Incidence and Outcomes of Patients With Early Cardiac Complications After Intracerebral Hemorrhage: A Report From VISTA.

BACKGROUND: The incidence and outcomes of early cardiac complications in patients with intracerebral hemorrhage (ICH) are poorly understood. These cardiac complications may be part of the so-called stroke-heart syndrome in patients with ICH. We investigated this issue in an individual patient data pooled analysis from an international repository of clinical trial data. METHODS: We used the Virtual International Stroke Trials Archive to investigate the incidence of cardiac complications within 30 days post-ICH or acute ischemic stroke (AIS). These complications included acute coronary syndrome encompassing myocardial injury, heart failure/left ventricular dysfunction, atrial fibrillation/atrial flutter, other arrhythmia/ECG abnormalities, and cardiorespiratory arrest. We used propensity score matching to compare the incidence of patients with stroke-heart syndrome in patients with ICH with those following AIS. Factors associated with 90-day mortality were evaluated using multivariate logistic regression analysis in the ICH cohort. RESULTS: We pooled data from 8698 participants recruited in acute stroke trials (mean age, 68±12 years; 56% male), of whom 914 (11%) were patients with ICH. Among the patients with ICH, 123 (13%) had stroke-heart syndrome in patients with ICH. Following propensity score matching, a total of 1828 patients (914 for each of the cohorts) were analyzed. While the overall incidence of cardiac events tended to be lower in the ICH group compared with the AIS group (the cumulative incidence freedom from the event, 86.3% [95% CI, 84.1-88.6] versus 83.6% [95% CI, 81.2-86.0]; P=0.100), the incidences cardiac events other than atrial fibrillation/atrial flutter were comparable between the 2 matched groups. The incidence of atrial fibrillation/atrial flutter was significantly lower in the ICH group than in the AIS group (P<0.001). The multivariate-adjusted analysis found that stroke-heart syndrome in patients with ICH was associated with 90-day mortality (adjusted odds ratio, 1.12 [95% CI, 1.06-1.19]; P<0.001). CONCLUSIONS: Cardiac events are common and negatively affect prognosis in patients with ICH, just as seen in AIS.

Intima media thickness of the carotid artery in primary antiphospholipid syndrome: A systematic review and meta-analysis.

BACKGROUND: Primary antiphospholipid syndrome (PAPS) has been associated with an increase in clinical events associated with atherosclerotic vascular disease. Intima media thickness (IMT) of carotid arteries is a surrogate marker of atherosclerotic vascular disease. OBJECTIVES: To conduct a systematic review and meta-analysis of studies evaluating IMT and their clinical correlates in PAPS. METHODS: Systematic search of EMBASE and PubMed databases from January 2000 to December 2023; we employed random effect meta-analyses for continuous outcomes and Peto's odds ratio for rare events. RESULTS: The meta-analysis included 21 studies (20 case control and 1 cohort) showing that PAPS patients (n = 1103) had thicker IM than controls (n = 832) (p < 0.0001) with wide heterogeneity (I2 = 86.9 %); PAPS patients (n = 782) also had a greater pooled prevalence of carotid plaques than controls (n = 537) (13.1 % vs 2.97 %, p < 0.0001). A sensitivity analysis by meta-regression indicated that mean age, gender, disease duration, lipid profile, blood pressures, smoking and statin use all explained the heterogeneity variance; a sensitivity analysis by subgroups confirmed smoking status and statin use as explanatory variables with the addition of ethnicity. CONCLUSION: Atherosclerosis of the carotid artery represents a clinical feature of PAPS in relation to the traditional risk factors and to statin use. Minimising the atherogenic risk with statins could reduce the late arterial atherothrombotic risks of PAPS.

Metabolomics: Implication in cardiovascular research and diseases.

Cellular metabolism influences all aspects of cellular function and is crucial for overall organismal health. Metabolic disorders related to cardiovascular health can lead to cardiovascular diseases (CVDs). Moreover, associated comorbidities may also damage cardiovascular metabolism, exacerbating CVD and perpetuating a vicious cycle. Given the prominent role of metabolic alterations in CVD, metabolomics has emerged as an imperative technique enabling a comprehensive assessment of metabolites and metabolic architecture within the body. Metabolite profile and metabolic pathways help to deepen and broaden our understanding of complex genomic landscape and pathophysiology of CVD. Here in this review, we aim to overview the experimental and clinical applications of metabolomics in pathogenesis, diagnosis, prognosis, and management of various CVD plus future perspectives and limitations.

Associations between central and brachial blood pressure in patients with hypertension and aortovascular disease: Implications for clinical practice.

Central blood pressure (CBP) measurements, compared to brachial blood pressure (bBP), offer a superior predictive accuracy for aortovascular disease outcomes. This emphasises the distinctiveness of central hemodynamic metrics such as CBP, measuring the pressure directly exerted from the cardiac muscle to the major arteries, and provides a more direct assessment of cardiovascular workload than bBP, which measures the pressure against peripheral artery walls. This review synthesises findings evaluating the correlation between CBP and key aortovascular disease markers. Thoracic aortic aneurysm (TAA) growth is a crucial aspect of aortovascular assessment. CBP more accurately correlates with arterial stiffness (AS), the growth of TAA, and cardiovascular diseases, offering a more dependable prediction of aortovascular diseases, adverse cardiovascular events (CVE) and organ damage compared to bBP. The incorporation of CBP into routine clinical practice could enhance aortovascular assessments and therapeutic strategies when compared to bBP, particularly through a deeper understanding of aortic wave dynamics, which could fundamentally alter aortovascular diagnostics and treatment. In conclusion, integrating CBP into aortovascular and cardiovascular risk management is encouraged. Further research is necessary to substantiate these aspects and explore the operative implications of CBP in clinical settings.

Sex Differences in Frequency, Severity, and Distribution of Cerebral Microbleeds.

Importance: Cerebral small vessel disease (SVD) is associated with various cerebrovascular outcomes, but data on sex differences in SVD are scarce. Objective: To investigate whether the frequency, severity, and distribution of cerebral microbleeds (CMB), other SVD markers on magnetic resonance imaging (MRI), and outcomes differ by sex. Design, Setting, and Participants: This cohort study used pooled individual patient data from the Microbleeds International Collaborative Network, including patients from 38 prospective cohort studies in 18 countries between 2000 and 2018, with clinical follow-up of at least 3 months (up to 5 years). Participants included patients with acute ischemic stroke or transient ischemic attack with available brain MRI. Data were analyzed from April to December 2023. Main Outcomes and Measures: Outcomes of interest were presence of CMB, lacunes, and severe white matter hyperintensities determined on MRI. Additionally, mortality, recurrent ischemic stroke, and intracranial hemorrhage during follow-up were assessed. Multivariable random-effects logistic regression models, Cox regression, and competing risk regression models were used to investigate sex differences in individual SVD markers, risk of recurrent cerebrovascular events, and death. Results: A total of 20 314 patients (mean [SD] age, 70.1 [12.7] years; 11 721 [57.7%] male) were included, of whom 5649 (27.8%) had CMB. CMB were more frequent in male patients, and this was consistent throughout different age groups, locations, and in multivariable models (female vs male adjusted odds ratio [aOR], 0.86; 95% CI, 0.80-0.92; P < .001). Female patients had fewer lacunes (aOR, 0.82; 95% CI, 0.74-0.90; P < .001) but a higher prevalence of severe white matter hyperintensities (aOR, 1.10; 95% CI, 1.01-1.20; P = .04) compared with male patients. A total of 2419 patients (11.9%) died during a median (IQR) follow-up of 1.4 (0.7-2.5) years. CMB presence was associated with a higher risk of mortality in female patients (hazard ratio, 1.15; 95% CI, 1.02-1.31), but not male patients (hazard ratio, 0.95; 95% CI, 0.84-1.07) (P for interaction = .01). A total of 1113 patients (5.5%) had recurrent ischemic stroke, and 189 patients (0.9%) had recurrent intracranial hemorrhage, with no sex differences. Conclusions and Relevance: This cohort study using pooled individual patient data found varying frequencies of individual SVD markers between female and male patients, indicating potential pathophysiological differences in manifestation and severity of SVD. Further research addressing differences in pathomechanisms and outcomes of SVD between female and male patients is required.

Clinical and subclinical acute brain injury caused by invasive cardiovascular procedures.

Over the past 50 years, the number and invasiveness of percutaneous cardiovascular procedures globally have increased substantially. However, cardiovascular interventions are inherently associated with a risk of acute brain injury, both periprocedurally and postprocedurally, which impairs medical outcomes and increases health-care costs. Current international clinical guidelines generally do not cover the area of acute brain injury related to cardiovascular invasive procedures. In this international Consensus Statement, we compile the available knowledge (including data on prevalence, pathophysiology, risk factors, clinical presentation and management) to formulate consensus recommendations on the prevention, diagnosis and treatment of acute brain injury caused by cardiovascular interventions. We also identify knowledge gaps and possible future directions in clinical research into acute brain injury related to cardiovascular interventions.

Circulating ketone bodies, genetic susceptibility, with left atrial structure, function and atrial fibrillation: A prospective study from UK Biobank.

BACKGROUND: Ketone bodies (KB) are important cardiac metabolic energy source. Metabolic remodeling has been recently pointed to play an important role in the pathological process of atrial fibrillation (AF). OBJECTIVE: To evaluate the associations between circulating KB levels with incident AF risk in the general population. METHODS: We studied 237,163 participants (mean age, 56.5 years; 55% women) from the UK Biobank who were free of AF at baseline and had data about circulating ß-hydroxybutyrate (ß-OHB), acetoacetate, and acetone. The associations between KB with new-onset AF were evaluated by Cox regression in the general population and across three genetic risk groups [low, moderate, and high polygenic risk score of AF]. RESULTS: During a median follow-up of 14.8 years, 16,638 (7.0%) participants developed AF. There was a U-shaped association between total KB and ß-OHB with incident AF, with nadirs at 60.6 and 40.8 µmol/L, respectively (P non-linear <0.05), whereas a positive association between acetoacetate and acetone with AF was observed (P overall <0.001, P non-linear >0.05). Consistently, a U-shaped association was observed between total KB and ß-OHB with left atrial (LA) volume parameters, including LA maximum volume (LAVmax), LA minimum volume (LAVmin), and their body surface area-indexed counterparts, and an inverted U-shaped association was observed for LA ejection fraction (all P non-linear <0.05). The association between KB with AF was greater among individuals with low genetic risk (Pinteraction <0.05), while the highest AF risk was for those at high genetic risk with high KB levels. Significant mediation effects of inflammatory markers on the associations between KB and AF were identified. CONCLUSIONS: There was a U-shaped association between circulating total KB and ß-OHB with incident AF, as well as a positive association between acetoacetate and acetone level with AF risk in the general population.

Gastrointestinal adverse events of metformin treatment in patients with type 2 diabetes mellitus: a systematic review and meta-analysis with meta-regression of observational studies.

INTRODUCTION: Metformin is the most prescribed medication for type 2 diabetes mellitus (T2DM); there is a well-established link with the elevated incidence of gastrointestinal (GI) adverse events (AE) limiting its administration or intensification. OBJECTIVES: The objective of this systematic review and meta-analysis of observational studies was to evaluate the pooled incidence of GI AE related to metformin use in patients with T2DM. MATERIALS AND METHODS: PUB MED/CINAHL/Web of Science/Scopus were searched from database inception until 29.07.2024 for observational studies in English describing the frequency of GI AE in patients with T2DM treated with metformin. Random-effects meta-analyses were used to derive effect sizes: event rates. RESULTS: From 7019 publications, we identified 211 potentially eligible full-text articles. Ultimately, 21 observational studies were included in the meta-analysis. The prevalence of GI AE was as follows: diarrhea 6.9% (95% CI: 0.038-0.123), bloating 6,2% (95% CI: 0.020-0.177), abdominal pain 5,3% (95% CI: 0.003-0.529), vomiting 2.4% (95%: CI 0.007-0.075), constipation 1.1% (95%: CI 0.001-0.100). The incidence of bloating (coefficient -4.46; p < 0.001), diarrhea (coefficient -1.17; p = 0.0951) abdominal pain (coefficient -2.80; p = 0.001), constipation (coefficient -5.78; p = 0.0014) and vomiting (coefficient -2.47; p < 0.001) were lower for extended release (XR) metformin than metformin immediate release (IR) formulation. CONCLUSIONS: This study highlights the prevalence of GI AE in patients receiving metformin, with a diarrhea predominance, followed by bloating, diarrhea, abdominal pain, constipation, and vomiting. The incidence is lower in patients administered with XR metformin. TRIAL REGISTRATION: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289975 , identifier CRD42021289975.

Stroke-heart syndrome and early mortality in patients with acute ischaemic stroke using hierarchical cluster analysis: An individual patient data pooled analysis from the VISTA database.

BACKGROUND: The patient clinical phenotypes at particularly high risk for early cardiac complications after a recent acute ischaemic stroke (AIS), that is, stroke-heart syndrome (SHS), remain poorly defined. We utilised hierarchical cluster analysis to identify specific phenotypic profiles associated with this risk. METHODS: We gathered data on patients with AIS from the Virtual International Stroke Trials Archive, a global repository of clinical trial data. We examined cardiac complications within 30 days post-stroke, including acute coronary syndrome, heart failure, arrhythmias and cardiorespiratory arrest. We employed hierarchical cluster analysis to define distinct phenotypic risk profiles. The incidence/risk of SHS and 90-day mortality were compared across these profiles. RESULTS: We included 12,482 patients (mean age 69 ± 12 years; 55% male), yielding five phenotypes: Profile 1 ('elderly and AF'), Profile 2 ('young and smoker'), Profile 3 ('young'), Profile 4 ('cardiac comorbidities') and Profile 5 ('hypertension with atherosclerotic comorbidities'). Profiles 4 and 1 exhibited the highest risk for SHS (adjusted HR (95% CI): 2.01 (1.70-2.38) and 1.26 (1.05-1.51), respectively, compared to Profile 3), while Profiles 5 and 2 showed moderate risk and Profile 3 had the lowest risk. Although Profiles 1 and 4 were at the highest risk for most SHS presentations, Profile 5 had the highest risk for cardiorespiratory arrest (adjusted HR (95% CI): 2.99 (1.22-7.34)). The 90-day mortality risk was stratified by phenotype, with the highest risk observed in Profiles 5, and 4. CONCLUSIONS: Hierarchical cluster analysis effectively identified phenotypes with the highest risk of SHS and early mortality in patients with AIS.

Challenging anticoagulation decisions in atrial fibrillation: a narrative review.

Atrial fibrillation (AF) is common and warrants consideration of oral anticoagulant (OAC) medication. Usually, the decision is straightforward, following the pathway outlined in the European Society of Cardiology's guideline; however, certain situations fall outside of this evidence base - such as a diagnosis of subclinical AF made via implanted devices or wearable electrocardiogram monitors, or alternatively diagnosis of 'secondary AF' following a major stressor. Subclinical AF is associated with stroke, though not to the extent of clinical AF, and the benefits of anticoagulation appear to be lower. Longer episodes are more clinically meaningful, and recent randomised controlled trials have demonstrated that some patients derive benefit from OAC. Similarly, when AF is triggered by sepsis or non-cardiac surgery, specific evidence supporting OAC initiation is lacking and clinician behaviour is variable. Observational data demonstrate poorer outcomes in these patients, implying that the perception of a transient, reversible phenomenon may not be correct. Contrastingly, cardiac surgery very frequently induces AF, and the benefits of anticoagulation rarely outweigh the risks of bleeding. Following ischaemic stroke, recent evidence suggests that early (re-)initiation of OAC should be considered as this does not increase the risk of haemorrhagic transformation as previously hypothesised. This narrative review summarises the available literature and outlines, where possible, practical advice for clinicians facing these common clinical dilemmas.

Potentially inappropriate prescribing in polymedicated older adults with atrial fibrillation and multimorbidity: a Swedish national register-based cohort study.

Introduction: Current research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults. Methods: Swedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (≥65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls. Results: PIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88-2.07]) and overall mortality (HR = 2.09 [2.03-2.16]), CV (HR = 1.34 [1.30-1.37]) and overall hospitalisation (HR = 1.48 [1.46-1.51]), stroke (HR = 1.93 [1.78-2.10]), bleeding (HR = 1.10 [1.01-1.21]), and falls (HR = 1.63 [1.56-1.71]). Conclusion: The present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population.

Implantable Cardioverter Defibrillator and Resynchronization Therapy in Patients With Overt Chronic Kidney Disease: JACC State-of-the-Art Review.

Heart failure and chronic kidney disease are common and clinically important conditions that regularly coexist. Electrophysiologic changes of advanced heart failure often result in abnormal conduction, causing dyssynchronous contraction, and development of ventricular arrhythmias, which can lead to sudden cardiac arrest. In the last 2 decades, implantable cardioverter-defibrillator and cardiac resynchronization therapy devices have been developed to address these complications. However, when the coexisting chronic kidney disease is advanced, the associated pathophysiologic cardiovascular changes can alter the efficacy and safety of those interventions and complicate the management. This review explores the impact of comorbid advanced heart failure and advanced chronic kidney disease on the efficacy and safety of implantable cardioverter-defibrillator and cardiac resynchronization therapy, the currently available evidence, and potential future directions.

Relationship between systolic blood pressure and renal function on clinical outcomes in patients with atrial fibrillation: a report from the prospective AF-GEN-UK Registry.

BACKGROUND: Blood pressure (BP) extremes and renal (dys)function contribute to poor outcomes in patients with atrial fibrillation (AF). Using data from the prospective AF-GEN-UK study, we investigated the effect of systolic BP and interaction with renal function for prognostication. METHODS: Baseline systolic BP (SBP) values were recorded for 1580 patients (mean [SD] age 71 [11] years, 60% male) and categorized as follows: 120-129 mmHg (n = 289, reference group) <110 mmHg (n = 165), 110-119 mmHg, (n = 254), 130-139 mmHg (n = 321), 140-159 mmHg (n = 385) and ≥160 mmHg (n = 166). Cox regression analysis, adjusted for age, oral anticoagulation (OAC) and CHA2DS2-VASc score established the impact of SBP, renal function and their interaction on 1-year outcomes. SBP groups were compared using ANOVA and chi-square tests. RESULTS: OAC use was 84% and similar across SBP groups. Renal dysfunction [estimated baseline glomerular filtration rate (eGFR) < 60 ml/min] was present in 24%, with significantly lower eGFR values in the SBP 110-119 mmHg group. History of heart failure was significantly higher in those with SBP <110 mmHg. SBP <110 mmHg was predictive of all cause-death on univariate [hazard ratio (HR) 2.36, 95% confidence interval (CI) 1.20-4.64] and adjusted (aHR 9.71, 95% CI 1.73-54.5) regression. There was no statistically significant interaction between SBP and eGFR, no associations of SBP with haemorrhagic or thromboembolic events. CONCLUSIONS: In people with AF, SBP <110 mmHg was independently predictive of all-cause death, with no significant interaction between SBP and renal (dys)function. This may reflect general poor health and/or excessive antihypertensive therapy, which should be avoided.

Phenotypic characterisation of people at risk of atrial fibrillation: Protocol for the FIND-AF longitudinal cohort study.

AIMS: The Future Innovations in Novel Detection of Atrial Fibrillation (FIND-AF) longitudinal cohort study is a multi-centre prospective cohort study of patients identified at risk of atrial fibrillation (AF). The aim of the FIND-AF longitudinal cohort study is to provide multi-modal phenotypic characterisation of these patients. METHODS AND RESULTS: 1955 participants identified as at risk of AF by the FIND-AF algorithm from primary care electronic health (EHR) data, aged 30 years and above and eligible for oral anticoagulation, will be be recruited between October 2023 and November 2024 to receive home-based intermittent ECG monitoring. About 500 participants without diagnosed AF will then undergo cross-sectional phenotypic characterisation including physical examination, symptoms assessment, serum blood biomarkers and echocardiography, and non-stress cardiac magnetic resonance imaging. Longitudinal information about cardio-renal-metabolic-pulmonary outcomes will be ascertained from linkages to EHR data. The study is funded by the British Heart Foundation (CC/22/250026). The study has ethical approval (North West - Greater Manchester South Research Ethics Committee reference 23/NW/0180). Findings will be announced at relevant conferences and published in peer-reviewed journals in line with the Funder's open access policy. CONCLUSIONS: The FIND-AF multi-centre prospective longitudinal cohort study aims to (i) provide evidence for the impact of comorbidities on AF genesis (ii) uncover actionable targets to prevent AF, and (iii) act as a platform for cohort randomised clinical trials that investigate enhanced detection and prevention of AF.

Atrial fibrillation (AF) is the most common abnormal heart rhythm encountered in clinical practice but we know little about changes to the heart before AF starts, and whether these can be reversed to reduce the risk of future AF. In this study people we will recruit people who have been identified as higher risk of AF using a decision support tool in their medical records, but who have not been found to have AF at the moment when they have had their ECG checked.We will look at the structure and function of their hearts using ultrasound and MRI, and we will also check their blood tests. We aim to learn if people without AF, but at higher risk of AF, have changes to their heart and then conduct studies to establish if these changes can be reversed.

Residual Risks of Thrombotic Complications in Anticoagulated Patients with Atrial Fibrillation: A Cluster Analysis Approach from the GLORIA-AF Registry.

BACKGROUND: Assessment of residual thromboembolic risk in patients with atrial fibrillation (AF) prescribed oral anticoagulants (OACs) remains unexplored. We performed hierarchical cluster analysis to identify phenotypic profiles of these patients and their risks of residual thromboembolic events. METHODS: We utilised data from non-valvular AF patients on OACs, as documented in phases II and III of the GLORIA-AF (Global Registry on Long-Term Oral Anti-thrombotic Treatment in Patients With Atrial Fibrillation) registry. We performed a hierarchical cluster analysis to identify distinct phenotypic profiles. We compared the incidence and risks of thromboembolic events (composite of ischaemic stroke, transient ischaemic attack, or systemic embolism) and related outcomes (major bleeding and all-cause death) across the profiles. We determined the optimal number of profiles through visual inspection of the generated dendrograms. RESULTS: We included 22,410 patients (mean age 70 ± 8 years; 56% male), from which five phenotypes were identified: profile 1 ("uncontrolled hypertension"), profile 2 ("young with a history of coronary artery disease"), profile 3 ("young and obese"), profile 4 ("frailty"), and profile 5 ("non-paroxysmal AF with tachycardia"). Profile 4 was associated with the highest rates of thromboembolic events (1.66/100 person-years [95% confidence interval, 1.46-1.89]), major bleeding (1.92/100 person-years [1.70-2.16]), and death (6.02/100 person-years [5.62-6.43]). Profile 3 was associated with the lowest risk across all measured outcomes (thromboembolic events, 0.64 events/100 person-years [0.48-0.82]; major bleeding, 0.83 events/100 person-years [0.65-1.04]; and death, 1.44 events/100 person-years [1.21-1.71]). Profile 1 had a moderate thromboembolic event rate (1.04/100 person-years [0.91-1.08]), while profiles 2 and 5 showed lower rates. CONCLUSIONS: The phenotypic profiles of patients with AF prescribed OACs identified using hierarchical cluster analysis are associated with distinct residual thromboembolic risks and related outcomes. This approach has the potential to enhance patient risk-stratification and holistic approaches to management.

Atrial fibrillation after cardiac surgery: identifying candidate predictors through a Delphi process.

OBJECTIVES: This study was undertaken to identify potential predictors of atrial fibrillation after cardiac surgery (AFACS) through a modified Delphi process and expert consensus. These will supplement predictors identified through a systematic review and cohort study to inform the development of two AFACS prediction models as part of the PARADISE project (NCT05255224). Atrial fibrillation is a common complication after cardiac surgery. It is associated with worse postoperative outcomes. Reliable prediction of AFACS would enable risk stratification and targeted prevention. Systematic identification of candidate predictors is important to improve validity of AFACS prediction tools. DESIGN: This study is a Delphi consensus exercise. SETTING: This study was undertaken through remote participation. PARTICIPANTS: The participants are an international multidisciplinary panel of experts selected through national research networks. INTERVENTIONS: This is a two-stage consensus exercise consisting of generating a long list of variables, followed by refinement by voting and retaining variables selected by at least 40% of panel members. RESULTS: The panel comprised 15 experts who participated in both stages, comprising cardiac intensive care physicians (n=3), cardiac anaesthetists (n=2), cardiac surgeons (n=1), cardiologists (n=4), cardiac pharmacists (n=1), critical care nurses (n=1), cardiac nurses (n=1) and patient representatives (n=2). Our Delphi process highlighted candidate AFACS predictors, including both patient factors and those related to the surgical intervention. We generated a final list of 72 candidate predictors. The final list comprised 3 demographic, 29 comorbidity, 4 vital sign, 13 intraoperative, 10 postoperative investigation and 13 postoperative intervention predictors. CONCLUSIONS: A Delphi consensus exercise has the potential to highlight predictors beyond the scope of existing literature. This method proved effective in identifying a range of candidate AFACS predictors. Our findings will inform the development of future AFACS prediction tools as part of the larger PARADISE project. TRIAL REGISTRATION NUMBER: NCT05255224.