2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association.

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association.

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association.

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

Physical function, psychological adjustment, and self-efficacy following sudden cardiac arrest and an initial implantable cardioverter defibrillator (ICD) in a social cognitive theory intervention: secondary analysis of a randomized control trial.

BACKGROUND: Sudden cardiac arrest (SCA) survivorship results in unique issues in return to physical and psychological function. The purpose of the study was to compare recovery across the first year between SCA survivors and other arrhythmia patients who received a first-time implantable cardioverter defibrillator (ICD) for secondary prevention, participating in a social cognitive theory (SCT) intervention. METHODS: 168 (129 males, 39 females) who received an ICD for secondary prevention (SCA N = 65; other arrhythmia N = 103) were randomized to one of two study conditions: SCT intervention (N = 85) or usual care (N = 83). Outcomes were measured at baseline hospital discharge, 1, 3, 6, & 12 months: (1) Physical Function: Patient Concerns Assessment (PCA), SF-36 (PCS); (2) Psychological Adjustment: State Trait Anxiety (STAI), CES-D depression, SF-36 (MCS); (3) Self-Efficacy: Self-Efficacy (SCA-SE), Self-management Behaviors (SMB), Outcome Expectations (OE). Outcomes were compared over 12 months for intervention condition x ICD indication using general estimating equations. RESULTS: Participants were Caucasian (89%), mean age 63.95 ± 12.3 years, EF% 33.95 ± 13.9, BMI 28.19 ± 6.2, and Charlson Index 4.27 ± 2.3. Physical symptoms (PCA) were higher over time for SCA survivors compared to the other arrhythmia group (p = 0.04), ICD shocks were lower in SCA survivors in the SCT intervention (p = 0.01); psychological adjustment (MCS) was significantly lower in SCA survivors in the SCT intervention over 6 months, which improved at 12 months (p = 0.05); outcome expectations (OE) were significantly lower for SCA survivors in the SCT intervention (p = 0.008). CONCLUSIONS: SCA survivors had greater number of physical symptoms, lower levels of mental health and outcome expectations over 12 months despite participation in a SCT intervention. Trial registration Clinicaltrials.gov: NCT04462887.

Quality of life and symptom experience measurement tools in adults with atrial fibrillation: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to identify and map measurement tools for evaluating disease-specific quality of life and symptoms in adults with atrial fibrillation. The review will also identify key concepts that differentiate quality of life from symptom experience. INTRODUCTION: Quality of life is a broad concept influenced by physical health, psychological state, degree of independence, and social/functional status. Symptoms of a chronic disease may influence quality of life through their effect on an individual's perception of physical health. Symptom experience is distinct from quality of life; however, the distinction is ill-defined, resulting in conceptual overlap in the measurement tools used to assess these concepts in patients with atrial fibrillation. INCLUSION CRITERIA: Included manuscripts will describe a scale, index, questionnaire, checklist, or other form of measurement tool designed to assess quality of life or symptom experience in adults with atrial fibrillation or supraventricular arrhythmia. Peer-reviewed research manuscripts and systematic reviews, gray literature, and conceptual/theoretical papers will be included. METHODS: The review will follow the JBI methodology for scoping reviews. MEDLINE, CINAHL, PsycINFO, the Cochrane Database of Systematic Reviews, and Embase will be searched, as well as Google Scholar, MedNar, and OpenGrey. Articles will be considered if they are published in English, Danish, Swedish, or Norwegian, with no date limitation. The title and abstract of each article will be independently screened by two authors, followed by full-text review of remaining articles, according to the inclusion criteria. Data will be independently extracted by two authors using a data extraction tool.

Left Ventricular Assist Device Caregiver Experiences and Health Outcomes: A Systematic Review of Qualitative and Quantitative Studies.

BACKGROUND: Knowledge synthesis is lacking regarding outcomes and experiences of caregivers of adult patients living with continuous flow left ventricular assist devices (CF-LVAD). The purpose of this systematic review was to summarize qualitative data related to the experience of caregivers of adult patients living with CF-LVAD as well as quantitative data related to health outcomes of caregivers. METHODS AND RESULTS: Multiple databases were systematically queried for studies of qualitative experiences and quantitative health outcomes for caregivers of adult CF-LVAD recipients. Search dates were constrained to articles published between 2004 and August of 2018 because CF-LVADs were not routinely implanted before 2004. Two authors independently screened 683 articles; 15 met predetermined inclusion criteria. Eligible articles reported results from 13 studies. Of those, 8 used either qualitative or mixed methods and 5 used quantitative methods. Caregivers were primarily female (81%) and their mean age was 59 years. Qualitative studies revealed 3 overarching themes related to the caregiver role, coping strategies, and LVAD decisions. Quantitative studies revealed caregiver strain peaked between 1 and 3 months after implantation, anxiety and depression were relatively stable, mental health status improved, and physical health status was stable from before to after implantation. CONCLUSIONS: CF-LVAD caregivers experience significant, sustained emotional strain for 3 months after implantation, reporting considerable stress in meeting their personal needs and those of their loved one.

Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial.

BACKGROUND: Sexual concerns and changes in sexual activity are common among patients and their intimate partners after an implantable cardioverter defibrillator (ICD). AIMS: Our aims were to (i) describe patient and partner sexual activity and related concerns from the time of an initial ICD implant through 12-month follow-up and (ii) identify factors predictive of return to sexual activity and fears associated with sexual activity. METHODS: This secondary descriptive analysis was conducted with data from a randomized controlled trial (2009-2015) designed to compare 2 interventions for patients (Patient-Only) and for patients and their partners (Patient+Partner) after implant of an initial ICD. The sample included 105 patients and their intimate partners who reported sexual activity during the 24 months before ICD implant. OUTCOMES: The Sexual Concerns Inventory was used to assess sexual activity and related concerns. RESULTS: Study participants comprised 72% male and were of mean age 65.6 ± 10.6 years; partners comprised 64% female and were of mean age 63 ± 11.6 years. Sexual activity increased after ICD: 73% of patients reported no sexual intercourse during 2 months before study enrollment, whereas only 46% reported no sexual intercourse during the 2 months before 12-month follow-up. Reductions in sexual concerns were evident 1 month after implant, with continued reductions through 12 months (patient 6.48 ± 4.03 to 5.22 ± 3.38, P = .004; partner 6.93 ± 4.01 to 5.2 ± 3.56, P < .001). Patient physical health predicted sexual activity 3 months after implant placement (P = .04); general ICD concerns (P < .001) predicted patient ICD-related sexual fears at 3 months. At 12 months, baseline general ICD concerns (P < .02) predicted sexual fears. CLINICAL IMPLICATIONS: ICD patients and partners report low levels of sexual activity at the time of initial ICD implant, with reported increases in sexual activity over the 12-month recovery period: Sexual concerns were highest immediately after ICD implant. STRENGTHS & LIMITATIONS: Notably, the major strengths of this study were the repeated measures and longitudinal study design; the main limitation of the study was the lack of a "usual care" control group. CONCLUSION: Sexual activity at the time of an initial ICD implant is low, and sexual concerns are most prominent for both patients and partners immediately after implant placement. Baseline physical health predicts subsequent sexual activity at 3 months, while general ICD-related worry predicts sexual fears at 3 and 12 months. Streur MM, Rosman LA, Sears SF, et al. Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial. J Sex Med 2020;17:892-902.

Multisymptom Profile Predicts Increased Risk of Poor Outcomes After Initial Placement of Implantable Cardioverter Defibrillator.

CONTEXT: Patients with implantable cardioverter defibrillators (ICDs) are at risk for multiple physical and psychological symptoms. Identification of specific symptom profiles associated with poor outcomes may elucidate novel strategies to enhance symptom management. OBJECTIVES: The objectives were to determine common symptoms after initial ICD implantation, identify classes of individuals with similar symptom profiles, describe patient characteristics associated with different symptom profiles, and determine if symptom profiles at hospital discharge predicted outcomes three and 12 months after implantation. METHODS: This was a secondary data analysis of a randomized controlled trial that compared patient + partner versus patient-only interventions designed to help patients manage symptoms, prepare for ICD shocks, and resume daily activities. Symptoms were measured with the Patient Concerns Assessment. Latent class regression analysis was used to identify symptom classes at baseline, three-month, and 12-month follow-up. Associations between patient characteristics, class membership, and outcomes were examined using chi-square, analysis of variance, and Poisson regression. RESULTS: The study included 301 patients (74% male, mean age 64 ± 11.9 years). Three classes were identified: Multi-Symptom (N = 119, 40%), Tired-Rundown (N = 130, 43%), and Mostly Asymptomatic (N = 52, 17%). Patients in the Multi-Symptom class were younger (59.9 years, P < 0.001) and reported more anxiety (P < 0.001) and depression (P < 0.01) than the other classes. Membership in the Multi-Symptom class predicted lower quality of life and resulted in nearly double the rate of hospitalizations after 12 months (P = 0.02, IRR 1.9). CONCLUSION: Evaluation of symptom profiles after ICD implantation offers a promising strategy for identifying patients at risk for poor health outcomes.

Atrial fibrillation symptom profiles associated with healthcare utilization: A latent class regression analysis.

BACKGROUND: Symptoms drive healthcare use among adults with atrial fibrillation, but limited data are available regarding which symptoms are most problematic and which patients are most at-risk. The purpose of this study was to: (1) identify clusters of patients with similar symptom profiles, (2) characterize the individuals within each cluster, and (3) determine whether specific symptom profiles are associated with healthcare utilization. METHODS: We conducted a cross-sectional secondary data analysis of 1,501 adults from the Vanderbilt Atrial Fibrillation Registry. Participants were recruited from Vanderbilt cardiology clinics, emergency department, and in-patient services. Subjects included in our analysis had clinically verified atrial fibrillation and a completed symptom survey. Symptom and healthcare utilization data were collected with the University of Toronto Atrial Fibrillation Severity Scale. Latent class regression analysis was used to identify symptom clusters, with clinical and demographic variables included as covariates. We used Poisson regression to examine the association between latent class membership and healthcare utilization. RESULTS: Participants were predominantly male (67%) with a mean age of 58.4 years (±11.9). Four latent classes were evident, including an Asymptomatic cluster (N = 487, 38%), Highly Symptomatic cluster (N = 142, 11%), With Activity cluster (N = 326, 25%), and Mild Diffuse cluster (N = 336, 26%). Highly Symptomatic membership was associated with the greatest rate of emergency department visits and hospitalizations (incident rate ratio 2.4, P < 0.001). CONCLUSIONS: Clinically meaningful atrial fibrillation symptom profiles were identified that were associated with increased rates of emergency department visits and hospitalizations.

Continuous warfarin versus periprocedural dabigatran to reduce stroke and systemic embolism in patients undergoing catheter ablation for atrial fibrillation or left atrial flutter.

PURPOSE: Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center. METHODS: We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3 months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24-30 h pre-procedure and restarted 4-6 h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3 months post-ablation. RESULTS: A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5 %), compared with one (0.7 %) in the warfarin group (p = 0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4 %, p = 0.07), major bleeding (1.6 vs. 0.7 %, p = 0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9 %, p = 0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24 h post-ablation). CONCLUSIONS: In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.