Estimating the burden of atrial fibrillation and atrial flutter with projection to 2050 in Iran.

Atrial fibrillation (AF)/atrial flutter (AFL) is the most common cardiac tachyarrhythmia, with an increasing trend in its burden in recent years. However, the burden of AF/AFL in Iran remains unclear. This study aimed to estimate the burden of AF/AFL and its attributable risk factors from 1990 to 2019 at national and subnational levels. Using the comparative risk assessment method of the Global Burden of Disease (GBD) Study 2019, we extracted data on AF/AFL incidence, prevalence, deaths, disability-adjusted life years (DALYs), and their age-standardized rates from 1990 to 2019 and analyzed them based on by age, sex, and socio-demographic index (SDI). The percentage contribution of AF/AFL major risk factors was calculated. Moreover, the AF/AFL burden in 2050 was projected using the United Nations world population prospect data. In 2019, there were 339.1 (259.4-433.7) thousand AF/AFL patients in Iran, with 30.2 (23.2-38.5) thousand new cases, 1.7 (1.5-2) thousand deaths and 48 (37.7-60.5) thousand DALYs. Females and 50-69-year-old patients recorded a higher burden for AF/AFL; however, the increasing trend was more pronounced in males and more than 85-year-old patients. High systolic blood pressure and elevated body mass index (BMI) were the predominant attributable risk factors for AF/AFL-related deaths and DALYs. It is estimated that in 2050, the number of AF/AFL patients will increase to 1.1 million people, the incidence of AF/AFL will increase to 91 thousand patients, and the number of AF/AFL-related deaths and DALYs will surge to 7.2 and 170.8 thousand, respectively. Despite advancements in prevention and treatment, AF/AFL remains a major public health problem in Iran. Given its largely preventable and treatable nature, more cost-effective strategies are required to target modifiable risk factors, especially within susceptible age and sex groups.

Arrhythmia in patients with systemic sclerosis: incidence, risk factors and impact on mortality in a Swedish register-based study.

OBJECTIVES: The objectives of this study are to study the risk of developing cardiac arrhythmia and its subtypes over time in patients with systemic sclerosis (SSc), to assess potential risk factors for arrhythmia in SSc and to explore whether arrhythmia is associated with mortality. METHODS: We used nationwide Swedish registers to identify patients with incident SSc 2004-2019 and matched general population comparators (1:10). The primary outcome was incident arrhythmia. Follow-up started at the date of SSc diagnosis and ended at the primary outcome, death, emigration or 31 December 2019. We estimated the incidence of arrhythmia overall and stratified by subtype and explored the relative risk in relation to time since diagnosis using flexible parametric models. We used Cox regression to study risk factors for arrhythmia and the association of arrhythmia with mortality. RESULTS: We identified 1565 patients and 16 009 comparators. The overall incidence of arrhythmia was 255 (95% CI 221 to 295) and 119 (95% CI 112 to 127) per 10 000 person years in patients with SSc and comparators, respectively, corresponding to an IRR of 2.1 (95% CI 1.8 to 2.5). The greatest hazard difference between patients with SSc compared with the comparators was seen in the first year of follow-up (HR for arrhythmia 3.0; 95% CI 2.3 to 3.8). Atrial fibrillation and flutter were the most common arrhythmia subtypes. Male sex, index age and pulmonary arterial hypertension were significant risk factors for arrhythmia in SSc. Incident arrhythmia was significantly associated with mortality (HR 2.2; 95% CI 1.6 to 3.0). CONCLUSION: SSc is associated with higher incidence of cardiac arrhythmia compared with general population. Arrhythmia seems to be an early manifestation of SSc and is associated with higher mortality.

Mitochondrial biological function and risk of atrial fibrillation and atrial flutter: A 2-sample Mendelian randomization study.

Current research suggests that mitochondrial dysfunction can be a contributing factor in the development of cardiac arrhythmias. In pursuit of elucidating the causal link between the biological functions of mitochondria and the occurrence of atrial fibrillation/flutter, we conducted a 2-sample Mendelian randomization (MR) study. Mitochondrial proteins were selected for exposure in this study. To enhance the accuracy of our study, we selected data on AF/AFL from the FinnGen study and the UK Biobank for MR analysis, respectively. The inverse variance-weighted method was utilized as the primary analysis technique for MR. In addition, we performed a series of sensitivity analyses to detect heterogeneity and horizontal pleiotropy. MR results indicated a significant positive association between NAD-dependent protein deacylase sirtuin-5 and AF/AFL (odds ratio = 1.084, 95% confidence interval: 1.037-1.133, P = 3.679 × 10-4, Adjusted P = .024), with consistent outcomes observed in replication analysis (odds ratio = 1.002, 95% confidence interval: 1.001-1.003, P = 4.808 × 10-4, Adjusted P = .032). NAD-dependent protein deacylase sirtuin-5 can significantly promote the occurrence of AF/AFL, and its specific mechanisms warrant further investigation.

Global burden of atrial fibrillation/atrial flutter and its attributable risk factors from 1990 to 2021.

AIMS: To devise effective preventive measures, a profound understanding of the evolving patterns and trends in atrial fibrillation (AF) and atrial flutter (AFL) burdens is pivotal. Our study was designed to quantify the burden and delineate the risk factors associated with AF and AFL across 204 countries and territories spanning 1990-2021. METHODS AND RESULTS: Data pertaining to AF and AFL were sourced from the Global Burden of Disease Study 2021. The burden of AF/AFL was evaluated using metrics such as incidence, disability-adjusted life years (DALYs), deaths, and their corresponding age-standardized rates (ASRs), stratified by age, sex, socio-demographic index (SDI), and human development index (HDI). The estimated annual percentage change was employed to quantify changes in ASRs. Population attributable fractions were calculated to determine the proportional contributions of major risk factors to age-standardized AF/AFL deaths. This analysis encompassed the period from 1990 to 2021. Globally, in 2021, there were 4.48 million incident cases [95% uncertainty interval (UI): 3.61-5.70], 8.36 million DALYs (95% UI: 6.97-10.13) and 0.34 million deaths (95% UI: 0.29-0.37) attributed to AF/AFL. The AF/AFL burden in 2021, as well as its trends from 1990 to 2021, displayed substantial variations based on gender, SDI quintiles, and geographical regions. High systolic blood pressure emerged as the leading contributor to age-standardized AF/AFL incidence, prevalence, death, and DALY rate globally among all potential risk factors, followed closely by high body mass index. CONCLUSION: Our study underscores the enduring significance of AF/AFL as a prominent public health concern worldwide, marked by profound regional and national variations. Despite the substantial potential for prevention and management of AF/AFL, there is a pressing imperative to adopt more cost-effective strategies and interventions to target modifiable risk factors, particularly in areas where the burden of AF/AFL is high or escalating.

The burden of atrial fibrillation/flutter in the Middle East and North Africa region and its associated risk factors from 1990 to 2019.

BACKGROUND: Atrial fibrillation and flutter (AFF) are the most common cardiac arrhythmias globally, contributing to substantial morbidity and mortality. The Middle East and North Africa (MENA) region face unique challenges in managing cardiovascular diseases, including AFF, due to diverse sociodemographic factors and healthcare infrastructure variability. This study aims to comprehensively evaluate the burden of AFF in MENA from 1990 to 2019. METHODS: Data were obtained from the Global Burden of Diseases Study 2019, a comprehensive source incorporating diverse data inputs. The study collected global, regional, and national Age-Standardized Incidence Rate (ASIR), Age-Standardized Mortality Rate (ASMR), and Age-Standardized Disability-Adjusted Rate (ASDR), Mortality across sex, age groups, and years. LOESS regression was employed to determine the relationship between age-standardized rates attributed to AFF and Socio-Demographic Index (SDI). RESULTS: The study found minimal change in ASIR of AFF in MENA from 1990 to 2019, with a slight increase observed in ASMR and ASDR during the same period. Notably, AFF burden was consistently higher in females compared to males, with age showing a direct positive relationship with AFF burden. Iraq, Iran, and Turkey exhibited the highest ASIR, while Qatar, Bahrain, and Oman had the highest ASMR and ASDR in 2019. Conversely, Kuwait, Libya, and Turkey displayed the lowest ASMR and ASDR rates. CONCLUSION: This study underscores the persistent burden of AFF in MENA and identifies significant disparities across countries. High systolic blood pressure emerged as a prominent risk factor for mortality in AFF patients. Findings provide crucial insights for policy-making efforts, resource allocation, and intervention strategies aimed at reducing the burden of cardiovascular diseases in the MENA region.

Thromboembolism after coronavirus disease 2019 vaccination in atrial fibrillation/flutter: a self-controlled case series study.

BACKGROUND AND AIMS: Concerns about the safety of coronavirus disease 2019 (COVID-19) vaccines in patients with atrial fibrillation/flutter (AF/AFL) have arisen due to reports of thrombo-embolic events following COVID-19 vaccination in the general population. This study aimed to evaluate the risk of thrombo-embolic events after COVID-19 vaccination in patients with AF/AFL. METHODS: This was a modified self-controlled case-series study using a comprehensive nationwide-linked database provided by the National Health Insurance Service in South Korea to calculate incidence rate ratios (IRRs) of thrombo-embolic events. The study population included individuals aged ≥12 years who were either vaccinated (e.g. one or two doses) or unvaccinated during the period from February to December 2021. The primary outcome was a composite of thrombo-embolic events, including ischaemic stroke, transient ischaemic attack, and systemic thromboembolism. The risk period was defined as 0-21 days following COVID-19 vaccination. RESULTS: The final analysis included 124 127 individuals with AF/AFL. The IRR of thrombo-embolic events within 21 days after COVID-19 vaccination, compared with that during the unexposed control period, was 0.93 [95% confidence interval (CI) 0.77-1.12]. No significant risk variations were noted by sex, age, or vaccine type. However, patients without anticoagulant therapy had an IRR of 1.88 (95% CI 1.39-2.54) following vaccination. CONCLUSIONS: In patients with AF/AFL, COVID-19 vaccination was generally not associated with an increased risk of thrombo-embolic events. However, careful individual risk assessment is required when advising vaccination for those not on oral anticoagulant, as these patients exhibited an increased risk of thrombo-embolic events post-vaccination.

Ten-Year Trend of Oral Anticoagulation Use in Postoperative and Nonpostoperative Atrial Fibrillation in Routine Clinical Practice.

BACKGROUND: The study aimed to describe the patterns and trends of initiation, discontinuation, and adherence of oral anticoagulation (OAC) in patients with new-onset postoperative atrial fibrillation (POAF), and compare with patients newly diagnosed with non-POAF. METHODS AND RESULTS: This retrospective cohort study identified patients newly diagnosed with atrial fibrillation or flutter between 2012 and 2021 using administrative claims data from OptumLabs Data Warehouse. The POAF cohort included 118 366 patients newly diagnosed with atrial fibrillation or flutter within 30 days after surgery. The non-POAF cohort included the remaining 315 832 patients who were newly diagnosed with atrial fibrillation or flutter but not within 30 days after a surgery. OAC initiation increased from 28.9% to 44.0% from 2012 to 2021 in POAF, and 37.8% to 59.9% in non-POAF; 12-month medication adherence increased from 47.0% to 61.8% in POAF, and 59.7% to 70.4% in non-POAF. The median time to OAC discontinuation was 177 days for POAF, and 242 days for non-POAF. Patients who saw a cardiologist within 90 days of the first atrial fibrillation or flutter diagnosis, regardless of POAF or non-POAF, were more likely to initiate OAC (odds ratio, 2.92 [95% CI, 2.87-2.98]; P <0.0001), adhere to OAC (odds ratio, 1.08 [95% CI, 1.04-1.13]; P <0.0001), and less likely to discontinue (odds ratio, 0.83 [95% CI, 0.82-0.85]; P <0.0001) than patients who saw a surgeon or other specialties. CONCLUSIONS: The use of and adherence to OAC were higher in non-POAF patients than in POAF patients, but they increased over time in both groups. Patients managed by cardiologists were more likely to use and adhere to OAC, regardless of POAF or non-POAF.

Atrial fibrillation and flutter and ocular diseases. The Ural eye and medical study and the Ural very old study.

PURPOSE: To assess associations between atrial fibrillation/atrial flutter (AF) and ocular parameters and diseases. METHODS: The population-based Ural Eye and Medical Study (UEMS) and the Ural Very Old Study (UVOS) included 4894 individuals (age: 40+ years) and 835 individuals (age: 85+ years), respectively. RESULTS: In the UEMS, AF prevalence (80/4894; 1.6%; 95% CI: 1.3, 2.0) increased from 1/1029 (0.1%) in the age group of 40 to <50 years to 29/619 (4.7%) and 12/159 (7.5%) in the age groups of 70 to <80 years and 80+ years, respectively. Higher AF prevalence correlated with older age (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), urban region of habitation (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), higher prevalence of cardiovascular disease/stroke (OR: 2.50; 95% CI: 1.32, 4.72; p < 0.001) and lower prevalence of neck pain (OR: 0.35; 95% CI: 0.14, 0.85; p = 0.02), higher serum concentration of bilirubin (OR: 1.03; 95% CI: 1.02, 1.05; p < 0.001) and lower prothrombin index (OR: 0.96; 95% CI: 0.93, 0.99; p = 0.003), higher stage of arterial hypertension (OR: 1.52; 95% CI: 1.01, 2.28; p = 0.04) and higher ankle-brachial index (OR: 22.1; 95% CI: 4.45, 1.10; p < 0.001). In that model, AF prevalence was not associated with ocular parameters such as intraocular pressure (p = 0.52), retinal nerve fibre layer thickness (p = 0.70), refractive error (p = 0.13), axial length (p = 0.14), nuclear cataract degree (p = 0.50) and prevalence (p = 0.40), cortical cataract degree (p = 0.43) and presence (p = 0.17), lens pseudoexfoliation (p = 0.58), status after cataract surgery (p = 0.38), age-related macular degeneration prevalence (p = 0.63), open-angle glaucoma presence (p = 0.90) and stage (p = 0.55), angle-closure glaucoma prevalence (p = 0.99) and stage (p = 0.99), diabetic retinopathy prevalence presence (p = 0.37) and stage (p = 0.32), and myopic macular degeneration (p = 0.98). In the UVOS, similar results were obtained. CONCLUSIONS: In these multi-ethnic populations from Russia, AF prevalence was not associated with any major ocular disease and may not play a major role in the pathogenesis of these disorders.

Impact of Posterior Wall Isolation During AF Ablation on the Incidence of Left Atrial Flutter.

BACKGROUND: Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown. OBJECTIVES: The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI + PWI vs PVI + PWI + LCEA. METHODS: Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12 months. RESULTS: In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI + PWI (6.2%) vs PVI alone (3.0%; P < 0.0001) and following PVI + PWI + LCEA vs PVI + PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI + PWI (P = 0.386), and 81.8% post-PVI + PWI + LCEA (P < 0.005). CONCLUSIONS: The incidence of LAMT following PVI + PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic.

Relationships between adrenal insufficiency and cardiovascular outcomes in patients with atrial fibrillation, atrial flutter and paroxysmal supraventricular tachycardia.

BACKGROUND: Patients with Adrenal Insufficiency (AI) face elevated cardiovascular risks, but little remains known about arrhythmia outcomes in this context. METHOD: Analyzing the 2016-2019 Nationwide Inpatient Sample, we identified cases of Atrial Fibrillation, Atrial Flutter, and paroxysmal supraventricular tachycardia (PSVT) with a secondary diagnosis of AI. Mortality was the primary outcome while vasopressors and/or mechanical ventilation use, length of stay (LOS), and total hospitalization charges (THC) constituted secondary outcomes. Multivariate linear and logistic regression models were used to adjust for confounders. RESULTS: Among patients with Atrial Fibrillation, Atrial Flutter, and PSVT (N=1,556,769), 0.2% had AI. AI was associated with higher mortality (adjusted OR [aOR] 2.29, p=0.001), vasopressor and/or mechanical ventilation use (aOR 2.54, p<0.001), THC ($62,347 vs. $41,627, p<0.001) and longer LOS (4.4 vs. 3.2 days, p<0.001) compared to no AI. CONCLUSION: AI was associated with higher adverse outcomes in cases of Atrial Fibrillation, Atrial Flutter, and PSVT.

Association Between Family History and Early-Onset Atrial Flutter Across Racial and Ethnic Groups.

BACKGROUND: Genetic and familial contributions to early-onset atrial fibrillation are described primarily in individuals of European ancestry. However, the role of racial and familial contributions in the pathogenesis of early-onset atrial flutter (EOAFL) is unclear. METHODS AND RESULTS: In this cross-sectional study, participants were enrolled prospectively from 2015 to 2021 in multiple academic centers with a diagnosis of atrial flutter (AFL) confirmed by ECG. EOAFL was defined as a diagnosis of AFL before age 66 years with no concomitant or previous diagnosis of atrial tachyarrhythmias. Family history was adjudicated through baseline questionnaires and direct family interviews about the diagnosis of atrial tachyarrhythmias, stroke, and cardiomyopathy. The primary exposure was a positive family history in first-degree relatives, and the primary outcome was the odds of EOAFL versus late-onset AFL. A total of 909 patients were enrolled. Participants with a positive family history of atrial tachyarrhythmias were younger, less likely to be of Black race, and more likely to have EOAFL. The adjusted odds ratio (OR) for EOAFL in those with a positive family history was 1.8 (95% CI, 1.1-3.0). There was an increased odds of EOAFL in those of Black race (OR, 2.1 [95% CI, 1.4-3.2]), alcohol use (OR, 1.6 [95% CI, 1.0-2.6]), and obstructive sleep apnea (OR, 1.9 [95% CI, 1.0-3.4]). Use of cardioselective ß blockers or calcium channel blockers before the diagnosis of AFL were associated with a lower odds of EOAFL (OR, 0.5 [95% CI, 0.2-0.9]). CONCLUSIONS: These findings suggest a potentially hereditary predisposition to EOAFL across race and ethnicity, warranting further study of the genetic contributions to AFL.

Global, regional, and national burden of atrial fibrillation/flutter related to metabolic risks over three decades: estimates from the global burden of disease study 2019.

AIMS: Atrial fibrillation/atrial flutter (AF/AFL) remains a significant public health concern on a global scale, with metabolic risks playing an increasingly prominent role. This study aimed to investigate comprehensive epidemiological data and trends concerning the metabolic risks related-AF/AFL burden based on the data from the Global Burden of Disease study in 2019. METHODS AND RESULTS: The analysis of disease burden focused on numbers, age-standardized rates of deaths, disability-adjusted life years (DALYs), and estimated annual percentage change, while considering factors of age, sex, sociodemographic index (SDI), and locations. In 2019, there was a culmination of 137 179 deaths and 4 099 146 DALYs caused by metabolic risks related-AF/AFL worldwide, with an increase of 162.95% and 120.30%, respectively from 1990. High and high-middle SDI regions predominantly carried the burden of AF/AFL associated with metabolic risks, while a shift towards lower SDI regions had been occurring. Montenegro had the highest recorded death rate (7.6 per 100 000) and DALYs rate (146.3 per 100 000). An asymmetrically inverted V-shaped correlation was found between SDI and deaths/DALYs rates. Moreover, females and the elderly exhibited higher AF/AFL burdens, and young adults (over 40 years old) also experienced an annual increase. CONCLUSION: The global AF/AFL burden related to metabolic risks has significantly increased over the past three decades, with considerable spatiotemporal, gender-based, and age-related heterogeneity. These findings shed valuable light on the trends in the burden of metabolic risks related-AF/AFL and offered insights into corresponding strategies.

Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study.

BACKGROUND: An immediate, temporal risk of heart failure and arrhythmias after a Chronic Obstructive Pulmonary Disease (COPD) exacerbation has been demonstrated, particularly in the first month post-exacerbation. However, the clinical profile of patients who develop heart failure (HF) or atrial fibrillation/flutter (AF) following exacerbation is unclear. Therefore we examined factors associated with people being hospitalized for HF or AF, respectively, following a COPD exacerbation. METHODS: We conducted two nested case-control studies, using primary care electronic healthcare records from the Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, Office for National Statistics for mortality, and socioeconomic data (2014-2020). Cases had hospitalization for HF or AF within 30 days of a COPD exacerbation, with controls matched by GP practice (HF 2:1;AF 3:1). We used conditional logistic regression to explore demographic and clinical factors associated with HF and AF hospitalization. RESULTS: Odds of HF hospitalization (1,569 cases, 3,138 controls) increased with age, type II diabetes, obesity, HF and arrhythmia history, exacerbation severity (hospitalization), most cardiovascular medications, GOLD airflow obstruction, MRC dyspnea score, and chronic kidney disease. Strongest associations were for severe exacerbations (adjusted odds ratio (aOR)=6.25, 95%CI 5.10-7.66), prior HF (aOR=2.57, 95%CI 1.73-3.83), age≥80 years (aOR=2.41, 95%CI 1.88-3.09), and prior diuretics prescription (aOR=2.81, 95%CI 2.29-3.45). Odds of AF hospitalization (841 cases, 2,523 controls) increased with age, male sex, severe exacerbation, arrhythmia and pulmonary hypertension history and most cardiovascular medications. Strongest associations were for severe exacerbations (aOR=5.78, 95%CI 4.45-7.50), age≥80 years (aOR=3.15, 95%CI 2.26-4.40), arrhythmia (aOR=3.55, 95%CI 2.53-4.98), pulmonary hypertension (aOR=3.05, 95%CI 1.21-7.68), and prescription of anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15). CONCLUSIONS: Cardiopulmonary factors were associated with hospitalization for HF in the 30 days following a COPD exacerbation, while only cardiovascular-related factors and exacerbation severity were associated with AF hospitalization. Understanding factors will help target people for prevention.

Prevalence and Predictors of Readmissions in Patients With Hypertrophic Cardiomyopathy and Atrial Fibrillation/Flutter.

Atrial fibrillation/flutter (AF) is the most common dysrhythmia in patients with hypertrophic cardiomyopathy (HCM). Unexplained left ventricular hypertrophy and left ventricular outflow tract obstruction are integral components of HCM pathology which can cause increased left atrial pressure and atrial myopathy contributing to the substrate for AF. We aimed to determine the impact of AF on hospital readmissions in patients with HCM. We conducted a retrospective analysis using the 2015 to 2019 Nationwide Readmission Database to analyze the effect of AF on 30-day readmission and causes of 30-day readmission in patients with HCM. We also determined the hospital, patient, and procedure-specific independent predictors of readmission in patients with HCM and AF. Of 191,235 index HCM hospitalizations, 81,390 (42.6%) had a secondary diagnosis of AF. A total of 16.9% of patients with HCM and AF were readmitted within 30 days as compared with 14% of HCM patients without AF. The presence of AF was independently associated with a higher risk of all-cause 30-day readmission (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.17 to 1.25, p <0.001). The foremost etiology of 30-day readmission in HCM patients with AF was hypertensive heart and chronic kidney disease with heart failure, whereas the foremost etiology of 30-day readmission in HCM patients without AF was sepsis. Interventions aimed toward AF management (electrical cardioversion: adjusted HR 0.91, 95% CI 0.82 to 1.01. p = 0.074, AF ablation: HR 0.92, 95% CI 0.74 to 1.13, p = 0.409, Watchman procedure: HR 1.50, 95% CI 0.16 to 14.6, p = 0.725) during index admission did not significantly impact the 30-day readmission in HCM patients with AF. Myectomy during index hospitalization (adjusted HR 0.54, 95% CI 0.34 to 0.86, p = 0.010) was most strongly associated with a lower risk of 30-day readmission in HCM patients with AF. In conclusion, in patients hospitalized for HCM, presence of AF was associated with excess risk of 30-day all-cause readmission. Interventions aimed toward HCM management, that is, myectomy rather than interventions aimed toward AF management predicted lower readmission rate in this patient population.

Long-term outcomes after hospitalization for atrial fibrillation or flutter.

BACKGROUND AND AIMS: Atrial fibrillation (AF) and flutter are common causes of hospitalizations but contemporary long-term outcomes following these episodes are uncertain. This study assessed outcomes up to 10 years after an acute AF or flutter hospitalization. METHODS: Patients hospitalized acutely with a primary diagnosis of AF or flutter from 2008-17 from all public and most private hospitals in Australia and New Zealand were included. Kaplan-Meier methods and flexible parametric survival modelling were used to estimate survival and loss in life expectancy, respectively. Competing risk model accounting for death was used when estimating incidence of non-fatal outcomes. RESULTS: A total of 260 492 adults (mean age 70.5 ± 14.4 years, 49.6% female) were followed up for 1 068 009 person-years (PY), during which 69 167 died (incidence rate 6.5/100 PY) with 91.2% survival at 1 year, 72.7% at 5 years, and 55.2% at 10 years. Estimated loss in life expectancy was 2.6 years, or 16.8% of expected life expectancy. Re-hospitalizations for heart failure (2.9/100 PY), stroke (1.7/100 PY), and myocardial infarction (1.1/100 PY) were common with respective cumulative incidences of 16.8%, 11.0%, and 7.1% by 10 years. Re-hospitalization for AF or flutter occurred in 21.3% by 1 year, 35.3% by 5 years, and 41.2% by 10 years (11.6/100 PY). The cumulative incidence of patients undergoing catheter ablation of AF was 6.5% at 10 years (1.2/100 PY). CONCLUSIONS: Patients hospitalized for AF or flutter had high death rates with an average 2.6-year loss in life expectancy. Moreover, re-hospitalizations for AF or flutter and related outcomes such as heart failure and stroke were common with catheter ablation used infrequently for treatment, which warrant further actions.

Incidence and patterns of atrial fibrillation after catheter ablation of typical atrial flutter-the FLUTFIB study.

AIMS: In patients with atrial flutter (AFL), ablation of the cavotricuspid isthmus (CTI) is a highly effective procedure to prevent AFL recurrence, but atrial fibrillation (AF) may occur during follow-up. The presented FLUTFIB study was designed to identify the exact incidence, duration, timely occurrence, and associated symptoms of AF after CTI ablation using continuous cardiac monitoring via implantable loop recorders. METHODS AND RESULTS: One hundred patients with AFL without prior AF diagnosis were included after CTI ablation (mean age 69.7 ± 9.7 years, 18% female) and received an implantable loop recorder for AF detection. After a median follow-up of 24 months 77 patients (77%) were diagnosed with AF episodes. Median time to first AF occurrence was 180 (43-298) days. Episodes lasted longer than 1 h in most patients (45/77, 58%). Forty patients (52%) had AF-associated symptoms.Patients with and without AF development showed similar baseline characteristics and neither HATCH- nor CHA2DS2-VASc scores were predictive of future AF episodes. Oral anticoagulation (OAC) was stopped during FU in 32 patients (32%) and was re-initiated after AF detection in 15 patients (15%). No strokes or transient ischaemic attack episodes were observed during follow-up. CONCLUSION: This study represents the largest investigation using implantable loop recorders (ILRs) to detect AF after AFL ablation and shows a high incidence of AF episodes, most of them being asymptomatic and lasting longer than 1 h. In anticipation of trials determining the duration of AF episodes that should trigger OAC initiation, these results will help to guide anticoagulation management after CTI ablation.

Localized Re-Entry Is a Frequent Mechanism of De Novo Atypical Flutter.

BACKGROUND: Limited data exist about the origins and mechanisms of atypical atrial flutter that occurs in the absence of prior ablation or surgery. OBJECTIVES: The aims of this study were to report a large cohort of patients who presented for catheter ablation of de novo atypical flutters, to identify the most common locations and mechanisms of arrhythmia, and to describe outcomes after ablation. METHODS: Demographic, electrophysiological, and outcome data were collected for patients who underwent ablation of de novo atypical flutter. RESULTS: The mechanisms of 85 atypical flutters were identified in 62 patients and localized to the left atrium (LA) in 58 and right atrium (RA) in 27. In the LA, mechanisms were classified as macro-re-entry in 29 (50%) and localized re-entry in 29 (50%), whereas in the RA, mechanisms were macro-re-entry in 8 (30%) and localized re-entry in 19 (70%) (proportion of localized re-entry in the LA vs. RA, P = 0.08). Nine patients had both localized and macro-re-entrant atypical flutters. In the LA, localized re-entry was commonly found in the anterior LA, followed by the pulmonary veins and septum. In the RA, localized re-entry was found at various sites, including the lateral or posterior RA, septum, and coronary sinus ostium. During 39.4 months (Q1-Q3: 18.2-65.8 months) of follow-up, atrial arrhythmias occurred in 66% of patients after a single ablation and in 50% after >1 ablation. Among patients who underwent repeat ablation, compared with the index arrhythmia, different tachycardia circuits or arrhythmias were documented in 13 of 18 cases (72%). CONCLUSIONS: Atypical atrial flutters in patients without prior surgery or complex ablation are often due to localized re-entry (approximately 50% in the LA and a higher frequency in the RA). Other atrial tachycardias commonly occur during long-term follow-up following ablation, suggesting progressive atrial myopathy in these patients.

Association of sleep duration with atrial fibrillation/flutter mortality in the United States: a cross-sectional analysis.

BACKGROUND: The association between sleep duration and atrial fibrillation risk is poorly understood, with inconsistent findings reported by several studies. We sought to assess the association between long sleep duration and mortality due to atrial fibrillation/atrial flutter (AF/AFL). METHODS: The 2016-2020 Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research dataset was used to identify death records secondary to AF/AFL in the United States population. We used the 2018 Behavioral Risk Factor Surveillance System (BRFSS) dataset of sleep duration at the county level. All counties were grouped into quartiles based on the percentage of their population with long sleep duration (i.e., ≥ 7 h), Q1 being the lowest and Q4 the highest quartile. Age-adjusted mortality rates (AAMR) were calculated for each quartile. County Health Rankings for Texas were used to adjust the AAMR for comorbidities using linear regression. RESULTS: Overall, the AAMR for AF/AFL were highest in Q4 (65.9 [95% CI, 65.5-66.2] per 100,000 person-years) and lowest in Q1 (52.3 [95% CI, 52.1-52.5] per 100,000 person-years). The AAMR for AF/AFL increased stepwise from the lowest to highest quartiles of the percentage population with long sleep duration. After adjustment for the county health ranks of Texas, long sleep duration remained associated with a significantly higher AAMR (coefficient 220.6 (95% CI, 21.53-419.72, p-value = 0.03). CONCLUSIONS: Long sleep duration was associated with higher AF/AFL mortality. Increased focus on risk reduction for AF, public awareness about the importance of optimal sleep duration, and further research to elucidate a potential causal relationship between sleep duration and AF are warranted.

Clinical Outcomes of Decompensated Heart Failure With Reduced Ejection Fraction Admissions With or Without Atrial Fibrillation and Atrial Flutter.

The aim of our retrospective study is to determine the influence of co-morbid atrial fibrillation or flutter (AF) on decompensated congestive heart failure (CHF) admissions using data from the 2020 nationwide inpatient sample. We identified 76,835 adults admitted nonelectively with decompensated CHF. After multivariate adjustment, we found decompensated heart failure with reduced ejection fraction (HFrEF) admissions with AF had 37% higher odds of in-hospital mortality, (OR 1.38 [95% CI 1.1-1.72] P < 0.01), 33% higher odds for mechanical ventilation (MV) (OR 1.33 [95% CI 1.14-1.55] P < 0.01), 39% higher odds of early MV (OR 1.39 [95% CI 1.16-1.66] P < 0.01), 54% higher odds of cardiogenic shock (OR 1.54 [95% CI 1.29-1.84] P < 0.01), 61% increased odds of mechanical circulatory support (MCS) requirement (OR 1.61 [95% CI 1.12-2.31] P < 0.02), significantly higher odds of acute renal failure (AKI) necessitating dialysis (OR 2.20 [95% CI 1.39-2.48] P < 0.01), 1-day increase in mean length of stay (LOS) (6.7 vs 5.7 days, adjusted difference: 0.99, P < 0.01), $13,281 increase in total hospitalization charges ($84,316 vs $74,279, adjusted difference: $13,281, P < 0.05) compared to the non-AF cohort. Moreover, we found decompensated heart failure with preserved ejection fraction (HFpEF) admissions with AF had a 23% increased odds of MV (OR 1.23 [95% CI 1.01-1.50] P < 0.01), 24% higher odds of early MV (OR 1.24 [95% CI 1.00-1.53] P < 0.01), 0.36 days increase in mean LOS (5.5 vs 5.2 days, adjusted difference: 0.36, P = < 0.01), but no significant difference in in-hospital mortality (OR 1.23 [95% CI 0.86-1.75] P = 0.25), cardiogenic shock (OR 1.75 [95% CI 0.96-3.19] P < 0.07), dialysis-dependent AKI (OR 0.46 [95% CI 0.18-1.17] P < 0.10), or mean total hospitalization charges ($52,086 vs $47,990, adjusted difference: $5584, P = 0.06) compared to the non-AF cohort.