterized according to the 4S-AF scheme and were ABC pathway adherent (group 3). As compared with group 1, group 2 and group 3 were independently associated with lower odds of the composite endpoint of all-cause death/any thromboembolic event, with the greatest benefit observed in group 3 (OR: 0.19; 95% CI 0.12-0.31) [for group 2: OR: 0.28; 95% CI 0.20-0.37]. Similar results were observed for all-cause death (group 2: OR: 0.18; 95% CI 0.12-0.27; group 3: OR: 0.14; 95% CI 0.07-0.25). CONCLUSIONS: In a contemporary real-word cohort of Chinese AF patients, it is feasible to characterize and manage AF patients using the novel 4S-AF scheme and ABC pathway for integrated care. The use of both these tools is associated with improved clinical outcomes.

Digoxin use and clinical outcomes in elderly Chinese patients with atrial fibrillation: a report from the Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry.

AIMS: Prior studies have reported conflicting results on digoxin's impact on clinical outcomes and quality of life, and there are limited data from Asia. The aim of this study is to evaluate the use of digoxin and its impact on clinical outcomes and quality of life in a high-risk cohort of elderly Chinese atrial fibrillation (AF) patients. METHODS AND RESULTS: The Optimal Thromboprophylaxis in Elderly Chinese Patients with Atrial Fibrillation (ChiOTEAF) registry is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. Endpoints of interest were the composite outcome of all-cause death/any thromboembolism (TE), all-cause death, cardiovascular death, sudden cardiac death, and TE events, as well as the quality of life. The eligible cohort for this analysis included 6391 individuals, of whom 751 (11.8%) patients were treated with digoxin. On multivariate analysis, the use of digoxin was associated with a higher odds ratio (OR) of composite outcome [OR: 1.71; 95% confidence interval (CI): 1.32-2.22], all-cause death (OR: 1.62; 95% CI: 1.23-2.14), and any TE (OR: 1.78; 95% CI: 1.08-2.95). Results were consistent in a subgroup of patients with diagnosed heart failure (HF) and patients with permanent AF. The use of digoxin was associated with worse health-related quality of life (mean EQ index: 0.76 ± 0.19 vs. 0.84 ± 0.18; P < 0.001). CONCLUSIONS: In this nationwide cohort study, digoxin use was associated with an overall higher risk of the composite outcome of all-cause death/any TE, all-cause death, and any TE, regardless of HF diagnosis. Patients treated with digoxin had a worse health-related quality of life.

Mobile health technology integrated care in older atrial fibrillation patients: a subgroup analysis of the mAFA-II randomised clinical trial.

BACKGROUND: The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) randomised trial demonstrated the efficacy of a mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway-approach (mAFA intervention) in reducing the risk of adverse events in patients with atrial fibrillation (AF). Whether these benefits also apply to older patients is unclear. In this ancillary analysis, we evaluated the effect of mAFA intervention among older AF patients. METHODS: The mAFA-II trial enrolled adult AF patients across 40 centres in China. For this analysis, we defined older patients as those aged ≥75 years. Primary outcome was the composite of ischemic stroke or thromboembolism, all-cause death and rehospitalisation. The effect of mAFA intervention was assessed through multivariable Cox-regression models. We also evaluated the interaction between age and effect of the mAFA intervention in the main trial population. RESULTS: In this analysis, we included 1,163 AF patients ≥75 years (mean age: 82.6 ± 5.3 years, 43.1% females); 520 were allocated to mAFA intervention, 643 to usual care. mAFA intervention was associated with a significant reduction of the primary composite outcome (adjusted hazard ratio [aHR]: 0.58, 95% confidence interval [CI]: 0.35-0.97) and rehospitalisations alone (aHR: 0.47, 95%CI: 0.24-0.91). Significant interaction between age and mAFA intervention effect was observed for both the composite outcome (P = 0.002) and rehospitalisation alone (P = 0.015), with the effect decreasing as age increased, particularly among patients ≥80 years old. CONCLUSIONS: A mHealth technology-implemented ABC pathway is effective in reducing adverse clinical outcomes in older AF patients. The benefits obtained with mAFA intervention were attenuated at extreme ages.

Relations between left atrial appendage contrast retention and thromboembolic risk in patients with atrial fibrillation.

Left atrial appendage (LAA), a blind pouch, accounts for more than 90% of the source of cardiac thrombus formation. Contrast retention (CR) in the LAA has been frequently observed during left atrial appendage occlusion (LAAO) procedures, especially in patients with stroke history. This study was designed to assess the relations between LAA contrast retention and thrombogenesis risk of the LAA in patients with non-valvular atrial fibrillation. A total of 132 consecutive patients who underwent LAAO were enrolled. The data collected from computed tomography (CT), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and blood samples were analyzed. Univariate and multivariate logistic regression models were constructed to assess the association between CR, left atrial appendage thrombus (LAAT) and other factors. Contrast retention was observed in 33 patients, accounting for 25% of the population. Compared to the non-CR group, patients in the CR group had a larger left atrium anteroposterior diameter (49.64 ± 11.57 vs. 42.42 ± 7.04, P = 0.002), higher CHADS2 (3.88 ± 0.99 vs. 2.97 ± 1.35, P = 0.001) and CHA2DS2-VASc scores (5.79 ± 1.14 vs. 4.89 ± 1.56, P = 0.003), a higher rate of prior stroke (90.9% vs. 66.7%, P = 0.007), more LAA lobes (3.13 ± 1.18 vs. 2.64 ± 1.12, P = 0.038), and a higher prevalence of LAAT (63.6% vs. 13.1%, P < 0.001). After having adjusted the logistic model, only contrast retention, LAA cauliflower morphology and left ventricular ejection fraction (LVEF) were independently associated with LAAT. Patients with LAA contrast retention have a higher risk of left atrial appendage thrombosis. Contrast retention may be a cardiac factor strongly associated with cardiogenic stroke.

Importance of attributes and willingness to pay for oral anticoagulant therapy in patients with atrial fibrillation in China: A discrete choice experiment.

BACKGROUND: Adherence to oral anticoagulant therapy in patients with atrial fibrillation (AF) in China is low. Patient preference, one of the main reasons for discontinuation of oral anticoagulant therapy, is an unfamiliar concept in China. METHODS AND FINDINGS: A discrete choice experiment (DCE) was conducted to quantify patient preference on 7 attributes of oral anticoagulant therapy: antidote (yes/no), food-drug interaction (yes/no), frequency of blood monitoring (no need, every 6/3/1 month[s]), risk of nonfatal major bleeding (0.7/3.1/5.5/7.8[%]), risk of nonfatal stroke (ischemic/hemorrhagic) or systemic embolism (0.6/3.2/5.8/8.4[%]), risk of nonfatal acute myocardial infarction (AMI) (0.2/1.0/1.8/2.5[%]), and monthly out-of-pocket cost (0/120/240/360 RMB) (0 to 56 USD). A total of 16 scenarios were generated by using D-Efficient design and were randomly divided into 2 blocks. Eligible patients were recruited and interviewed from outpatient and inpatient settings of 2 public hospitals in Beijing and Shenzhen, respectively. Patients were presented with 8 scenarios and asked to select 1 of 3 options: 2 unlabeled hypothetical treatments and 1 opt-out option. Mixed logit regression model was used for estimating patients' preferences of attributes of oral anticoagulants and willingness to pay (WTP) with adjustments for age, sex, education level, income level, city, self-evaluated health score, histories of cardiovascular disease/other vascular disease/any stroke/any bleeding, and use of anticoagulant/antiplatelet therapy. A total of 506 patients were recruited between May 2018 and December 2019 (mean age 70.3 years, 42.1% women). Patients were mainly concerned about the risks of AMI (ß: -1.03; 95% CI: -1.31, -0.75; p < 0.001), stroke or systemic embolism (ß: -0.81; 95% CI: -0.90, -0.73; p < 0.001), and major bleeding (ß: -0.69; 95% CI: -0.78, -0.60; p < 0.001) and were willing to pay more, from up to 798 RMB to 536 RMB (124 to 83 USD) monthly. The least concerning attribute was frequency of blood monitoring (ß: -0.31; 95% CI: -0.39, -0.24; p < 0.001). Patients had more concerns about food-drug interactions even exceeding preferences on the 3 risks, if they had a history of stroke or bleeding (ß: -2.47; 95% CI: -3.92, -1.02; p < 0.001), recruited from Beijing (ß: -1.82; 95% CI: -2.56, -1.07; p < 0.001), or men (ß: -0.96; 95% CI: -1.36, -0.56; p < 0.001). Patients with lower educational attainment or lower income weighted all attributes lower, and their WTP for incremental efficacy and safety was minimal. Since the patients were recruited from 2 major hospitals from developed cities in China, further studies with better representative samples would be needed. CONCLUSIONS: Patients with AF in China were mainly concerned about the safety and effectiveness of oral anticoagulant therapy. The preference weighting on food-drug interaction varied widely. Patients with lower educational attainment or income levels and less experience of bleeding or stroke had more reservations about paying for oral anticoagulant therapies with superior efficacy, safety, and convenience of use.

Characteristics and Outcomes in Patients With COVID-19 and Acute Ischemic Stroke: The Global COVID-19 Stroke Registry.

Recent case-series of small size implied a pathophysiological association between coronavirus disease 2019 (COVID-19) and severe large-vessel acute ischemic stroke. Given that severe strokes are typically associated with poor prognosis and can be very efficiently treated with recanalization techniques, confirmation of this putative association is urgently warranted in a large representative patient cohort to alert stroke clinicians, and inform pre- and in-hospital acute stroke patient pathways. We pooled all consecutive patients hospitalized with laboratory-confirmed COVID-19 and acute ischemic stroke in 28 sites from 16 countries. To assess whether stroke severity and outcomes (assessed at discharge or at the latest assessment for those patients still hospitalized) in patients with acute ischemic stroke are different between patients with COVID-19 and non-COVID-19, we performed 1:1 propensity score matching analyses of our COVID-19 patients with non-COVID-19 patients registered in the Acute Stroke Registry and Analysis of Lausanne Registry between 2003 and 2019. Between January 27, 2020, and May 19, 2020, 174 patients (median age 71.2 years; 37.9% females) with COVID-19 and acute ischemic stroke were hospitalized (median of 12 patients per site). The median National Institutes of Health Stroke Scale was 10 (interquartile range [IQR], 4-18). In the 1:1 matched sample of 336 patients with COVID-19 and non-COVID-19, the median National Institutes of Health Stroke Scale was higher in patients with COVID-19 (10 [IQR, 4-18] versus 6 [IQR, 3-14]), P=0.03; (odds ratio, 1.69 [95% CI, 1.08-2.65] for higher National Institutes of Health Stroke Scale score). There were 48 (27.6%) deaths, of which 22 were attributed to COVID-19 and 26 to stroke. Among 96 survivors with available information about disability status, 49 (51%) had severe disability at discharge. In the propensity score-matched population (n=330), patients with COVID-19 had higher risk for severe disability (median mRS 4 [IQR, 2-6] versus 2 [IQR, 1-4], P<0.001) and death (odds ratio, 4.3 [95% CI, 2.22-8.30]) compared with patients without COVID-19. Our findings suggest that COVID-19 associated ischemic strokes are more severe with worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.

'Real-world' observational studies in arrhythmia research: data sources, methodology, and interpretation. A position document from European Heart Rhythm Association (EHRA), endorsed by Heart Rhythm Society (HRS), Asia-Pacific HRS (APHRS), and Latin America HRS (LAHRS).

The field of observational studies or "real world studies" is in rapid development with many new techniques introduced and increased understanding of traditional methods. For this reason the current paper provides an overview of current methods with focus on new techniques. Some highlights can be emphasized: We provide an overview of sources of data for observational studies. There is an overview of sources of bias and confounding. Next There is an overview of causal inference techniques that are increasingly used. The most commonly used techniques for statistical modelling are reviewed with focus on the important distinction of risk versus prediction. The final section provides examples of common problems with reporting observational data.

Genome-wide analysis and characterization of F-box gene family in Gossypium hirsutum L.

BACKGROUND: F-box proteins are substrate-recognition components of the Skp1-Rbx1-Cul1-F-box protein (SCF) ubiquitin ligases. By selectively targeting the key regulatory proteins or enzymes for ubiquitination and 26S proteasome mediated degradation, F-box proteins play diverse roles in plant growth/development and in the responses of plants to both environmental and endogenous signals. Studies of F-box proteins from the model plant Arabidopsis and from many additional plant species have demonstrated that they belong to a super gene family, and function across almost all aspects of the plant life cycle. However, systematic exploration of F-box family genes in the important fiber crop cotton (Gossypium hirsutum) has not been previously performed. The genome-wide analysis of the cotton F-box gene family is now possible thanks to the completion of several cotton genome sequencing projects. RESULTS: In current study, we first conducted a genome-wide investigation of cotton F-box family genes by reference to the published F-box protein sequences from other plant species. 592 F-box protein encoding genes were identified in the Gossypium hirsutume acc.TM-1 genome and, subsequently, we were able to present their gene structures, chromosomal locations, syntenic relationships with their parent species. In addition, duplication modes analysis showed that cotton F-box genes were distributed to 26 chromosomes, with the maximum number of genes being detected on chromosome 5. Although the WGD (whole-genome duplication) mode seems play a dominant role during cotton F-box gene expansion process, other duplication modes including TD (tandem duplication), PD (proximal duplication), and TRD (transposed duplication) also contribute significantly to the evolutionary expansion of cotton F-box genes. Collectively, these bioinformatic analysis suggest possible evolutionary forces underlying F-box gene diversification. Additionally, we also conducted analyses of gene ontology, and expression profiles in silico, allowing identification of F-box gene members potentially involved in hormone signal transduction. CONCLUSION: The results of this study provide first insights into the Gossypium hirsutum F-box gene family, which lays the foundation for future studies of functionality, particularly those involving F-box protein family members that play a role in hormone signal transduction.

Mobile Health (mHealth) technology for improved screening, patient involvement and optimising integrated care in atrial fibrillation: The mAFA (mAF-App) II randomised trial.

BACKGROUND: Current management of patients with atrial fibrillation (AF) is limited by low detection of AF, non-adherence to guidelines and lack of consideration of patient's preferences, thus highlighting the need for a holistic and integrated approach to AF management. This study aims to determine whether a mHealth technology-supported AF integrated management strategy will reduce AF-related adverse events. METHODS/DESIGN: The mAFA II trial is a prospective, cluster randomised controlled trial. The 40 sites will be randomised to mAFA-integrated care intervention or usual care arms. Prior to randomisation, study sites will be paired to be matched in size and the proportion of study eligible patients. All AF patients aged over 18 years old with CHA2 DS2 -VASc score ≥ 2 will be enrolled. Assuming a composite adverse event rate of 10% pre-intervention, reduced to 5% after intervention, we aim to recruit 3660 patients assuming a 10% loss to follow-up. The primary study endpoint is a composite of stroke/thromboembolism, all-cause death and rehospitalisation. Ancillary analyses would determine patient-related outcome measures, health economics and cost effectiveness, as well as an embedded qualitative study. DISCUSSION: The mAFA II trial will provide evidence for an integrated care approach to holistic AF care, supported by mobile health technology to improve screening, patient involvement and optimisation of management.

Validation of Single Centre Pre-Mobile Atrial Fibrillation Apps for Continuous Monitoring of Atrial Fibrillation in a Real-World Setting: Pilot Cohort Study.

BACKGROUND: Atrial fibrillation is the most common recurrent arrhythmia in clinical practice, with most clinical events occurring outside the hospital. Low detection and nonadherence to guidelines are the primary obstacles to atrial fibrillation management. Photoplethysmography is a novel technology developed for atrial fibrillation screening. However, there has been limited validation of photoplethysmography-based smart devices for the detection of atrial fibrillation and its underlying clinical factors impacting detection. OBJECTIVE: This study aimed to explore the feasibility of photoplethysmography-based smart devices for the detection of atrial fibrillation in real-world settings. METHODS: Subjects aged ≥18 years (n=361) were recruited from September 14 to October 16, 2018, for screening of atrial fibrillation with active measurement, initiated by the users, using photoplethysmography-based smart wearable devices (ie, a smart band or smart watches). Of these, 200 subjects were also automatically and periodically monitored for 14 days with a smart band. The baseline diagnosis of "suspected" atrial fibrillation was confirmed by electrocardiogram and physical examination. The sensitivity and accuracy of photoplethysmography-based smart devices for monitoring atrial fibrillation were evaluated. RESULTS: A total of 2353 active measurement signals and 23,864 periodic measurement signals were recorded. Eleven subjects were confirmed to have persistent atrial fibrillation, and 20 were confirmed to have paroxysmal atrial fibrillation. Smart devices demonstrated >91% predictive ability for atrial fibrillation. The sensitivity and specificity of devices in detecting atrial fibrillation among active recording of the 361 subjects were 100% and about 99%, respectively. For subjects with persistent atrial fibrillation, 127 (97.0%) active measurements and 2240 (99.2%) periodic measurements were identified as atrial fibrillation by the algorithm. For subjects with paroxysmal atrial fibrillation, 36 (17%) active measurements and 717 (19.8%) periodic measurements were identified as atrial fibrillation by the algorithm. All persistent atrial fibrillation cases could be detected as "atrial fibrillation episodes" by the photoplethysmography algorithm on the first monitoring day, while 14 (70%) patients with paroxysmal atrial fibrillation demonstrated "atrial fibrillation episodes" within the first 6 days. The average time to detect paroxysmal atrial fibrillation was 2 days (interquartile range: 1.25-5.75) by active measurement and 1 day (interquartile range: 1.00-2.00) by periodic measurement (P=.10). The first detection time of atrial fibrillation burden of <50% per 24 hours was 4 days by active measurement and 2 days by periodic measurementThe first detection time of atrial fibrillation burden of >50% per 24 hours was 1 day for both active and periodic measurements (active measurement: P=.02, periodic measurement: P=.03). CONCLUSIONS: Photoplethysmography-based smart devices demonstrated good atrial fibrillation predictive ability in both active and periodic measurements. However, atrial fibrillation type could impact detection, resulting in increased monitoring time. TRIAL REGISTRATION: Chinese Clinical Trial Registry of the International Clinical Trials Registry Platform of the World Health Organization ChiCTR-OOC-17014138; http://www.chictr.org.cn/showprojen.aspx?proj=24191.

Plasma CX3CL1 levels and long term outcomes of patients with atrial fibrillation: the West Birmingham Atrial Fibrillation Project.

BACKGROUND: There is growing evidence that chemokines are potentially important mediators of the pathogenesis of atherosclerotic disease. Major atherothrombotic complications, such as stroke and myocardial infarction, are common among atrial fibrillation (AF) patients. This increase in risk of adverse events may be predicted by a score based on the presence of certain clinical features of chronic heart failure, hypertension, age 75 years or greater, diabetes and stroke (the CHADS2 score). Our objective was to assess the prognostic value of plasma chemokines CCL2, CXCL4 and CX3CL1, and their relationship with the CHADS2 score, in AF patients. METHODS: Plasma CCL2, CXCL4 and CX3CL1 were measured in 441 patients (59% male, mean age 75 years, 12% paroxysmal, 99% on warfarin) with AF. Baseline clinical and demographic factors were used to define each subject's CHADS2 score. Patients were followed up for a mean 2.1 years, and major adverse cardiovascular and cerebrovascular events (MACCE) were sought, being the combination of cardiovascular death, acute coronary events, stroke and systemic embolism. RESULTS: Fifty-five of the AF patients suffered a MACCE (6% per year). Those in the lowest CX3CL1 quartile (≤ 0.24 ng/ml) had fewest MACCE (p = 0.02). In the Cox regression analysis, CX3CL1 levels >0.24 ng/ml (Hazard ratio 2.8, 95% CI 1.02-8.2, p = 0.045) and age (p = 0.042) were independently linked with adverse outcomes. The CX3CL1 levels rose directly with the CHADS2 risk score (p = 0.009). The addition of CX3CL1 did not significantly increased the discriminatory ability of the CHADS2 clinical factor-based risk stratification (c-index 0.60 for CHADS2 alone versus 0.67 for CHADS2 plus CX3CL1 >0.24 ng/ml, p = 0.1). Aspirin use was associated with lower levels of CX3CL1 (p = 0.0002) and diabetes with higher levels (p = 0.031). There was no association between CXCL4 and CCL2 plasma levels and outcomes. CONCLUSION: There is an independent association between low plasma CX3CL1 levels and low risk of major cardiovascular events in AF patients, as well as a linear association between CX3CL1 plasma levels and CHADS2-defined cardiovascular risk. The potential for CX3CL1 in refining risk stratification in AF patients merits consideration.

Higher ambient temperatures may worsen obstructive sleep apnea: A nationwide smartwatch-based analysis of 6.2 million person-days.

Obstructive sleep apnea (OSA) is a serious type of sleep disorder that can lead to cardiometabolic and neurocognitive diseases. We utilized smart device-based photoplethysmography technology to collect sleep data from the Chinese population from 2019 to 2022. Distributed lag nonlinear models combined with a generalized nonlinear model or a linear mixed effects model were used to investigate the short-term associations between daily temperature and indicators of OSA severity. We included a total of 6,232,056 d of sleep monitoring data from 51,842 participants with moderate to severe risk of OSA from 313 Chinese cities. The relationships between ambient temperature and OSA exacerbation, apnea-hypopnea index (AHI), and minimum oxygen saturation (MinSpO2) were almost linear and present only on the same day. Higher temperatures were associated with a greater risk of OSA exacerbation, with an 8.4% (95% confidence interval (CI): 7.6%-9.3%) increase per 10 °C increase in temperature. A 10 °C increase in daily temperature corresponded to an AHI increase of 0.70 events/h (95% CI: 0.65-0.76) and a MinSpO2 decrease of 0.18% (95% CI: 0.16%-0.19%). Exposure to elevated temperatures during the night can also lead to adverse effects. The effects of higher temperatures on OSA severity were stronger among men, participants with a body mass index ≥ 24 kg/m2, those aged 45 years and older, individuals with a history of hypertension and diabetes, and during the cold season. This large-scale, nationwide, longitudinal study provides robust evidence suggesting that higher ambient temperatures may immediately worsen OSA.