Association between epicardial adipose tissue and embolic stroke after catheter ablation of atrial fibrillation.

INTRODUCTION: Risk factors of embolic stroke (ES) after atrial fibrillation (AF) ablation have not been fully elucidated especially among the Asian subjects, particularly regarding epicardial adipose tissue (EAT) in cardiac imaging. We aimed to assess the incidence of ES during a long-term follow-up period after AF ablation and to identify the risk factors associated with postablation ES, specifically focusing on EAT. METHODS AND RESULTS: We enrolled patients who experienced postablation ES and control subjects from a consortium of AF ablation registries from three institutes in Korea. EAT was assessed using multislice computed tomography before AF ablation. A total of 3464 patients who underwent AF ablation were recruited and followed-up. During a follow-up of 47.2 ± 36.4 months, ES occurred in 47 patients (1.36%) with a CHA2 DS2 -VASc score of 1.48 ± 1.39 and the overall annual incidence of ES was 0.34%. Compared with the control group (n = 190), the ES group showed significantly higher prior thromboembolism (TE) and AF recurrence rates, larger left atrium size, lower creatinine clearance rate (CCr), and greater total and peri-atrial EAT volume. Multivariate regression analysis demonstrated larger peri-atrial EAT volume (hazards ratio, 1.065; 95% confidence interval, 1.005-1.128), in addition to a prior history of TE and lower CCr, was independently associated with postablation ES. When a cut-off value of peri-atrial EAT volume of ≥20.15 mL was applied, patients with smaller peri-atrial EAT volume showed significantly higher ES-free survival. CONCLUSION: Larger peri-atrial EAT volume, in addition to prior TE and lower CCr, was independently associated with postablation ES regardless of AF recurrence and CHA2 DS2 -VASc score. (ClinicalTrials.gov number, NCT03479073).

Outcomes of Rate-Control Treatment in Patients With Atrial Fibrillation and Heart Failure　- A Nationwide Cohort Study.

BACKGROUND: Rate control is now a front-line therapy in the management of atrial fibrillation (AF). However, the survival benefits of different rate-control medications remain controversial, so we assessed the efficacy of rate-control medications in AF patients with concomitant heart failure (HF).Methods and Results:From January 2002 to December 2008, a total of 7,034 AF patients with a single type of rate-control drug or without rate-control treatment were enrolled from the Korea National Health Insurance Service database. The death rates over a mean follow-up of 4.5±1.2 years were 12.6% (580 of 4,593) and 29.0% (709 of 2,441) in non-HF and HF patients, respectively. Among the total subjects, the risk of death was lower in patients receiving ß-blockers (adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.64-0.88) and calcium-channel blockers (adjusted HR 0.74, 95% CI 0.55-0.98) compared with those who did not receive rate-control medications. In patients without HF, use of rate-control medications did not affect the risk of death. In patients with HF, ß-blockers significantly decreased the mortality risk (adjusted HR 0.63, 95% CI 0.50-0.79), whereas use of calcium-channel blockers or digoxin was not associated with death. The results were observed consistently among the cohorts after propensity matching. CONCLUSIONS: Use of ß-blockers was associated with a reduced mortality rate for AF patient with HF but not for those without HF. These findings should be examined in a large randomized trial.

Junctional bradycardia is a potential risk factor of stroke.

BACKGROUND: This study aimed to determine the risk of thromboembolic events in patients with junctional bradycardia(JB). METHODS: We retrospectively reviewed electrocardiograms(ECGs) for 380,682 patients. Those with JB on an ECG at least twice over a ≥3-month interval were included for analysis. We additionally included 138 CHADS2 score-matched patients(age, 68.4 ± 15.7 years; male, 52.2%) in sinus rhythm as a control group. Between the JB patients(with or without retrograde P wave) and controls, we compared incidences of ischemic stroke and a composite of ischemic stroke, renal infarction, ischemic colitis, acute limb ischemia, and pulmonary embolism. RESULTS: Among 380,682 patients (age, 47.6 ± 19.9 years; male, 49.3%), 69 patients (age, 68.5 ± 16.5 years; male, 50.7%) exhibited JB on an ECG at least twice over a ≥3-month interval; the overall prevalence of JB was 0.02%. The mean follow-up period was 27.2 ± 26.2 months. Forty-five patients (65.2%) in the JB group had no retrograde P wave. Ischemic stroke incidence was significantly higher in JB patients without a retrograde P wave than in controls (6/45 patients [13.3%] and 3/138 patients [2.2%], respectively; P = 0.007). The incidence of composite thromboembolic events was also significantly higher in JB patients without a retrograde P wave than in controls (8/45 patients [17.8%] and 4/138 patients [2.9%], respectively; P = 0.011). In a Cox proportional hazards model, JB patients without a P wave showed a greater incidence of stroke (hazard ratio, 8.89 [2.20-33.01], P = 0.007) than controls and JB patients with a P wave. CONCLUSIONS: Junctional bradycardia is potentially associated with ischemic stroke, particularly in the absence of an identifiable retrograde P wave.

Left Atrial Appendage Occlusion in Non-Valvular Atrial Fibrillation in a Korean Multi-Center Registry.

BACKGROUND: The aim of this study was to evaluate clinical outcome after left atrial appendage (LAA) occlusion in real clinical practice and compare between Amplatzer cardiac plug (ACP) and Watchman. METHODS AND RESULTS: From October 2010 to February 2015, 96 successful LAA occlusion procedures were performed using either ACP (n=50) or Watchman device (n=46) in non-valvular atrial fibrillation (AF) patients (59 male; age, 65.1±9.4 years; CHADS2, 2.5±1.2; CHA2DS2-VASC, 3.9±1.6; HAS-BLED, 2.7±1.3). The procedure success rate was 96.8%. There were serious complications in 4 patients (4.1%; 2 cardiac tamponade, 1 device embolization, and 1 major bleed). The anticoagulation cessation rate after 6 weeks was 92.7%. During mean 21.9-month follow-up, the incidence of death, stroke, systemic embolization and major bleeding was 5.2%, 4.2%, 0% and 1.0%, respectively. On transesophageal echocardiography of 93 patients within 6 months after the procedure, 24 residual leaks were observed (25.8%; 2 mild, 18 moderate, and 4 major). Clinical outcome was similar for the 2 devices, but peridevice leakage was more frequent with the Watchman than the ACP. CONCLUSIONS: LAA occlusion was feasible in non-valvular AF patients with high risk of stroke and hemorrhage. The ACP and Watchman devices were similar in terms of procedural and clinical outcomes. (Circ J 2016; 80: 1123-1130).

Cardiac Vein Accessibility According to Heart Diseases and Sex: Implications for Cardiac Resynchronization Therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) is an important therapy in patients with heart failure (HF) and dyssynchrony. We performed the present study to elucidate clinical factors associated with cardiac vein accessibility. METHODS: In 255 consecutive patients (age, 48.7 ± 19.4 years; male, 126), cardiac venography was performed during CRT implantation or an electrophysiological study. We measured the diameters and the proximal branching angles of the lateral cardiac and posterior ventricular veins. Easy accessibility of the cardiac vein was defined as a lumen diameter ≥1.6 mm with an angle of ≥90°. We compared baseline characteristics between patients with and without easily accessible cardiac veins. We compared cardiac vein accessibility between patients with and without HF, including ischemic and nonischemic HF, and between males and females. RESULTS: In 189 (74.1%) patients, the cardiac veins were easily accessible. The cardiac veins were more easily accessible in patients with HF (n = 75) compared with patients without HF (n = 180; 89.3% and 67.8%, respectively; P < 0.001). The cardiac veins were more easily accessible in patients with nonischemic HF (n = 56) compared with patients with ischemic HF (n = 19; 96.4% and 68.4%, respectively; P = 0.003). The cardiac veins were more easily accessible in females compared with males (79.8% and 68.3%, respectively; P = 0.035). CONCLUSIONS: Accessing the cardiac veins for CRT implantation was difficult in ∼10% of patients with HF. Cardiac vein accessibility was high in patients with nonischemic HF and in females.

High-Frequency Vestibular Function Is Vulnerable to Presbyvestibulopathy.

INTRODUCTION: In 2019, mild vestibular function deficiency in elder populations was defined as presbyvestibulopathy (PVP) by the Classification Committee of the Bárány Society. The diagnostic criteria include tests for low-, mid-, and high-frequency vestibular function, represented by caloric testing, rotary chair testing, and head impulse testing, respectively. However, there is still a lack of large-scale reports supporting the relationship between vestibular function tests (VFTs) and aging. In this study, we evaluated whether each test is correlated with aging in the elderly population aged over 50. METHODS: This study retrospectively enrolled 1043 subjects from a single university hospital database after excluding those with unilateral and bilateral vestibulopathy, central dizziness, and acute dizziness. Enrolled subjects had caloric canal paresis <20%, vHIT lateral canal gain >0.6, vHIT interaural difference <0.3, and age >50 years old. RESULTS: Significant negative correlations with age were identified in the vHIT (p < 0.001) and rotary chair test (RCT) 1.0 Hz gain (p = 0.030). However, the caloric test (p = 0.739 and 0.745 on the left and right sides, respectively) and RCT 0.12 Hz gain (p = 0.298) did not show a significant correlation with age. A total of 4.83% of subjects aged 70 years or older showed sub-normal vHIT gain that met the criteria of PVP, whereas only 0.50% of subjects aged 60 to 69 did. The prevalence of sub-normal caloric test results, however, was not significantly different between the two age groups (21.55% in the 60-69 age group and 26.59% in the >70 age group). CONCLUSIONS: The high-frequency range vestibular function seems vulnerable to aging, and this is more discernible at age >70 years. The weak correlation between age and low-frequency vestibular function tests, such as the caloric test and low-frequency rotary chair testing, suggests the need to revisit the diagnostic criteria for PVP.

Differential impact of metabolic syndrome on subclinical atherosclerosis according to the presence of diabetes.

BACKGROUND: Metabolic syndrome (MS) is associated with increased risks of diabetes and atherosclerotic cardiovascular disease. However, data on the impact of MS and its individual components on subclinical atherosclerosis (SCA) according to diabetes status are scarce. METHODS: Surrogate markers of SCA, brachial-ankle pulse wave velocity (baPWV), and carotid intima-medial thickness (IMT) and plaque were assessed in 2,560 subjects (60 ± 8 years, 33% men) who participated in baseline health examinations for a community-based cohort study. RESULTS: The participants included 2,149 non-diabetics (84%) and 411 diabetics (16%); 667 non-diabetics (31%) and 285 diabetics (69%) had MS, respectively. Diabetics had significantly higher baPWV and carotid IMT, and more plaques than non-diabetics (p < 0.001, respectively). Individuals with MS had significantly higher baPWV and carotid IMT than those without MS only among non-diabetics (p < 0.001, respectively). Among MS components, increased blood pressure was significantly associated with the exacerbation of all SCA markers in non-diabetics. The number of MS components was significantly correlated with both baPWV and carotid IMT in non-diabetics (baPWV: r = 0.302, p < 0.001; carotid IMT: r = 0.217, p < 0.001). Multiple regression showed both MS and diabetes were significantly associated with baPWV (p < 0.001, respectively), carotid IMT (MS: p < 0.001; diabetes: p = 0.005), and the presence of plaque (MS: p = 0.041; diabetes: p = 0.002). CONCLUSIONS: MS has an incremental impact on SCA in conditions without diabetes. The identification of MS and its individual components is more important for the risk stratification of CVD in non-diabetic individuals.

Long-term stroke and major bleeding risk in patients with non-valvular atrial fibrillation: A comparative analysis between non-vitamin K antagonist oral anticoagulants and warfarin using a clinical data warehouse.

Introduction: Non-vitamin K antagonist oral anticoagulants (NOACs) has been the drug of choice for preventing ischemic stroke in patients with atrial fibrillation (AF) since 2014. Many studies based on claim data revealed that NOACs had comparable effect to warfarin in preventing ischemic stroke with fewer hemorrhagic side effects. We analyzed the difference in clinical outcomes according to the drugs in patients with AF based on the clinical data warehouse (CDW). Methods: We extracted data of patients with AF from our hospital's CDW and obtained clinical information including test results. All claim data of the patients were extracted from National Health Insurance Service, and dataset was constructed by combining it with CDW data. Separately, another dataset was constructed with patients who could obtain sufficient clinical information from the CDW. The patients were divided NOAC and warfarin groups. The occurrence of ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and death were confirmed as clinical outcome. The factors influencing the risk of clinical outcomes were analyzed. Results: The patients who were diagnosed AF between 2009 and 2020 were included in the dataset construction. In the combined dataset, 858 patients were treated with warfarin, 2,343 patients were treated with NOACs. After the diagnosis of AF, the incidence of ischemic stroke during follow-up was 199 (23.2%) in the warfarin group, 209 (8.9%) in the NOAC group. Intracranial hemorrhage occurred in 70 patients (8.2%) among the warfarin group, 61 (2.6%) of the NOAC group. Gastrointestinal bleeding occurred in 69 patients (8.0%) in the warfarin group, 78 patients (3.3%) in the NOAC group. NOAC's hazard ratio (HR) of ischemic stroke was 0.479 (95% CI 0.39-0.589, p < 0.0001), HR of intracranial hemorrhage was 0.453 (95% CI 0.31-0.664, p < 0.0001), and HR of gastrointestinal bleeding was 0.579 (95% CI 0.406-0.824, p = 0.0024). In the dataset constructed using only CDW, the NOAC group also had a lower risk of ischemic stroke and intracranial hemorrhage than warfarin group. Conclusions: In this CDW based study, NOACs are more effective and safer than warfarin in patients with AF even with long-term follow-up. NOACs should be used to prevent ischemic stroke in patients with AF.

The characteristic large-scale annual analysis by gender and age in heart failure patients: cohort for 10 years in Korea.

AIMS: The prevalence and incidence rate of heart failure (HF) continues to increase along with the aging of the population and the increase of ischaemic heart disease. The morbidity and mortality of HF are also on the rise in the industrialized countries; it can be a great public health problem. A detailed and accurate analysis of the demographical incidence and prevalence of HF is an important first step in predicting the occurrence of the disease in the future and proper preparing for prevention. Here, we aimed to analyse the annual prevalence and incidence of HF by gender and age using long-term national health insurance service data in the Republic of Korea. METHODS AND RESULTS: A total of 47 243 patients newly diagnosed with HF between 2006 and 2015 among nationally representative random subjects of 1 000 000 were included. The data of age and gender were analysed by year, and the total population information of the Ministry of Land, Infrastructure, and Transport of Korea was referred to compare the data of HF patients with the total population (2008-15). Over the decade from 2006 to 2015, the prevalence of HF patients showed tendency of increase (P < 0.001). The overall incidence rate was also gradually increasing (P < 0.001), but in women, it tended to decrease gradually. Women significantly accounted higher than the male group in incidence of HF over the period (54.6% vs. 45.4%, P < 0.001). The mean age at the time of diagnosis gradually increased (P = 0.002 for total, P = 0.001 for each gender). Total incidence was highest in 70s (27.22%), but males were the most in their 60s and females were in their 70s. Analysis of annual trend by age and gender distribution of HF incidence in men presented highest in the 50s-70s with a similar pattern annually, and the incidence is increasing more recently. Different from that of men, in the case of women, the incidence gradually increased with age in a similar annual pattern, peaking in their 70s and gradually decreasing in recent years. CONCLUSIONS: The prevalence and incidence of HF are gradually increasing. It increased rapidly in their 50s and older. It showed an increased incidence of HF especially in men between their 50s and 70s, and more observation and caution for the management of the risk factors may be needed to prevent HF in the male group.

Delayed blood pressure recovery after exercise stress test is associated with autonomic dysfunction and pulse pressure in a middle-aged healthy group.

BACKGROUND: Delayed heart rate (HR) and blood pressure recovery after exercise test is known as the reliable indexes of autonomic dysfunction. Here we tried to evaluate the serial changes in various indicators during exercise test and correlations with recovery of HR and blood pressure in a normotensive healthy middle-aged group. METHODS: A total of 122 patients without hypertension or diabetes was enrolled (mean age, 55.6 ± 11.0; male, 56.6%; mean blood pressure, 124.8 ± 16.6 / 81.5 ± 9.6 mmHg). Treadmill test was performed for evaluation of chest pain. Patients with coronary artery disease, positive treadmill test result, left ventricular dysfunction or renal failure were excluded. Heart rate recovery was calculated by subtracting the HR in the first or second minute of recovery period from the HR of peak exercise (HRR1 or HRR2). Systolic blood pressure in the 4th minute of recovery stage (SBPR4) was used to show delayed blood pressure recovery. RESULTS: Metabolic equivalents (METs) and HR in stage 2 to 4 were significantly correlated with both HRR1 and HRR2. Multiple regression analysis of HRR revealed significant correlation of METs and SBPR4. SBPR4 was significantly correlated with both HRR1 and HRR2 (HRR1, r = -0.376, p<0.001; HRR2, r = -0.244, p = 0.008) as well as SBP in the baseline to stage 3 and pulse pressure (r = 0.406, p<0.001). CONCLUSIONS: Delayed BP recovery after peak exercise test revealed significant association with autonomic dysfunction and increased pulse pressure in normotensive middle-aged healthy group. It can be a simple and useful marker of autonomic dysfunction and arterial stiffness.

Effect of High-Intensity Rosuvastatin vs. Combination of Low-Intensity Rosuvastatin and Ezetimibe on HbA1c Levels in Patients without Diabetes: A Randomized IDEAL Trial.

There is a dearth of studies investigating whether the combination of low-intensity statins with ezetimibe can reduce the risk of diabetes in patients requiring statin therapy. Therefore, we aimed to evaluate the effects of combination therapy on the prevention of glycated hemoglobin (HbA1c) elevation in patients without diabetes. Sixty-eight patients were randomly assigned in a 1:1 ratio to receive a combination of low-intensity rosuvastatin (5 mg/day) and ezetimibe (10 mg/day) or high-intensity rosuvastatin (20 mg/day). The primary endpoint was the absolute difference in the HbA1c levels at 12 weeks. The HbA1c level showed an overall elevation of 0.11% at 12 weeks compared to that at baseline (mean ± standard deviation: 5.78 ± 0.3%, 95% confidence interval [CI]: 5.86-6.07, p = 0.044). The HbA1c levels did not differ between the groups at 12 weeks (least square mean difference: 0.001, 95% CI: 0.164-0.16, p = 0.999). Our study found that the combination of low-intensity rosuvastatin and ezetimibe did not yield significant differences in HbA1c levels compared to high-intensity rosuvastatin alone after 12 weeks in patients without diabetes. This suggests that the combination of low-intensity rosuvastatin and ezetimibe may not be an effective strategy for preventing HbA1c elevation in patients without diabetes requiring statins.

Efficacy and Safety of Coadministered Ezetimibe-Rosuvastatin plus Telmisartan in South Korean Patients with Dyslipidemia and Hypertension: A Multicenter, Randomized, Double-Blind, Active-Controlled, Phase III Trial.

BACKGROUND: The introduction of a fixed-dose combination (FDC) is expected to improve treatment compliance. METHODS: There were 181 subjects who were randomized to three groups: ezetimibe-rosuvastatin 10/20 mg + telmisartan 80 mg, ezetimibe-rosuvastatin 10/20 mg, and telmisartan 80 mg. The primary outcomes were change in mean sitting systolic blood pressure (MSSBP) and percentage change in low-density-lipoprotein cholesterol (LDL-C) compared to baseline at week 8. RESULTS: The least-square mean (SE) in MSSBP changes between the ezetimibe-rosuvastatin 10/20 mg + telmisartan 80 mg group and the ezetimibe-rosuvastatin 10/20 mg group were -25.81 (2.34) mmHg and -7.66 (2.45) mmHg. There was a significant difference between the two groups (-18.15 (2.83) mmHg, 95% CI -23.75 to -12.56, p < 0.0001). Changes in least-square mean (SE) in LDL-C between the ezetimibe-rosuvastatin 10/20 mg + telmisartan 80 mg group and the telmisartan 80 mg group were -63.82 (2.87)% and -2.48 (3.12)%. A significant difference was observed between the two groups (-61.34 (3.33)%, 95% CI -67.91 to -54.78, p < 0.0001). No serious adverse events were observed. CONCLUSIONS: Ezetimibe-rosuvastatin plus telmisartan treatment is effective and safe when compared to either ezetimibe-rosuvastatin or telmisartan.

Efficacy and Tolerability of Telmisartan/Amlodipine and Rosuvastatin Coadministration in Hypertensive Patients with Hyperlipidemia: A Phase III, Multicenter, Randomized, Double-blind Study.

PURPOSE: Dyslipidemia and hypertension increase the risk for cardiovascular disease. Combination therapy improves patient compliance. This study was conducted to compare the efficacy and tolerability of the combination therapies telmisartan/amlodipine + rosuvastatin, telmisartan/amlodipine, and telmisartan + rosuvastatin in patients with hypercholesterolemia and hypertension. METHODS: In this Phase III, multicenter, 8-week randomized, double-blind study, participants with hypertension and dyslipidemia (defined as a sitting systolic blood pressure [sitSBP] of ≥140 mm Hg, a low-density lipoprotein-cholesterol [LDL-C] level of ≤250 mg/dL, and a triglyceride level of ≤400 mg/dL) were screened. After a 4-week washout/run-in period involving therapeutic lifestyle changes and telmisartan 80 mg once a day, eligible patients had a sitSBP of ≥140 mm Hg and met the LDL-C level criteria according to the National Cholesterol Education Program Adult Treatment Panel III cardiovascular disease risk category. Patients were randomly assigned to 1 of 3 groups: (1) telmisartan/amlodipine 80/10 mg + rosuvastatin 20 mg (TAR group); (2) telmisartan/amlodipine 80/10 mg (TA group); or (3) telmisartan 80 mg + rosuvastatin 20 mg (TR group). The primary efficacy end points were the percentage changes from baseline in LDL-C in the TAR and TA groups and the mean changes in sitSBP in the TAR and TR groups at week 8 compared to baseline. Continuous variables were compared using the unpaired t test or the Wilcoxon rank sum model, and categorical variables were compared using the χ2 or Fisher exact test. Tolerability was assessed based on adverse events found on physical examination including vital sign measurements, laboratory evaluations, and 12-lead ECG. FINDINGS: A total of 134 patients were enrolled. The least squares mean percentage changes in LDL-C at 8 weeks after administration of the drug compared to baseline were -51.9% (3.0%) in the TAR group and -3.2% (2.9%) in the TA group (P < 0.001). At 8 weeks after baseline, the least squares mean (SE) changes sitSBP were -28.3 (2.4) mm Hg in the TAR group and -10.7 (2.1) mm Hg in the TR group (P < 0.001). The prevalence rates of treatment-emergent adverse events were 15.0%, 25.0%, and 12.2% in the TAR, TA, and TR groups, respectively; those of adverse drug reactions were 15.0%, 22.7%, and 10.2%. None of the differences in rates were significant among 3 groups. IMPLICATIONS: Triple therapy with TAR can be an effective treatment in patients with dyslipidemia and hypertension. The TAR combination has value for hypertensive patients with hyperlipidemia in terms of convenience, tolerability, and efficacy. ClinicalTrials.gov identifier: NCT03566316.

Meteorological Factors and Air Pollutants Contributing to Seasonal Variation of Acute Exacerbation of Atrial Fibrillation: A Population-Based Study.

OBJECTIVE: We investigated seasonal variation of acute exacerbation of atrial fibrillation (AAF) and contributing environmental factors. METHODS: AAF events, meteorological elements, and air pollutants in Seoul between 2013 and 2015 were obtained from the nationwide database. AAF was defined if a patient visited the emergency room due to any AF-relevant symptoms or signs. RESULTS: AAF occurred less frequently in summer than in other seasons (6.71 vs 7.25 events/d, P = 0.005). AAF tended to decrease with an increase of air temperature (r = -0.058). Among air pollutants, NO2 was significantly lower in summer and positively correlated with AAF after adjusting for other variables (ß = 3.197). CONCLUSIONS: The rate of AAF events was the lowest in summer; air temperature and NO2 were contributing factors. The weather and environmental conditions should be considered as risk factors of AAF.

Catheter ablation of a left free-wall accessory pathway via the radial artery approach.

Catheter ablation of the left free-wall accessory pathways (APs) is normally performed by the retrograde transaortic approach via a femoral artery or the transseptal approach. Here we report a case of an overt left free-wall AP, which was successfully ablated with a retrograde transaortic approach via the radial artery without any vascular complications. The patient has remained free of any symptoms or pre-excitation observed on the ECG during a 10-month post- ablation follow-up.

The Trends of Atrial Fibrillation-Related Hospital Visit and Cost, Treatment Pattern and Mortality in Korea: 10-Year Nationwide Sample Cohort Data.

BACKGROUND AND OBJECTIVES: The change of in-hospital and out-hospital treatments, and hospital costs for atrial fibrillation (AF) were not well known in rapidly aging Asian countries. This study is to examine the trends of AF management and outcomes in Korea. SUBJECTS AND METHODS: In the sample cohort from Korean National Health Insurance Data Sample Cohort (K-NHID-Sample Cohort) from 2004 through 2013, we identified patients with AF and hospital visit records using Korean Classification of Diseases, 6th Revision (KCD-6). Hospital cost, prescribed medications, radiofrequency catheter ablation (RFCA), morbidity and mortality were identified. RESULTS: AF-related hospitalization and outpatient clinic visits increased by 2.19 and 3.06-fold, respectively. While the total cost increased from 3.6 to 11.3 billion won (p<0.001), the mean cost per patient increased from 0.68 to 0.83 million won (p<0.001). Although the mean CHA2DS2-VASc score increased from 3.5 to 4.4 in the total AF population, the proportion of patients who receive anticoagulation therapy with warfarin showed no significant change for the decade. The proportion of hospitalization for RFCA was increased (0.4% to 1.1%, p<0.001). All-cause mortality (6.7% to 5.0%), cardiovascular mortality (1.4% to 1.1%) and stroke-related death (1.3% to 0.8%) showed a modest decrease from 2004 to 2013. CONCLUSION: During the last decade, AF-related hospitalization and outpatient clinic visits have increased with the increase of many other comorbidities, whereas the rate of anticoagulation did not improved. Although mortality in patients with AF showed a modest decrease from 2004 to 2013, proper anticoagulation therapy is warranted for the improvement of public health.

Gender Difference in the Long-Term Clinical Implications of New-Onset Atrial Fibrillation after Coronary Artery Bypass Grafting.

PURPOSE: New-onset postoperative atrial fibrillation (POAF) is associated with poor short- and long-term outcomes after isolated coronary artery bypass graft (CABG) surgery. This study evaluated gender differences in the long-term clinical implications of POAF. MATERIALS AND METHODS: After propensity score matching, a gender-based comparison of long-term (>1 year) newly developed atrial fibrillation (LTAF) and mortality between 1664 (480 females) consecutive patients with (POAF) and without POAF (no-POAF) who had undergone CABG was performed. RESULTS: During a follow-up of 49±28 months, cumulative survival free of LTAF was lower in the POAF group than in the no-POAF group for both males (92.1% vs. 98.2%, p<0.001) and females (84.1% vs. 98.0%, p<0.001). However, female patients with POAF more frequently developed LTAF than male POAF patients (13.9 % vs. 6.9%, p=0.049). In multivariate analysis, POAF was a significant predictor of LTAF among males [hazard ratio (HR) 4.91; 95% confidence interval (CI) 1.22-19.79, p=0.031] and females (HR 16.50; 95% CI 4.79-56.78; p<0.001). POAF was a predictor of long-term mortality among females (adjusted HR 3.96; 95% CI 1.13-13.87, p=0.033), but not among males. CONCLUSION: Although POAF was related to LTAF in both genders, cumulative survival free of LTAF was poorer among females than among males. Additionally, a significant correlation with long-term mortality after CABG was observed among female patients with POAF.

Prolonged atrial refractoriness predicts the onset of atrial fibrillation: A 12-year follow-up study.

BACKGROUND: Tissue refractoriness to conduction is a crucial electrophysiological factor in determining susceptibility to fibrillation. The relationship between atrial refractoriness and future onset of atrial fibrillation (AF) has not been well studied. OBJECTIVES: We investigated whether atrial effective refractory period (AERP) was associated with AF occurrence in a relatively healthy population. METHODS: A total of 1308 patients with no overt structural heart diseases and no evidence of congestive heart failure who underwent electrophysiology studies for paroxysmal supraventricular tachycardia from January 1986 to January 2011 were included in the study (626 male, mean age 44 ± 16 years). RESULTS: AERP increased with increasing age. Over a mean follow-up of 12 years, 51 of 1308 subjects (3.9%) developed AF. In univariate analysis, baseline AERP ≥280 ms (hazard ratio [HR] 2.54, 95% confidence interval [CI] 1.27-5.07, P = .008) was strongly associated with new-onset AF. In multivariate Cox regression analysis, age (adjusted HR 1.40 per 10 years, 95% CI 1.15-1.70, P = .001) and AERP ≥280 ms (adjusted HR 2.08, 95% CI 1.03-4.21, P = .041) were associated with new-onset AF. Kaplan-Meier AF-free survival curves demonstrated that subjects with an AERP of ≥280 ms had significantly lower AF-free survival compared those with AERP of <280 ms. CONCLUSIONS: AERP increases with age and AERP of ≥280 ms was predictive of patients at significantly increased future risk of developing AF.