Rates and predictors of hospital and emergency department care after catheter ablation of atrial fibrillation.

INTRODUCTION: Although atrial fibrillation (AF) ablation has become increasingly safer, rehospitalization and emergency department (ED) evaluations can occur in the postablation period. Better understanding of the frequency, causes, and predictors for hospitalization and ED evaluation after ablation are needed, particularly as same-day discharge programs expand. METHODS: The Optum Clinformatics database was used to define rates, causes, and predictors of hospital and ED care after AF ablation performed between January 2016 and May 2019. Primary outcomes were all-cause hospital and ED care within 30 days of discharge. Independent predictors of all-cause ED and hospital admissions care were determined via logistic regression. RESULTS: Of the 18 848 patients in this study, the mean age was 67.5 ± 10 years, 37.9% were female, and the mean CHA2 DS2 -VASc score was 3.27 ± 1.84. Within 30 days of AF ablation, 1440 of 18 848 patients (7.6%) required hospital care of which 15% had >1 admission; 7.9% required ED care of which 28.6% had >1 ED visit. The most common reasons for hospital admission (which occurred on average 12.3 days after discharge) were supraventricular tachycardia (SVT) or AF (33.2%), heart failure (12.7%), and infection (12.2%). The most common reasons for ED care were SVT/AF (15.0%), noncardiac chest pain (13.3%), and noninfectious respiratory illness (12.2%). Age, female sex, ablation in an inpatient setting, and co-morbidities were associated with increased risk of rehospitalization. Age, female sex, patient comorbidities, and non-use of direct oral anticoagulation were associated with increased risk of ED visit. CONCLUSION: Approximately 7%-8% of patients require unplanned hospitalization or ED care after AF ablation, most commonly due to SVT/AF. Predictors of unscheduled care include patient age, sex, and several patient comorbidities. This study can inform quality improvement initiatives by identifying common causes for unscheduled care.

Comparative risk of dementia among patients with atrial fibrillation treated with catheter ablation versus anti-arrhythmic drugs.

Atrial fibrillation (AF) is associated with an increased risk of dementia. Emerging evidence suggests AF suppression is associated with reduced risk of dementia, but the optimal strategy to achieve this is unknown. We sought to compare the risk of dementia in patients with AF who underwent catheter ablation (CA) versus anti-arrhythmic drug (AAD) treatment. METHODS AND RESULTS: Using the 2000 to 2021 Optum Clinformatics database, patients with AF who underwent CA versus AAD treatment (≥1 prescription fill for ≥2 different AADs) were identified and propensity score matched overall and within sex subgroups. A cause-specific hazard model was performed to assess dementia overall and in sex-specific subgroups. After matching, there were 19,088 patients per group. CA was associated with a 41% lower risk of dementia compared with AAD alone (1.9% vs 3.3%; hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.52-0.67, log-rank P < .0001). When examined by sex, dementia risk reduction associated with CA versus AAD use alone was observed among both males (HR 0.55, 95% CI 0.46-0.66) and females (HR 0.60, 95% CI 0.50-0.72). Though not studied as a primary outcome, patients treated with CA were also observed to have 49% lower associated risk of mortality compared with AAD only (HR 0.51 95% CI 0.46-0.55, P < .0001). CONCLUSIONS: Among patients treated for AF, CA was associated with significantly lower risk of dementia and death compared with AADs only. These reductions in risk associated with CA versus AAD were seen in both males and females.

Three-year incidence of pacemaker implantation in patients with atrial fibrillation and sinus node dysfunction receiving ablation versus antiarrhythmic drugs.

BACKGROUND: Sinus node dysfunction (SND) is commonly seen in patients with atrial fibrillation (AF). The purpose of this study was to compare the incidence of pacemaker implantation among patients with SND and AF treated with catheter ablation (CA) versus anti-arrhythmic drugs (AADs). METHODS: The 2013-2022 Optum Clinformatics database, an administrative claims database for commercially insured individuals in the United States (US), was used for this study. Patients with AF and SND and a history of at least one AAD prescription were identified and classified into CA or AAD cohorts based on subsequent treatment received. Inverse probability treatment weighting was applied to balance socio-demographic and clinical characteristics between the cohorts. Weighted Cox regression modeling was used to evaluate the differential risk of incident permanent pacemaker (PPM) implantation. Sub-analyses were performed by AF type (paroxysmal versus persistent). RESULTS: A total of 1206 patients in the AAD cohort and 1624 patients in the CA cohort were included. Study cohorts were well-balanced post-weighting. The incidence rate of PPM implantation (per 1000 person-year) was 55.8 for the CA cohort and 117.8 for the AAD cohort. Regression analysis demonstrated that the CA cohort had 42% lower risk of incident PPM implantation than those treated with AADs (hazard ratio [HR], 0.58; 95% CI, 0.46-0.72, p < 0.001). CA-treated patients had lower risks of PPM implantation versus AAD-treated patients among those with paroxysmal AF (HR, 0.48; 95% CI, 0.34-0.69, p < 0.001) and persistent AF (HR, 0.57; 95% CI, 0.40-0.81, p = 0.002). CONCLUSIONS: Patients with AF and SND treated with CA have significantly lower risks of incident PPM implantation compared with those treated with an AAD.

Atrial flutter-related health care use and costs: An analysis of a nationally representative administrative claims database in the United States.

Background: Atrial flutter (AFL) is a common arrhythmia associated with significant morbidity, yet the incremental burden of this condition has not been well documented. Objective: Using real-world data, we sought to evaluate the healthcare use and cost burden of incident AFL in the United States. Methods: From 2017 to 2020, persons with an incident diagnosis of AFL were identified through Optum Clinformatics, a nationally representative administrative claims database of commercially insured individuals in the United States. We constructed 2 cohorts (AFL patient; non-AFL comparator) and used a matching weights method to balance covariates between cohorts. Using logistic regression and general linear models, 12-month all-cause and cardiovascular (CV)-related health care use (inpatient, outpatient, emergency room [ER] visits, and other) as well as medical expenditures were compared between the matched cohorts. Results: The matching weight sample sizes were 13,270 for AFL and 13,683 for the non-AFL cohorts. In the AFL cohort, ∼71% were at least 70 years of age, 62% identified as male, and 78% identified as White. The AFL cohort had significantly higher health care use, including all-cause (relative risk [RR] 1.14; 95% confidence interval [CI] 1.11-1.18) and CV-related ER visits (RR 1.60; 95% CI 1.52-1.70) compared with the non-AFL cohort. Mean total health care costs (per patient annually) were almost $21,783 (95% CI $18,967-$24,599) higher among patients with AFL compared to those without AFL ($71,201 vs $49,418, respectively; P <.001). Conclusion: Amidst the backdrop of an aging population, findings from this study draw attention to the importance of timely and adequate treatment of AFL.

The association between COVID-19 infection and incident atrial fibrillation: results from a retrospective cohort study using a large US commercial insurance database.

BACKGROUND: We sought to examine a 1-year incidence of atrial fibrillation (AF) among patients with SARS-CoV-2 virus (COVID-19) in comparison to those with non-COVID-19 acute upper respiratory infection (AURI). METHODS: Patients with a diagnosis of COVID-19 (in any setting) between April 2020 and June 2021 were identified in Optum Clinformatics. Two comparator cohorts were constructed: an 'AURI pandemic' cohort (AURI diagnosis between April 2020 and June 2021) and an 'AURI prepandemic' cohort (AURI diagnosis between January 2018 and December 2018). One-year incidence of AF was compared among: COVID-19 versus AURI pandemic cohort; COVID-19 versus AURI prepandemic cohort; and AURI pandemic versus AURI prepandemic cohort. For each comparison, we applied a matching weights technique to balance covariates. Logistic regression was used to compare the odds of incident AF among the matched cohorts. RESULTS: When comparing the matched COVID-19 (n=102 227) cohort with the AURI pandemic (n=102 101) cohort, higher incidence of AF was observed among the COVID-19 cohort (2.2% vs 1.2%; p<0.001; OR 1.83; 95% CI 1.72 to 1.95). Similar findings were observed for the COVID-19 (n=169 687) versus AURI prepandemic (n=169 486) comparison (2.7% vs 1.6%; p<0.001; OR 1.70; 95% CI 1.63 to 1.78). When comparing the AURI pandemic (n=1 26 392) versus AURI prepandemic (n=1 26 394) cohort, no significant differences in incident AF were observed (1.1% vs 1.2%; p=0.133; OR 0.95, 95% CI 0.90 to 1.01). CONCLUSION: Patients diagnosed with COVID-19 were found to be at a higher risk of incident AF as compared with those with AURI. Timely diagnosis and appropriate treatment of AF may potentially mitigate the burden of AF conferred by COVID-19.

Heart failure risk in patients with atrial fibrillation treated with catheter ablation vs antiarrhythmic drugs.

Background: Atrial fibrillation (AF) increases heart failure (HF) risk. Whereas the risk of HF-related hospitalization and mortality are known in the setting of AF, the impact of AF treatment on HF development is understudied. Objective: The purpose of this study was to compare HF incidence among AF patients treated with antiarrhythmic drugs (AADs) vs catheter ablation (CA). Methods: AF patients with 1 prior AAD usage were identified in 2014-2022 Optum Clinformatics database. Patients were classified into 2 cohorts: those receiving CA vs those receiving a different AAD prescription. The 2 cohorts were matched on sociodemographic and clinical covariates using propensity score matching technique. Cox regression model was used to compare incident HF risk in the 2 cohorts. Subgroup analyses were performed by race/ethnicity, sex, AF subtype, and CHA2DS2-VASc score. Results: After matching, 9246 patients were identified in each cohort (AAD and CA). Patients receiving CA had a 57% lower risk of incident HF than those treated with AADs (hazard ratio [HR] 0.43; 95% confidence interval [CI] 0.40-0.46). Subgroup analysis by race/ethnicity depicted similar results, with non-Hispanic White (HR 0.43; 95% CI 0.40-0.46), non-Hispanic Black (HR 0.46; 95% CI 0.35-0.60), Hispanic (HR 0.53; 95% CI 0.40-0.70), and Asian (HR 0.46; 95% CI 0.24-0.92) patients treated with CA (vs AAD) having significantly lower risk of HF, respectively. The effect size of CA remained significant in subgroups defined by sex, AF subtypes, and CHA2DS2-VASc score. Conclusion: AF patients receiving CA had ∼57% lower risk of developing HF than those receiving AAD. The lower risk of HF associated with CA vs AAD persisted across different race/ethnicity, sex, AF subtypes, and CHA2DS2-VASc score.

Healthcare utilization and costs associated with a diagnosis of incident atrial fibrillation.

Background: Atrial fibrillation (AF) is the most common heart rhythm disorder among adults and leads to substantial morbidity and mortality. Objectives: The purpose of the study was to provide current estimates on the incremental healthcare utilization and cost burden associated with incident AF diagnosis in the United States. Methods: Adults with an incident diagnosis of AF (2017-2020) were identified using the Optum Clinformatics database. Propensity matching was employed to match patients with incident AF to a comparator group of non-AF patients on several demographic and clinical characteristics. Outcomes including 12-month all-cause and cardiovascular (CV)-related healthcare utilization, as well as the medical cost associated with health services use, were assessed. Logistic and general linear models were used to examine study outcomes. Sub-analyses were performed to determine the incremental AF burden by specific sex and racial/ethnic categories. Results: A total of 79,621 patients were identified in each cohort (AF and non-AF). As compared to the non-AF cohort, patients with AF had significantly higher all-cause inpatient visits (relative risk [RR] 1.77; 95% confidence interval [CI] 1.76-1.78), CV-related inpatient visits (RR 2.51; 95% CI 2:49-2:53), and CV-related emergency room visits (RR: 2.41; 95% CI 2:35-2:47). The mean total healthcare cost for patients with AF was $27,896 more (per patient per year) than the non-AF cohort ($63,031 vs $35,135, P < .001). Conclusion: Medical services utilization and cost were significantly higher among AF patients than non-AF patients. Early treatment is likely to be critical to addressing the considerable disease burden imposed by AF.

Structure-function relationships of the antigenicity of mycolic acids in tuberculosis patients.

Cell wall mycolic acids (MA) from Mycobacterium tuberculosis (M.tb) are CD1b presented antigens that can be used to detect antibodies as surrogate markers of active TB, even in HIV coinfected patients. The use of the complex mixtures of natural MA is complicated by an apparent antibody cross-reactivity with cholesterol. Here firstly we report three recombinant monoclonal scFv antibody fragments in the chicken germ-line antibody repertoire, which demonstrate the possibilities for cross-reactivity: the first recognized both cholesterol and mycolic acids, the second mycolic acids but not cholesterol, and the third cholesterol but not mycolic acids. Secondly, MA structure is experimentally interrogated to try to understand the cross-reactivity. Unique synthetic mycolic acids representative of the three main functional classes show varying antigenicity against human TB patient sera, depending on the functional groups present and on their stereochemistry. Oxygenated (methoxy- and keto-) mycolic acid was found to be more antigenic than alpha-mycolic acids. Synthetic methoxy-mycolic acids were the most antigenic, one containing a trans-cyclopropane apparently being somewhat more antigenic than the natural mixture. Trans-cyclopropane-containing keto- and hydroxy-mycolic acids were also found to be the most antigenic among each of these classes. However, none of the individual synthetic mycolic acids significantly and reproducibly distinguished the pooled serum of TB positive patients from that of TB negative patients better than the natural mixture of MA. This argues against the potential to improve the specificity of serodiagnosis of TB with a defined single synthetic mycolic acid antigen from this set, although sensitivity may be facilitated by using a synthetic methoxy-mycolic acid.