Increasing time between first diagnosis of atrial fibrillation and catheter ablation adversely affects long-term outcomes in patients with and without structural heart disease.

INTRODUCTION: Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown. METHODS: All patients that received a catheter ablation for AF(n = 9979) with 1 year of follow-up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF ≤ 35% (n = 1024) and EF > 35% (n = 8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30-180(n = 2689), 2:181-545(n = 1747), 3:546-1825(n = 2941), and 4:>1825(n = 2602) days. RESULTS: The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF > 35%: 3.5 ± 3.8 years, EF ≤ 35%: 3.4 ± 3.8 years, p = .66). In the EF > 35% group, delays in treatment (181-545 vs. 30-180, 546-1825 vs. 30-180, >1825 vs. 30-180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p < .0001), 2.62(p < .0001), and 4.39(p < .0001) respectively with significant risks for HF hospitalization (HR:1.44-3.69), stroke (HR:1.11-2.14), and AF recurrence (HR:1.42-1.81). In patients with an EF ≤ 35%, treatment delays also significantly increased risk of death (HR 2.07-3.77) with similar trends in HF hospitalization (HR:1.63-1.09) and AF recurrence (HR:0.79-1.24). CONCLUSION: Delays in catheter ablation for AF resulted in increased all-cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease.

Atrial fibrillation is a risk factor for major adverse cardiovascular events in COVID-19.

Background: New-onset atrial fibrillation (AF) during COVID-19 infection is associated with worse cardiovascular outcomes and mortality, with new-onset AF being associated with worse clinical outcomes than recurrent AF. However, it is not known whether a prior history of AF is an independent cardiovascular risk factor predicting worse outcomes in COVID-19 patients. The present investigation sought to determine whether AF should be considered a risk factor for worse outcomes in COVID-19 illness. Methods: From March 2020-September 2021 patients testing positive for SARS-CoV-2 with a prior AF diagnosis (n = 3623) were propensity matched to non-AF SARS-CoV-2 positive patients (n = 3610). Multivariable Cox hazard regression was used to determine subsequent MACE (all-cause death, myocardial infarction, HF and stroke) risk among patients with and without AF. Results: COVID-19 patients with a prior history of AF were more likely to be hospitalized, require ICU care, supplemental oxygen, and ventilator support compared COVID-19 patients without a history of AF. There was a 1.40 times higher rate of MACE in the COVID-19 patients with prior AF compared to patients without prior AF (p < 0.0001). The increased rate of MACE in patients with a prior AF was primarily secondary to increases in heart failure hospitalization and death. This finding was confirmed even after controlling for acute AF during COVID-19 illness (HR 1.22, p = 0.0009). Conclusion: AF history was shown to be an independent risk factor for MACE during a COVID-19 illness. Both recurrent and principally new-onset AF were associated with an increased risk of poor clinical outcomes during COVID-19 illness.

Long-term outcomes in patients treated with flecainide for atrial fibrillation with stable coronary artery disease.

BACKGROUND: Class 1C antiarrhythmic drugs (AAD) have been associated with harm in patients treated for ventricular arrhythmias with a prior myocardial infarction. Consensus guidelines have advocated that these drugs not be used in patients with stable coronary artery disease (CAD). However, long-term data are lacking to know if unique risks exist when these drugs are used for atrial fibrillation (AF) in patients with CAD without a prior myocardial infarction. METHODS: In 24,315 patients treated with the initiation of AADs, two populations were evaluated: (1) propensity-matched AF patients with CAD were created based upon AAD class (flecainide, n = 1,114, vs class-3 AAD, n = 1,114) and (2) AF patients who had undergone a percutaneous coronary intervention or coronary artery bypass graft (flecainide, n = 150, and class-3 AAD, n = 1,453). Outcomes at 3 years for mortality, heart failure (HF) hospitalization, ventricular tachycardia (VT), and MACE were compared between the groups. RESULTS: At 3 years, mortality (9.1% vs 19.3%, P < .0001), HF hospitalization (12.5% vs 18.3%, P < .0001), MACE (22.9% vs 36.6%, P < .0001), and VT (5.8% vs 8.5%, P = .02) rates were significantly lower in the flecainide group for population 1. In population 2, adverse event rates were also lower, although not significantly, in the flecainide compared to the class-3 AAD group for mortality (20.9% vs 25.8%, P = .26), HF hospitalization (24.5% vs 26.1%, P = .73), VT (10.9% vs 14.7%, P = .28) and MACE (44.5% vs 49.5%, P = .32). CONCLUSIONS: Flecainide in select patients with stable CAD for AF has a favorable safety profile compared to class-3 AADs. These data suggest the need for prospective trials of flecainide in AF patients with CAD to determine if the current guideline-recommended exclusion is warranted.

Stroke and dementia risk in patients with and without atrial fibrillation and carotid arterial disease.

BACKGROUND: Patients with carotid arterial disease (CD) with and without atrial fibrillation (AF) are at risk of stroke. Patients with AF are at a higher risk of stroke and dementia. OBJECTIVES: We sought to understand the risks of stroke, transient ischemic attack (TIA), and dementia in patients with and without AF and CD or a combination of both as well as to determine whether therapies for each disease may influence risks. METHODS: A total of 11,572 patients were included in 4 groups, with 2893 patients populating each group (1: no AF or CD; 2: AF, no CD; 3: CD and no AF; 4: AF and CD) and matched for age, sex, and comorbidities. Long-term outcomes of stroke/TIA and dementia were assessed. Subset analyses of these outcomes were performed in patients with CD treated with revascularization and in patients with AF treated with ablation. RESULTS: CD increased the risk of stroke/TIA (hazard ratio [HR] 2.74; P < .0001) and dementia (HR 1.44; P < .0001). Similarly, AF increased the risk of stroke/TIA (HR 2.08; P < .0001) and dementia (HR 1.30; P = .004). The coexistence of AF and CD further augmented the risk of both end points. CD revascularization was associated with a decreased risk of dementia (HR 0.47; P < .0001) but not stroke. Ablation of AF improved outcomes of stroke/TIA (HR 0.55; P = .002), particularly in those with CD (HR 0.36; P < .0001), and was associated with a reduced risk of dementia (HR 0.51; P = .04). CONCLUSION: CD and AF augment risk of stroke/TIA and dementia in the general population, and the coexistence of both diseases is additive in risk. Ablation of AF was associated with lower risk, the magnitude of which was greater in those with CD.

Long-term outcomes after low power, slower movement versus high power, faster movement irrigated-tip catheter ablation for atrial fibrillation.

BACKGROUND: High power, shorter duration (HPSD) ablation strategies have been advocated to increase efficacy and minimize posterior wall deep tissue thermal injury during atrial fibrillation (AF) ablation. OBJECTIVE: The purpose of this study was to determine the long-term outcomes of arrhythmia-free survival from AF and atrial flutter (AFL) between HPSD and low power, longer duration (LPLD) ablation strategies. METHODS: Of a total of 1333 first time AF ablation procedures with 3 years of follow-up, propensity-matched populations for baseline risk factors were created, comprising 402 patients treated with LPLD ablation (30 W for 5 seconds: posterior wall; 30 W for 10-20 seconds: anterior wall) and 402 patients treated with HPSD ablation (50 W for 2-3 seconds: posterior wall; 50 W for 5-15 seconds: anterior wall). AF/AFL outcomes after a 90-day blanking period were assessed. RESULTS: HPSD ablation was associated with shorter procedure and fluoroscopy times (P < .0001 for both). The recurrence of AF at 1 year (12.9% vs 16.2%; P = .19) and 3 years (26.5% vs 30.7%; P = .23) was similar between LPLD and HPSD groups. AFL was higher at 1 year (7.2% vs 11.2%; P = .03) and 3 years (16.1% vs 21.8%; P = .06; P = .04 after multivariate adjustment) with HPSD ablation. Patients who underwent an LPLD approach had lower rates of need for repeat ablation (21% vs 30%; P = .002). CONCLUSION: Long-term freedom from AF rates were not significantly different between both approaches. An HPSD ablation strategy compared with an LPLD approach was associated with an increased risk of AFL and need for repeat ablation but with lowered procedure times.

The Impact of Gender on Atrial Fibrillation Incidence and Progression to Dementia.

There are a paucity of data regarding the role of gender and atrial fibrillation (AF) on cognitive decline and incidence of dementia. Such data may provide insight into the disproportionate incidence of dementia in women and may help identify high-risk characteristics to target for prevention. We examined patients who underwent coronary angiography at an Intermountain Healthcare Medical Center and enrolled in a prospective cardiovascular database. To be included, patients could not have a previous diagnosis of AF or dementia and had to have 5years of follow-up. Endpoints included incident AF and dementia. Study cohort consisted of 35,608 patients without a previous history of AF or dementia, with 14,377 (40.4%) being woman. Women had lower rates of hypertension, diabetes, coronary artery disease, and prior myocardial infarction, but higher rates of prior stroke. Men had a higher incidence of 5-year and long-term AF. However, women trended toward a higher incidence of 5-year and long-term dementia and stroke compared with men. In all groups of patients with and without AF, prior stroke predicted cognitive decline. In patients without a history of or development of AF, diabetes significantly increased risk of dementia. Women have higher rates of dementia over time than men, driven by higher baseline stroke rates and nontraditional cardiovascular risk factors. The higher dementia rates were in the setting of lower AF rates. However, in both men and women who develop AF, dementia rates are increased and do not show gender-based differences in risk.

Vagus nerve injury symptoms after catheter ablation for atrial fibrillation.

BACKGROUND: Vagus nerve injury during catheter ablation for atrial fibrillation can significantly impact quality of life and result in lingering gastrointestinal symptoms. This study was designed to define risk factors of vagus nerve injury, symptoms, prevalence, and temporal resolution. METHODS: A total of 100 patients undergoing radiofrequency catheter ablation (RFCA) were enrolled and consented to participate in the study. Patients completed a 22-item questionnaire that included questions specific to vagus nerve injury symptomatology during their baseline visit and at 1 and 3 months post-RFCA. RESULTS: The average age of the population was 63 ± 10.6 years and 68% were male. A total of 100 patients completed their baseline questionnaire (90 patients completed the 1-month questionnaires and 85 patients completed the 3-month questionnaires). Symptoms rated as moderate were prevalent at baseline (trouble swallowing 13%, bloating 26%, feeling full 20%), and increased in all categories analyzed at 1 month and with the exception of trouble swallowing returned to the preablation percentages at 3 months (heartburn 22.4%, trouble swallowing 18.8%, bloating 16.5%, nausea 8.2%, vomiting 3.5%, constipation 18.8%, diarrhea 16.4%, feeling full 15.3%). Severe rated symptoms of trouble swallowing (2-5.5%), bloating (5-7.6%), and early satiety (5-9.8%) increased at 1 month and bloating and early satiety percentages remained approximately two times higher at 3 months (trouble swallowing 2.4%, bloating 8.2%, early satiety 7.1%). CONCLUSION: The majority of symptoms were resolved by 3 months, although those patients who rate bloating and early satiety at a severe rating may have persistent symptoms.

Five-year impact of catheter ablation for atrial fibrillation in patients with a prior history of stroke.

BACKGROUND: Catheter ablation of atrial fibrillation (AF) is an established therapeutic rhythm approach. Patients with a prior history of a stroke (CVA) represent a unique high-risk population for recurrent thromboembolic events. The role of antiarrhythmic treatment on the natural history of stroke recurrence in these patients is not fully understood. METHODS: Three patient groups with a prior CVA and 5 years of follow-up were matched 1:3:3 by propensity score (±0.01): AF ablation patients receiving their first ablation (n  =  139), AF patients that did not receive an ablation (n  =  416), and CVA patients without clinical AF (n  =  416). Prior CVA was determined by medical chart review. Patients were followed for outcomes of recurrent CVA, heart failure, and death. RESULTS: The average age of the population was 69 ± 11 years and 51% male. AF ablation patients had higher rates of hypertension and heart failure (P < 0.0001), but diabetes prevalence was similar between the groups (P  =  0.5). Note that 5-year risk of CVA (HR  =  2.26, P < 0.0001) and death (HR  =  2.43, P < 0.0001) were higher in the AF, no ablation group compared those that were ablated. When comparing AF, ablation to no AF patients, there was not a significant difference in 5-year risk of for CVA (HR  =  0.82, P  =  0.39) and death (HR  =  0.92, P  =  0.70); however, heart failure risk was increased (HR  =  3.08, P  =  0.001). CONCLUSION: In patients with AF and a prior CVA, patients undergoing ablation have lower rates of recurrent stroke compared to AF patients not ablated. Although the full mechanisms of benefit are unknown, as CVA rates are similar to patients without AF these data are suggestive of a potential altering of the natural history of disease progression.

Long-term aspirin does not lower risk of stroke and increases bleeding risk in low-risk atrial fibrillation ablation patients.

BACKGROUND: Stroke risk is a significant concern in patients with atrial fibrillation (AF). Low stroke risk patients (CHADS2 VASc 0-2) are often treated long-term with aspirin after catheter ablation. Defining the long-term risks versus benefits of aspirin therapy, after an ablation, is essential to validate this common clinical approach. METHODS: A total of 4,124 AF ablation patients undergoing their index ablation were included in this retrospective observational study. We compared 1- and 3-year outcomes for cerebrovascular accident (CVA), transient ischemic attack (TIA), gastrointestinal (GI) bleeding, genitourinary (GU) bleeding, any bleeding, and AF recurrence among patients receiving: none, aspirin, or warfarin as long-term therapies. RESULTS: Patient distribution by CHADS2 VASc scores was as follows: 0: 1,143 (28%), 1: 1,588 (39%), and 2: 1,393 (34%). Significantly higher incidents of: female gender, hypertension, diabetes mellitus, heart failure, and vascular disease were seen with higher CHADS2 VASc scores (P < 0.0001 for all). At 3 years, 238 (5.9%) patients were on warfarin, 743 (18.6) on aspirin, and 3,013 (75.5%) on no therapy; with occurrences of CVA/TIA (1.4%, 3.0%, 3.9%, P < 0.0001, respectively), GI bleeding (0.8%, 1.9%, 1.1%, P = 0.06, respectively), and GU bleeding (1.7%, 2.8%, 2.1%, P = 0.008, respectively) that increased with advancing CHA2 DS2 VASc score. There was a significantly increased risk for both CVA/TIA with aspirin therapy, when compared to no therapy or warfarin therapy in general, and across all CHA2 DS2 VASc scores. CONCLUSIONS: After catheter ablation, low risk patients do not benefit from long-term aspirin therapy, but are at risk for higher rates of bleeding when compared to no therapy or warfarin.

Atrial fibrillation incrementally increases dementia risk across all CHADS2 and CHA2DS2VASc strata in patients receiving long-term warfarin.

BACKGROUND: Patients with atrial fibrillation (AF) are at higher risk for developing dementia. Warfarin is a common therapy for the prevention of thromboembolism in AF, valve replacement, and thrombosis patients. The extent to which AF itself increases dementia risk remains unknown. METHODS: A total 6030 patients with no history of dementia and chronically anticoagulated with warfarin were studied. Warfarin management was provided through a Clinical Pharmacy Anticoagulation Service. Patients were stratified by warfarin indication of AF (n=3015) and non-AF (n=3015) and matched by propensity score (±0.01). Patients were stratified by the congestive heart failure, hypertension, age >75 years, diabetes, stroke (CHADS2) score calculated at the time of warfarin initiation and followed for incident dementia. RESULTS: The average age of the AF cohort was 69.3±11.2 years, and 52.7% were male; average age of non-AF cohort was 69.3±10.9 years, and 51.5% were male. Increasing CHADS2 score was associated with increased dementia incidence, P trend=.004. When stratified by warfarin indication, AF patients had an increased risk of dementia incidence. After multivariable adjustment, AF patients continued to display a significantly increased risk of dementia when compared with non-AF patients across all CHADS2 scores strata. CONCLUSIONS: In patients receiving long-term warfarin therapy, dementia risk increased with increasing CHADS2 scores. However, the presence of AF was associated with higher rates of dementia across all CHADS2 score strata. These data suggest that AF contributes to the risk of dementia and that this risk is not solely attributable to anticoagulant use. Dementia may be an end manifestation of a systemic disease state, and AF likely contributes to its progression.

The Population-Based Long-Term Impact of Anticoagulant and Antiplatelet Therapies in Low-Risk Patients With Atrial Fibrillation.

Among patients with atrial fibrillation (AF), the risk of stroke risk is a significant concern. CHADS2 and CHA2DS2-VASc ≤2 scoring have been used to stratify patients into categories of risk. Without randomized, prospective data, the need and type of long-term antithrombotic medications for thromboembolism prevention in lower risk AF patients remains controversial. We sought to define the long-term impact of anticoagulant and antiplatelet therapy use in AF patients at low risk of stroke. A total of 56,764 patients diagnosed with AF and a CHADS2 score of 0 or 1, or CHA2DS2-VASc score of 0, 1, or 2 were studied. Antithrombotic therapy was defined as aspirin, clopidogrel (antiplatelet therapy), or warfarin monotherapy (anticoagulation) initiated within 6 months of AF diagnosis. End points included all-cause mortality, cerebrovascular accident, transient ischemic attack (TIA), and major bleed. The average age of the population was 67.0 ± 14.1 years and 56.6% were male. In total, 9,682 received aspirin, 1,802 received clopidogrel, 1,164 received warfarin, and 46,042 did not receive any antithrombotic therapy. Event rates differed between patients with a CHADS2 score of 0 and 1; 18.5% and 37.8% had died, 1.7% and 3.4% had a stroke, 2.2% and 3.2% had a TIA, and 14% and 12.5% had a major bleed, respectively (p <0.0001 for all). The rates of stroke, TIA, and major bleeding increased as antithrombotic therapy intensity increased from no therapy, to aspirin, to clopidogrel, and to warfarin (all p <0.0001). Similar outcomes were observed in low-risk CHA2DS2-VASc scores (0 to 2). In low-risk AF patients with a CHADS2 score of 0 to 1 or CHA2DS2-VASc score of 0 to 2, the use of aspirin, clopidogrel, and warfarin was not associated with lower stroke rates at 5 years compared with no therapy. However, the use of antithrombotic agents was associated with a significant risk of bleed.

Atrial Fibrillation Patients Treated With Long-Term Warfarin Anticoagulation Have Higher Rates of All Dementia Types Compared With Patients Receiving Long-Term Warfarin for Other Indications.

BACKGROUND: The mechanisms behind the association of atrial fibrillation (AF) and dementia are unknown. We previously found a significantly increased risk of dementia in AF patients taking warfarin with a low percentage of time in therapeutic range. The purpose of this study was to determine the extent to which AF itself increases dementia risk, in addition to long-term anticoagulation exposure. METHODS AND RESULTS: A total of 10 537 patients anticoagulated with warfarin (target INR 2-3), managed by the Clinical Pharmacist Anticoagulation Service with no history of dementia were included. Warfarin indication was for AF (n=4460), thromboembolism (n=5868), and mechanical heart valve(s) (n=209). Patients in the latter 2 categories were included only if they had no prior history of AF. The primary outcome was dementia. Patients with AF were older and had higher rates of hypertension, diabetes, heart failure, and stroke. AF patients experienced higher rates of total dementia (5.8% versus 1.6%, P<0.0001), Alzheimer disease (2.8% versus 0.9%, P<0.0001), and vascular dementia (1.0% versus 0.2%, P<0.0001). A propensity analysis of 6030 patients was performed to account for baseline demographics differences. Long-term risk of dementia remained significant in AF patients compared with matched non-AF patients (total dementia: hazard ratio [HR]=2.42 [1.85-3.18], P<0.0001; Alzheimer: HR=2.04 [1.40-2.98], P<0.0001; senile: HR=2.46 [1.58-3.86], P<0.0001). Low percent therapeutic range compared with a higher percent therapeutic range was associated with dementia risk in both AF (26-50% versus >75%: HR=2.51, P=0.005) and non-AF groups (≤25% versus >75%: HR=3.92, P<0.0001). CONCLUSIONS: The presence of AF significantly increases risk of dementia, including Alzheimer's disease, compared with matched patients receiving warfarin anticoagulation for other reasons. Quality of anticoagulation management remains an important risk factor for dementia in all patients.

Long-term influence of body mass index on cardiovascular events after atrial fibrillation ablation.

BACKGROUND: Catheter ablation of atrial fibrillation (AF) is an established therapeutic rhythm approach in symptomatic patients. Obesity is a dominant driver of AF recurrence after ablation. However, being both overweight and underweight drives long-term cardiac and general health risks. Long-term data are needed to understand the influence of body mass index (BMI) on outcomes after ablation in regard to arrhythmia recurrence and cardiovascular outcomes. METHODS: All patients who underwent an index ablation with a BMI recorded and at least 3 years of follow-up were included (n = 1558). The group was separated and compared by index ablation BMI status (≤20, 21-25, 26-30, >30 kg/m(2)). Long-term outcomes included AF recurrence, stroke/TIA, heart failure (HF) hospitalization, and death. RESULTS: Patients with advancing BMI status were more likely to be male and have hypertension, a smoking history, diabetes, HF, and a prior cardioversion. Patients with a BMI ≤20 were more likely to have a moderate-high congestive heart failure, hypertension, age >75, diabetes, stroke (CHADS2) score. At 3 years, recurrence rates of AF increased significantly with increasing BMI status (p = 0.02); paradoxically, there was a trend for increased stroke risk with decreasing BMI (p = 0.06). Long-term death rates tended to increase inversely with BMI status, and HF rates were greatest in the highest and lowest BMI groups. CONCLUSIONS: Lower weight at AF ablation lowers arrhythmia recurrence risk. However, AF ablation patients who are normal or underweight remain at high risk of other cardiovascular outcomes including increased stroke risk with less AF burden.

Long-Term Population-Based Cerebral Ischemic Event and Cognitive Outcomes of Direct Oral Anticoagulants Compared With Warfarin Among Long-term Anticoagulated Patients for Atrial Fibrillation.

Direct oral anticoagulants (DOACs) have been used in clinical practice in the United States for the last 4 to 6 years. Although DOACs may be an attractive alternative to warfarin in many patients, long-term outcomes of use of these medications are unknown. We performed a propensity-matched analysis to report patient important outcomes of death, stroke/transient ischemic attack (TIA), bleeding, major bleeding, and dementia in patients taking a DOAC or warfarin. Patients receiving long-term anticoagulation from June 2010 to December 2014 for thromboembolism prevention with either warfarin or a DOAC were matched 1:1 by index date and propensity score. Multivariable Cox hazard regression was performed to determine the risk of death, stroke/TIA, major bleed, and dementia by the anticoagulant therapy received. A total of 5,254 patients were studied (2,627 per group). Average age was 72.4 ± 10.9 years, and 59.0% were men. Most patients were receiving long-term anticoagulation for AF management (warfarin: 96.5% vs DOAC: 92.7%, p <0.0001). Rivaroxaban (55.3%) was the most commonly used DOAC, followed by apixaban (22.5%) and dabigatran (22.2%). The use of DOACs compared with warfarin was associated with a reduced risk of long-term adverse outcomes: death (p = 0.09), stroke/TIA (p <0.0001), major bleed (p <0.0001), and bleed (p = 0.14). No significant outcome variance was noted in DOAC-type comparison. In the AF multivariable model patients taking DOAC were 43% less likely to develop stroke/TIA/dementia (hazard ratio 0.57 [CI 0.17, 1.97], p = 0.38) than those taking warfarin. Our community-based results suggest better long-term efficacy and safety of DOACs compared with warfarin. DOAC use was associated with a lower risk of cerebral ischemic events and new-onset dementia.

A Comparison of Remote Magnetic Irrigated Tip Ablation versus Manual Catheter Irrigated Tip Catheter Ablation With and Without Force Sensing Feedback.

BACKGROUND: Remote magnetic navigation (RMN) and contact force (CF) sensing technologies have been utilized in an effort to improve safety and efficacy of catheter ablation. A comparative analysis of the relative short- and long-term outcomes of AF patients has not been performed. As such, we comparatively evaluated the safety and efficacy of these technologies. METHODS: A total of 627 patients who underwent catheter ablation with either a manual irrigated tip catheter: (312, 49.8%) or by RMN: (315, 50.2%) were included in this single-center cohort study. Patients treated with CF (59) were analyzed separately as well. One- and 3-year endpoints included death, HF hospitalization, stroke, TIA, and atrial flutter or AF recurrence. RESULTS: Age averaged 65.1 ± 10.7 years and 64.1% male. One- and 3-year endpoints of death, HF hospitalization, stroke, TIA, and atrial flutter or AF recurrence were statistically similar between manual and RMN treated groups. Fluoroscopy times were significantly lower in the RMN group compared to the manual ablation group (8.47 ± 0.45 vs. 9.63 ± 4.06 minutes, P < 0.0001). CF guided patients had 1-year recurrence rate of AF/atrial flutter statistically identical to patients treated with RMN (36.8% vs. 38.6%; P = 1.00). CONCLUSION: RMN results in outcomes similar to manual navigation. The addition of CF sensing catheters did not improve relative procedural outcome or safety profile in comparison to RMN guided ablation in this large observational study of AF ablation.

The Impact of Age on 5-Year Outcomes After Atrial Fibrillation Catheter Ablation.

BACKGROUND: Catheter ablation of atrial fibrillation (AF) is an established therapeutic rhythm approach in symptomatic patients. Many studies have shown that age has little to no impact on outcomes during the first year after ablation. However, AF is a disease of aging and age-based substrate for arrhythmia is likely to progress. To this regard, we examined patients with 5-year outcome data following an index AF ablation procedure to define the impact of age on long-term outcomes. METHODS: A total of 923 patients that underwent their index AF ablation and had 5 years of follow-up were studied. Patients were followed up for atrial flutter/AF recurrence, heart failure, stroke, death, and cardiac function. Patients were separated and compared in 5 age-based groups (<50, 51-60, 61-70, 71-80, >80). RESULTS: The average age of the population was 66 ± 11 years and 59% were male. The AF was paroxysmal in 55%, persistent in 27%, and longstanding persistent in 18%. Older patients were more likely female and had higher rates of cardiovascular diseases. For every 10-year increase in age there was a higher multivariate-adjusted risk of atrial flutter/AF recurrence (HR: 1.13, P = 0.01), death (HR:1.91, P < 0.0001), and major adverse cardiac events (HR: 1.09, P = 0.07). Although atrial flutter/AF recurrence rates by age were similar at 1 year, at 5 years, younger patients had significantly lower rates of recurrences. CONCLUSION: Age significantly impacts outcomes after AF ablation when analyzed with long-term follow-up. These data highlight the progressive nature of AF and the need to consider interventions early.

Long-Term Natural History of Adult Wolff-Parkinson-White Syndrome Patients Treated With and Without Catheter Ablation.

BACKGROUND: There are a paucity of data about the long-term natural history of adult Wolff-Parkinson-White syndrome (WPW) patients in regard to risk of mortality and atrial fibrillation. We sought to describe the long-term outcomes of WPW patients and ascertain the impact of ablation on the natural history. METHODS AND RESULTS: Three groups of patients were studied: 2 WPW populations (ablation: 872, no ablation: 1461) and a 1:5 control population (n=11 175). Long-term mortality and atrial fibrillation rates were determined. The average follow-up for the WPW group was 7.9±5.9 (median: 6.9) years and was similar between the ablation and nonablation groups. Death rates were similar between the WPW group versus the control group (hazard ratio, 0.96; 95% confidence interval, 0.83-1.11; P=0.56). Nonablated WPW patients had a higher long-term death risk compared with ablated WPW patients (hazard ratio, 2.10; 95% confidence interval: 1.50-20.93; P<0.0001). Incident atrial fibrillation risk was higher in the WPW group compared with the control population (hazard ratio, 1.55; 95% confidence interval, 1.29-1.87; P<0.0001). Nonablated WPW patients had lower risk than ablated patients (hazard ratio, 0.39; 95% confidence interval, 0.28-0.53; P<0.0001). CONCLUSIONS: Long-term mortality rates in WPW patients are low and similar to an age-matched and gender-matched control population. WPW patients that underwent the multifactorial process of ablation had a lower mortality compared to nonablated WPW patients. Atrial fibrillation rates are high long-term, and ablation does not reduce this risk.

Percent Time With a Supratherapeutic INR in Atrial Fibrillation Patients Also Using an Antiplatelet Agent Is Associated With Long-Term Risk of Dementia.

BACKGROUND: Patients with atrial fibrillation (AF) are at higher risk of developing dementia. AF patients treated with warfarin with poor time in therapeutic ranges are significantly more likely to develop dementia. AF patients are also frequently treated with antiplatelet agents due to coexistent vascular disease. We hypothesize that AF patients with anticoagulation and antiplatelet therapies will be at higher risk of dementia, particularly with chronic exposure to over-anticoagulation. METHODS: Chronically anticoagulated patients receiving warfarin (target INR 2-3) for AF and managed by the Intermountain Healthcare Clinical Pharmacist Anticoagulation Service (CPAS) on concurrent antiplatelet agents with no history of dementia or stroke/TIA were included. The primary outcome was the presence of dementia defined by neurologist determined ICD-9 codes. Percent time with an INR>3.0 was determined and then compared by 3 strata <10% (n = 340), 10-24% (n = 417), ≥25% (n = 235). Multivariable Cox hazard regression was utilized to determine dementia incidence by percent time. RESULTS: A total of 992 patients were studied. Patients with an INR>3 more than 25% of the time were 2.40 times more likely to develop dementia (P = 0.04). A comparison between < 10% group and 10-24.9% group with INR>3 indicated no difference in risk for the development of dementia (P = 0.74). The risk was significantly increased in patients using triple antithrombotic therapy, although the number of patients within this group was small. CONCLUSION: In AF patients receiving antiplatelet and anticoagulant therapies, the percent of time exposed to over-anticoagulation increased dementia risk. These data support the possibility of chronic cerebral injury from microbleeds as a mechanism underlying the association of AF and dementia.

The impact of risk score (CHADS2 versus CHA2DS2-VASc) on long-term outcomes after atrial fibrillation ablation.

BACKGROUND: Risk stratification tools are needed to select the right candidates for catheter ablation of atrial fibrillation (AF). Both the CHADS2 and CHA2DS2-VASc scores have utility in predicting AF-related outcomes and guiding anticoagulation treatment. OBJECTIVE: We sought to determine whether these risk scores predict long-term outcomes after AF ablation and whether one risk score provides comparatively superior performance. METHODS: CHADS2 and CHA2DS2-VASc scores were calculated in 2179 patients who underwent a first ablation procedure for AF enrolled in the Intermountain Heart Collaborative Study. CHADS2 and CHA2DS2-VASc scores were categorized as 0-1, 2-4, and ≥5. Patient outcomes were analyzed over 5 years for AF/atrial flutter recurrence and major adverse cardiovascular events (MACE: composite of death, stroke, and heart failure hospitalization). RESULTS: The mean age was 65.7 ± 10.5 years, and 61.1% were men. Both scores incrementally predicted risk of AF recurrence, stroke, heart failure, and death at 5 years. Increasing CHADS2 (hazard ratio [HR] 1.19; P < .001) and CHA2DS2-VASc (HR 1.15; P < .0001) scores were both associated with AF/atrial flutter recurrence. The results were similar for MACE where increasing CHADS2 (HR 1.54; P < .0001) and CHA2DS2-VASc (HR 1.32; P < .0001) scores were associated with risk. When CHADS2 and CHA2DS2-VASc scores were modeled together, only CHA2DS2-VASc scores significantly predicted AF recurrence (HR 1.13; P = .001), but both were associated with MACE. CONCLUSION: Both the CHADS2 and CHA2DS2-VASc scores were excellent in stratifying patients for 5-year outcomes after AF ablation. However, the CHA2DS2-VASc score was superior to the CHADS2 score in predicting AF recurrence and AF-related morbidities.