Stroke and bleeding risk in atrial fibrillation with CHA2DS2-VASC risk score of one: the Norwegian AFNOR study.

BACKGROUND AND AIMS: The benefit of oral anticoagulant (OAC) therapy in atrial fibrillation (AF) and intermediate stroke risk is debated. In a nationwide Norwegian cohort with a non-sex CHA2DS2-VASc risk score of one, this study aimed to investigate (i) stroke and bleeding risk in AF patients with and without OAC treatment, and (ii) the risk of stroke in non-anticoagulated individuals with and without AF. METHODS: A total of 1 118 762 individuals including 34 460 AF patients were followed during 2011-18 until ischaemic stroke, intracranial haemorrhage, increased CHA2DS2-VASc score, or study end. One-year incidence rates (IRs) were calculated as events per 100 person-years (%/py). Cox regression models provided adjusted hazard ratios (aHRs [95% confidence intervals]). RESULTS: Among AF patients, the ischaemic stroke IR was 0.51%/py in OAC users and 1.05%/py in non-users (aHR 0.47 [0.37-0.59]). Intracranial haemorrhage IR was 0.28%/py in OAC users and 0.19%/py in non-users (aHR 1.23 [0.88-1.72]). Oral anticoagulant use was associated with an increased risk of major bleeding (aHR 1.37 [1.16-1.63]) but lower risk of the combined outcome of ischaemic stroke, major bleeding, and mortality (aHR 0.57 [0.51-0.63]). Non-anticoagulated individuals with AF had higher risk of ischaemic stroke compared to non-AF individuals with the same risk profile (aHR 2.47 [2.17-2.81]). CONCLUSIONS: In AF patients at intermediate risk of stroke, OAC use was associated with overall favourable clinical outcomes. Non-anticoagulated AF patients had higher risk of ischaemic stroke compared to the general population without AF with the same risk profile.

Sleep duration and cognitive function, The Akershus Cardiac Examination 1950 Study.

INTRODUCTION: Sleep duration are proposed as a lifestyle-related risk factor for cognitive impairment. We investigated the association between sleep duration and cognitive function in a large population-based cohort aged 62-65 years. METHODS: Cross-sectional analyses from the The Akershus Cardiac Examination 1950 Study. Linear and non-linear models were conducted to explore the association between self-reported sleep duration and cognitive function, adjusted for established risk factors for cognitive impairment. RESULTS: We included 3,348 participants, mean age (SD) was 63.9 ±0.6 years, 48.2% were women and 47.9% had education >12 years. Mean sleep duration (SD) was 7.0±1.0 hours, and 10.2% had abnormal sleep duration (<6 or >8 hours). Individuals reporting <6 hours or >8 hours of sleep scored significantly lower on MoCA test and Delayed recall trial in adjusted analysis. CONCLUSIONS: Sleep duration showed an inverted U-shaped association with global cognitive function and memory, suggesting that both shortened and prolonged sleep are related to adverse brain health.

Left atrial function in middle-aged men and women with and without paroxysmal atrial fibrillation: Data from the Akershus Cardiac Examination (ACE) 1950 study.

PURPOSE: To assess left atrial (LA) function in individuals with known paroxysmal atrial fibrillation (AF) compared with healthy and nonhealthy individuals without atrial fibrillation. METHODS: The Akershus Cardiac Examination 1950 Study included 3,706 individuals all born in 1950. LA strain assessment of reservoir (LASr), conduit (LAScd) and contractile (LASct) functions were performed in all participants by investigators blinded to clinical data. Participants with cardiovascular disease, obesity, diabetes, pulmonary or renal disease were defined as nonhealthy, and those without as healthy. Patients with paroxysmal AF were identified through medical history and ECG documentation. RESULTS: LA strain assessment was feasible in 3,229 (87%) of the participants (50% women). The healthy group (n = 758) had significantly higher LASr and LAScd than the nonhealthy (n = 2,376), but LASct was similar between the groups. Participants with paroxysmal AF had significantly lower values of all strain parameters than the other groups. Multivariable logistic regression showed a significantly reduced probability of having AF per standard deviation increase in LASr and LASct. A nonlinear restricted cubic spline model fitted better with the association of LASr with paroxysmal AF than the linear model, and LA strain values below the population mean associated with an increased probability of having AF, but for values above the population mean no such association was present. CONCLUSION: Compared to participants without AF, those with known paroxysmal AF had significantly lower values of all LA strain parameters during sinus rhythm. Lower values of LA strain were associated with a significantly increased probability of having AF.

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration.

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.

Serial blood pressure measurements, left ventricular remodelling and cardiovascular outcomes.

BACKGROUND: Hypertension is a risk factor for the development of cardiovascular disease. Whether serial blood pressure (BP) measurements are more closely associated with subclinical left ventricular (LV) remodelling and better predict risk of cardiovascular events over individual BP measurements are not known. METHODS: We assessed systolic BP, diastolic BP and pulse pressure at several time points during adulthood in 1333 women and 1211 men participating in the Akershus Cardiac Examination 1950 Study. We defined serial BP measurements as the sum of averaged BPs from adjacent consecutive visits indexed to total exposure time between measurements. We assessed the associations between serial and individual BP measurements and (1) LV structure, function and volumes and (2) incident myocardial infarction, ischemic stroke, heart failure and cardiovascular death. RESULTS: All indices of higher serial BP measurements were associated with increased indexed LV mass, and the associations were stronger than those of individual BP measurements. Serial diastolic BP pressure was strongly and inversely associated with LV systolic function, while higher serial systolic BP was primarily associated with higher LV volumes. Both serial systolic (incidence rate ratio [IRR] 1.10, 95% CI 1.03 to 1.17) and diastolic BPs (IRR 1.14, 95% CI 1.02 to 1.27) were associated with increased incidence of clinical events. CONCLUSION: In healthy community dwellers without established cardiovascular disease, different serial BP indices associate strongly with LV remodelling and cardiovascular outcomes. Whether the use of serial BP indices for guiding treatment is superior to individual measurements should be explored in additional prospective studies.

Fully digital self-screening for atrial fibrillation with patch electrocardiogram.

AIMS: Atrial fibrillation (AF) is the most common arrhythmia worldwide. The AF is associated with severe mortality, morbidity, and healthcare costs, and guidelines recommend screening people at risk. However, screening methods and organization still need to be clarified. The current study aimed to assess the feasibility of a fully digital self-screening procedure and to assess the prevalence of undetected AF using a continuous patch electrocardiogram (ECG) monitoring system. METHODS AND RESULTS: Individuals ≥65 years old with at least one additional risk factor for stroke from the general population of Norway were invited to a fully digital continuous self-screening for AF using a patch ECG device (ECG247 Smart Heart Sensor). Participants self-reported clinical characteristics and usability online, and all participants received digital feedback of their results. A total of 2118 individuals with a mean CHA2DS2-VASc risk score of 2.6 (0.9) were enrolled in the study [74% women; mean age 70.1 years (4.2)]. Of these, 1849 (87.3%) participants completed the ECG self-screening test, while 215 (10.2%) did not try to start the test and 54 (2.5%) failed to start the test. The system usability score was 84.5. The mean ECG monitoring time was 153 h (87). Atrial fibrillation was detected in 41 (2.2%) individuals. CONCLUSION: This fully digitalized self-screening procedure for AF demonstrated excellent feasibility. The number needed to screen was 45 to detect one unrecognized case of AF in subjects at risk for stroke. Randomized studies with long-term follow-up are needed to assess whether self-screening for AF can reduce the incidence of AF-related complications. CLINICAL TRIALS: NCT04700865.

Feasibility of Patient-Managed ECG Recordings to Detect the Time of Atrial Fibrillation Recurrence after Electrical Cardioversion: Results from the PRE-ELECTRIC Study.

BACKGROUND: Electrical cardioversion (ECV) is a common procedure to terminate persistent atrial fibrillation (AF). The recurrence rate is high, and the patients often fail to recognize AF recurrence. OBJECTIVES: The aim of the study was to evaluate the feasibility of patient-managed electrocardiography (ECG) to detect the time to AF recurrence after ECV. METHODS: PRE-ELECTRIC (predictors for recurrence of atrial fibrillation after electrical cardioversion) is a prospective, observational study. Patients ≥18 years of age scheduled for ECV of persistent AF at Bærum Hospital were eligible for inclusion in the study. Time to recurrence of AF was detected by thumb ECG, recorded twice daily and whenever experiencing symptoms. The observation period was 28 days. We defined adherence as the observed number of days with ECG recordings divided by the expected number of days with ECG recordings. Study personnel contacted the participants by phone to assess their awareness of AF recurrence after a recurrence was detected in the thumb ECG. RESULTS: The study enrolled 200 patients scheduled for ECV of persistent AF at Bærum Hospital between 2018 and 2022. The mean age was 66.2 ± 9.3 years, and 21.0% (42/200) were women. The most frequent comorbidities were hypertension (n = 94, 47.0%) and heart failure (n = 51, 25.5%). A total of 164 participants underwent ECV of AF. The procedure was initially successful in 90.9%, of which 50.3% had a recurrence of AF within 4 weeks. The median time to recurrence was 5 days. Among the cardioverted participants, 123 (75.0%) had no missing days of thumb ECG recording during the observation period, and 97.0% had ≤3 missing days. More than a third (37.3%) of the participants with AF recurrence were unaware of the recurrence at the time of contact. Women were older and more symptomatic than men but had similar outcomes after ECV. CONCLUSIONS: Recurrence of AF after ECV was common. Using patient-managed thumb ECG was a feasible method to detect AF recurrence following ECV. Further studies are needed to investigate whether patient-managed ECG after ECV can optimize AF treatment.

Screen-detected atrial fibrillation and 'micro-atrial fibrillation' and risk of cardiovascular events after myocardial infarction in elderly patients.

BACKGROUND: Incident atrial fibrillation (AF) occurs in 5-10% of patients after acute myocardial infarction (AMI) and is associated with adverse outcomes. Guidelines now recommend screening for AF in all elderly patients. However, the relevance of screen-detected AF and short episodes of irregular supraventricular ectopic beats ('micro-AF') after AMI is unknown. OBJECTIVES: To investigate the value of two-week intermittent ECG screening to detect incident AF and 'micro-AF' in elderly patients 12 months after an AMI, and its association with risk of cardiovascular events. METHODS: This was an investigator-initiated, multicenter substudy of the OMega-3 fatty acids in Elderly patients with Myocardial Infarction (OMEMI) trial, in Norway. Women and men aged 70-82 years, with a recent AMI, were recruited during 2012-2018. All participants had a 12-lead ECG performed at 3, 12 and 24 months. Patients without AF one year after the index AMI underwent 2 weeks of intermittent 30-second 'thumb ECG' screening. Incident AF and 'micro-AF' (episodes of ≥3 consecutive irregular supraventricular ectopic beats) were registered, and the association with risk of major cardiovascular events (MACE; non-fatal AMI, stroke, coronary revascularization, hospitalization for heart failure, or all-cause death) was analyzed with logistic regression. RESULTS: Among 1014 patients (198 (28.7%) women), 255 (25.1%) had known AF or AF identified at baseline. New-onset AF was detected clinically or at study visits in 39 (3.8%) patients. By screening participants without AF (n=567), unknown AF was identified in 4 (0.7%) and 'micro-AF' in 27 (4.8%) patients. Among 43 patients with incident AF, 21 (48.8%) experienced a MACE, which was significantly higher than those without AF (n=114, 15.9%; p<0.001), driven by a higher risk of AMI or revascularization. Nine (33.3%) patients with 'micro-AF' and 75 (13.9%) without 'micro-AF' experienced a MACE (p=0.002), explained mostly by a higher risk of heart failure hospitalization (p<0.001). Using patients without AF and 'micro-AF' as reference, 'micro-AF' was associated with an intermediate risk of MACE (OR 2.8; 95% CI 1.2-6.4) and new-onset AF with a high risk of MACE (OR 5.3; 95% CI 2.8-10.0). CONCLUSIONS: Two-week intermittent ECG screening identified few cases of new-onset AF, but a substantial number of patients with 'micro-AF'. 'Micro-AF' was associated with an increased risk of major cardiovascular events, albeit with an intermediate risk compared to those with new-onset AF.

Cardiac pathology 6 months after hospitalization for COVID-19 and association with the acute disease severity.

BACKGROUND: Coronavirus disease 2019 (COVID-19) may cause myocardial injury and myocarditis, and reports of persistent cardiac pathology after COVID-19 have raised concerns of long-term cardiac consequences. We aimed to assess the presence of abnormal cardiovascular resonance imaging (CMR) findings in patients recovered from moderate-to-severe COVID-19, and its association with markers of disease severity in the acute phase. METHODS: Fifty-eight (49%) survivors from the prospective COVID MECH study, underwent CMR median 175 [IQR 105-217] days after COVID-19 hospitalization. Abnormal CMR was defined as left ventricular ejection fraction (LVEF) <50% or myocardial scar by late gadolinium enhancement. CMR indices were compared to healthy controls (n = 32), and to circulating biomarkers measured during the index hospitalization. RESULTS: Abnormal CMR was present in 12 (21%) patients, of whom 3 were classified with major pathology (scar and LVEF <50% or LVEF <40%). There was no difference in the need of mechanical ventilation, length of hospital stay, and vital signs between patients with vs without abnormal CMR after 6 months. Severe acute respiratory syndrome coronavirus 2 viremia and concentrations of inflammatory biomarkers during the index hospitalization were not associated with persistent CMR pathology. Cardiac troponin T and N-terminal pro-B-type natriuretic peptide concentrations on admission, were higher in patients with CMR pathology, but these associations were not significant after adjusting for demographics and established cardiovascular disease. CONCLUSIONS: CMR pathology 6 months after moderate-to-severe COVID-19 was present in 21% of patients and did not correlate with severity of the disease. Cardiovascular biomarkers during COVID-19 were higher in patients with CMR pathology, but with no significant association after adjusting for confounders. TRIAL REGISTRATION: COVID MECH Study ClinicalTrials.gov Identifier: NCT04314232.

B-Type Natriuretic Peptide Is Associated with Indices of Left Ventricular Dysfunction in Healthy Subjects from the General Population: The Akershus Cardiac Examination 1950 Study.

BACKGROUND: Concentrations of B-type natriuretic peptide (BNP) reflect myocardial distension and stress, and are associated with poor prognosis in patients with cardiovascular disease. Accordingly, we hypothesized that concentrations of BNP would be associated with indices of adverse left ventricular (LV) remodeling and early stages of LV systolic and diastolic dysfunction in healthy participants from the general population. METHODS: We measured BNP in 1757 women and 1677 men free from known coronary heart disease participating in the prospective observational Akershus Cardiac Examination 1950 Study. All study participants underwent extensive cardiovascular phenotyping at baseline, including detailed echocardiography with assessment of indexed LV mass (LVMI), diastolic [tissue Doppler e', E/e' ratio, indexed left atrial volume (LAVI), maximal tricuspid regurgitation velocity (TRVmax), and E/A ratio], and systolic [global longitudinal strain (GLS) and LV ejection fraction (LVEF)] function. RESULTS: Study participants with the highest BNP concentrations had higher GLS, LVMI, e', E/e' ratio, LAVI, TRVmax, and E/A ratio. In adjusted analyses, both GLS and LVEF exhibited significant nonlinear associations with BNP, with reduced LV systolic function observed in both the low and high concentration range of BNP. CONCLUSIONS: In healthy participants recruited from the general population, concentrations of BNP exhibit nonlinear associations with LV systolic function, and both low and high concentrations are associated with reduced LV systolic function. This supports the notion that natriuretic peptides are beneficial and elicit cardioprotective effects, and may have important implications for the interpretation of BNP measurements in the general population.

Cardiac Troponin I and T Are Associated with Left Ventricular Function and Structure: Data from the Akershus Cardiac Examination 1950 Study.

BACKGROUND: Concentrations of cardiac troponin I (cTnI) and T (cTnT) are associated with clinical cardiac outcomes, but do not correlate closely in subjects recruited from the general population. Accordingly, we hypothesized that cTnI and cTnT concentrations would be influenced by different cardiovascular (CV) and non-CV risk factors and reflect different CV phenotypes. METHODS: We measured cTnI and cTnT with last generation assays in 1236 women and 1157 men with no known CV disease participating in the prospective observational Akershus Cardiac Examination 1950 Study. All study participants underwent extensive CV phenotyping at baseline, including detailed echocardiography. RESULTS: Concentrations of cTnI were measurable in 60.3% and cTnT in 72.5% of study participants (P < 0.001), and correlated moderately (r = 0.53; P < 0.001). cTnI was more strongly associated with male sex (P = 0.018), higher education (P < 0.001), history of hypertension (P < 0.001), and age (P < 0.001), whereas cTnT was more strongly associated with eGFR (P = 0.015). Both cTnI and cTnT were inversely associated with global longitudinal strain and positively associated with LV mass index (LVMI) in analyses adjusted for CV risk factors. The association between cTnI and LVMI was stronger than the association between cTnT and LVMI (P = 0.035). Concentrations of cTnI improved diagnostic accuracy for LV hypertrophy when added to established CV risk factors, but concentrations of cTnT did not improve these models further. CONCLUSIONS: In a large community-based cohort examined with extensive echocardiography, concentrations of cTnI and cTnT are associated with subclinical LV hypertrophy and dysfunction. Concentrations of cTnI appear superior to cTnT in predicting subclinical LV hypertrophy.

Plasma marine n-3 polyunsaturated fatty acids and cardiovascular risk factors: data from the ACE 1950 study.

PURPOSE: A high intake of marine n-3 polyunsaturated fatty acids (PUFAs) might improve cardiovascular (CV) health. We conducted a cross-sectional study to investigate associations between plasma phospholipid levels of marine n-3 PUFAs and CV risk factors, educational level, physical activity and smoking habits. METHODS: A total of 3706 individuals from a general population, all born in 1950 and residing in Akershus County, Norway, were included in this study. The main statistical approach was multivariable adjusted linear regression. RESULTS: Plasma marine n-3 PUFA levels ranged from 2.7 to 20.3 wt%, with a median level of 7.7 wt% (interquartile range 4.3-11.1 wt%). High levels of plasma marine n-3 PUFAs were associated with lower serum triglycerides [Standardized regression coefficient (Std.ß-coeff.) - 0.14, p < 0.001], body mass index (Std. ß-coeff. -0.08, p < 0.001), serum creatinine (Std. ß-coeff. -0.03, p = 0.05), C-reactive protein levels (Std. ß-coeff. - 0.03, p = 0.04), higher levels of serum high-density lipoprotein cholesterol (Std. ß-coeff. 0.08, p < 0.001) and low-density lipoprotein cholesterol (Std. ß-coeff. 0.04, p = 0.003). High levels of plasma marine n-3 PUFAs were also associated with lower glycated hemoglobin (Std. ß-coeff. - 0.04, p = 0.01), however, only in individuals without diabetes. We found no associations between plasma marine n-3 PUFA levels and fasting plasma glucose or carotid intima-media thickness. High levels of plasma marine n-3 PUFAs were associated with higher educational level, more physical activity and lower prevalence of smoking. CONCLUSION: In this cross-sectional study of Norwegian individuals born in 1950, high levels of plasma marine n-3 PUFAs were favourably associated with several CV risk factors, suggesting that fish consumption might improve CV health.

COVID-19: Symptoms, course of illness and use of clinical scoring systems for the first 42 patients admitted to a Norwegian local hospital. / Covid-19: Symptomer, forløp og bruk av kliniske skåringsverktøy hos de 42 første pasientene innlagt på et norsk lokalsykehus.

BACKGROUND: The COVID-19 outbreak is presenting the health system with new challenges, and there is a great need for knowledge about symptoms, clinical findings and course of illness in patients admitted to Norwegian hospitals with COVID-19. MATERIAL AND METHOD: In this observational qualitative study, all patients admitted to a Norwegian local hospital (Bærum Hospital) with proven COVID-19 infection were included consecutively from the start of the outbreak. We present here patient characteristics, symptoms, clinical findings, experience of using clinical scoring systems and course of illness based on data in medical records. RESULTS: In the period 9-31 March 2020, 42 patients, of whom 28 (67 %) were men, were admitted to hospital with COVID-19 infection. The median age was 72.5 years (range 30-95). Fever (79 %), reduced general condition (79 %), dyspnoea (69 %) and cough (67 %) were the most common symptoms. A total of nine patients (21 %) had a critical course of illness with treatment in the Intensive Care Department and/or death during their stay in hospital. Patients with a critical course had a higher average score on National Early Warning Score 2 (NEWS2) on admission (7.6 vs 3.3). Only one of the most severely ill patients scored ≥ 2 on the quick Sepsis-related Organ Failure Assessment (qSOFA) on admission. INTERPRETATION: Most patients admitted to our hospital with COVID-19 had a fever and respiratory tract symptoms. A high percentage of patients had a critical course of illness. A NEWS2 score of ≥ 5 on admission may be a useful aid in identifying patients at risk of a critical course of illness, while CRB-65 and qSOFA score ≥ 2 proved to be of little usefulness for this purpose in our material.

Complications and mortality among patients hospitalised with COVID-19. / Komplikasjoner og dødelighet blant pasienter innlagt med covid-19.

BACKGROUND: The course of disease, complications and hospital mortality among patients with COVID-19 admitted to Norwegian hospitals has not been widely described. The purpose of this study was to survey patients with COVID-19 admitted to a local hospital. MATERIAL AND METHOD: The data were retrieved from a prospective observational study of all patients admitted with COVID-19 to Bærum Hospital since the start of the coronavirus outbreak. RESULTS: A total of 73 patients with COVID-19 admitted in the period 9 March 2020-7 May 2020 were included. The mean age was 67.9 years, and 43 patients (59 %) were men. The average number of days hospitalised was 10.1. Altogether 19 patients (26 %) had a very severe course of disease, and 14 (19 %) died during their stay in hospital. The mean age among the patients who died was 79.5 years. A total of 49 patients (67 %) had hypoxaemia and required oxygen therapy for an average of 10.1 days. Of these, 9 patients were given invasive respiratory support for a median 18 days. Symptoms of delirium occurred in 26 patients (36 %) and was the most frequent non-respiratory complication. INTERPRETATION: The majority of the patients hospitalised with COVID-19 needed prolonged oxygen therapy, and there was a high incidence of severe complications.

Systematic screening for atrial fibrillation in a 65-year-old population with risk factors for stroke: data from the Akershus Cardiac Examination 1950 study.

Aims: To investigate the yield of screening for atrial fibrillation (AF) in a cohort of 65-year-old individuals from the general population with additional risk factors for stroke. Methods and results: We invited participants with additional risk factors for stroke (CHA2DS2-VASc score ≥2 for men or ≥ 3 for women) without previously known AF from a population-based study in Norway to participate in a 2-week screening for AF. Screening was performed by one-lead 'thumb electrocardiography (ECG)' recordings of 30 s twice daily or when the participants experienced symptoms. In total, 1742 (47.0%) participants of the Akershus Cardiac Examination (ACE) 1950 study had at least one additional risk factor for stroke. Of these, 123 cases reported a history of AF and 101 (5.8%) cases were ECG validated. Eight [0.5%, 95% confidence interval (CI) 0.2-0.9] new AF cases were diagnosed by 12-lead ECG at baseline, and 10 additional participants were diagnosed with AF before screening commenced. We invited all 1601 participants who met the inclusion criteria for screening, of which 1510 (94.3%) participants were included (44% women and 56% men). The screening revealed AF in 13 (0.9%, 95% CI 0.5-1.5) participants. The total prevalence of ECG-validated AF after screening among the 65-year-olds with risk factors for stroke was 7.6% (95% CI 6.4-8.9), in men 10.0% (95% CI 8.2-12.0), and in women 4.3% (95% CI 3.0-6.1) (P < 0.001). Conclusion: In a group of 1510 well-characterized 65-year-olds with risk factors for stroke, 2-week intermittent ECG screening identified undiagnosed AF in 0.9%. The total prevalence of AF was 7.6%.

Effect of sinus rhythm restoration on markers of thrombin generation in atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) confers a hypercoagulable state; however, it is not clear whether restoration of sinus rhythm is associated with normalisation of markers of thrombogenesis. We studied the impact of sustained sinus rhythm on prothrombotic markers, and their predictive abilities in foreseeing rhythm outcome after cardioversion. METHODS: In a double blind, placebo-controlled study, 171 patients referred for electrical cardioversion of persistent AF were randomised to receive candesartan or placebo for 3-6 weeks before and 6 months after cardioversion. Endogenous thrombin potential (ETP), prothrombin fragment 1 + 2 (F1 + 2) and D-dimer were measured before cardioversion and at end of study. These markers were also measured in a reference group comprising 49 subjects without AF. RESULTS: The markers remained unchanged in those 28 patients who maintained sinus rhythm. Discontinuation of warfarin treatment in a subset of 13 low-risk patients in sinus rhythm was associated with significantly higher levels of D-dimer and F1 + 2 compared to the reference group; D-dimer (456 ng/mL (276, 763) vs. 279 ng/mL (192, 348), p = 0.002) and F1 + 2 (700 pmol/L (345, 845) vs. 232 pmol/L (190, 281), p < 0.001). None of the markers were associated with rhythm outcome after electrical cardioversion. CONCLUSIONS: Sustained sinus rhythm for 6 months after cardioversion for AF had no impact on ETP, F1 + 2 or D-dimer levels. Discontinuation of warfarin in low-risk patients with sustained sinus rhythm was associated with significantly higher levels of D-dimer and F1 + 2 compared to the reference group. Our results suggest persistent hypercoagulability in AF patients despite long-term maintenance of sinus rhythm. TRIAL REGISTRATION: The CAPRAF study was registered at clinicaltrials.gov (NCT00130975) in August 2005.

Heart and Brain Interactions--the Akershus Cardiac Examination (ACE) 1950 Study Design.

OBJECTIVES: The aim of the Akershus Cardiac Examination (ACE) 1950 Study is to investigate the development and progression of cardiovascular and cerebrovascular disease (CVD/CeVD) in an extensively characterized age cohort of middle-aged subjects with longitudinal long-term follow-up. DESIGN: The ACE 1950 Study is a prospective, population-based, age-cohort study of all men and women born in 1950 in Akershus County, Norway. The study involves a comprehensive baseline examination, especially for CVD/CeVD, including advanced ultrasound imaging and biobanking ("deep phenotyping"). We expect to obtain an inclusion rate of > 60% from the total study population of 5,827 eligible subjects. Enrollment will be completed during 2015. CONCLUSIONS: The ACE 1950 Study will have potential to generate new and relevant insight into identification of subclinical disease progression. Extensive phenotyping will enable identification of novel disease markers and mechanisms for subclinical disease, which can prove important for future disease prevention.

Impact of atrial fibrillation on levels of high-sensitivity troponin I in a 75-year-old population.

PURPOSE: Atrial fibrillation (AF) has been associated with elevated levels of cardiac troponins; however, it is not clear if this association is independent of underlying cardiovascular disease. The aim of this study was to investigate the impact of AF on cardiac troponin I levels in a 75-year-old cohort from the general population, using a recently introduced, highly sensitive assay. METHODS: All 75-year-old citizens in Asker and Baerum counties were invited to participate in a prevalence study of AF. High-sensitive troponin I (hs-TnI) levels were measured (Abbott Diagnostics) in serum samples collected from 62 subjects with AF and a gender-matched control group of 126 subjects in sinus rhythm. RESULTS: Hs-TnI was detectable in all subjects (median 7.3 ng/L [range 3.0-88.7]). Patients with AF had higher levels than subjects in sinus rhythm (8.3 ng/L [3.7-88.7] vs. 6.8 ng/L [3.0-77.5]; p = 0.011). Male gender (p = 0.002), hypertension (p = 0.001), coronary heart disease (p < 0.001), heart failure (p < 0.001), prior stroke or transient ischemic attack (p = 0.013) and serum creatinine (p < 0.001) were all associated with higher levels of hs-TnI in univariate analysis. Heart failure and coronary heart disease remained significantly associated with hs-TnI in multivariate analysis, whereas the relation between AF and hs-TnI was no longer statistically significant. CONCLUSION: All subjects had detectable levels of hs-TnI. AF patients had higher hs-TnI levels than subjects in sinus rhythm; however, this difference was not statistically significant after adjustment for heart failure and coronary heart disease.

Digital recruitment and compliance to treatment recommendations in the Norwegian Atrial Fibrillation self-screening pilot study.

Aims: Atrial fibrillation (AF) is prevalent, undiagnosed in approximately one-third of cases, and is associated with severe complications. Guidelines recommend screening individuals at increased risk of stroke. This report evaluated the digital recruitment procedure and compliance with the follow-up recommendations in participants with screen-detected AF in the Norwegian Atrial Fibrillation self-screening pilot study. Methods and results: Norwegians ≥65 years were invited through Facebooks posts, web pages, and newspapers to participate in the study. Targeted Facebook posts promoted over 11 days reached 84 208 users and 10 582 visitors to the study homepage. This accounted for 51% of the total homepage visitors (n = 20 704). A total of 2118 (10%) of the homepage visitors provided digital consent to participate after they met the inclusion criteria. The mean (standard deviation) age of the participants was 70 (4) years, and the majority [n = 1569 (74%)] were women. A total of 1849 (87%) participants completed the electrocardiogram self-screening test, identifying AF in 41 (2.2%) individuals. Of these, 39 (95%) participants consulted a general practitioner, and 34 (83%) participants initiated anticoagulation therapy. Conclusion: Digital recruitment and inclusion in digital AF screening with a high rate of initiation of anticoagulation therapy in AF positive screening cases are feasible. However, digital recruitment and inclusion may introduce selection bias with regard to age and gender. Larger studies are needed to determine the efficacy and cost-effectiveness of a fully digital AF screening. Trial registration: Clinical trials: NCT04700865.

Screening for Atrial Fibrillation by Digital Health Technology in Older People in Homecare Settings: A Feasibility Trial.

Aims: Users of homecare services are often excluded from clinical trials due to advanced age, multimorbidity, and frailty. Atrial fibrillation (AF) is a common and frequently undiagnosed arrhythmia in the elderly and is associated with severe mortality, morbidity, and healthcare costs. Timely identification prevents associated complications through evidence-based treatment. This study is aimed at assessing the feasibility of AF screening using new digital health technology in older people in a homecare setting. Methods: Users of homecare services ≥ 65 years old with at least one additional risk factor for stroke in two Norwegian municipalities were assessed for study participation by nurses. Participants performed a continuous prolonged ECG recording using a patch ECG device (ECG247 Smart Heart Sensor). Results: A total of 144 individuals were assessed for study participation, but only 18 (13%) were included. The main reasons for noninclusion were known AF and/or anticoagulation therapy (25%), severe cognitive impairment (26%), and lack of willingness to participate (36%). The mean age of participants performing the ECG test was 81 (SD ± 7) years, and 9 (50%) were women. All ECG tests were interpretable; the mean ECG monitoring time was 104 hours (IQR 34-338 hours). AF was detected in one individual (6%). Conclusion: This feasibility study highlights the challenges of enrolling older people receiving homecare services in clinical trials. However, all included participants performed an interpretable and prolonged continuous ECG recording with a digital ECG patch device. This trial is registered with NCT04700865.