The "obesity paradox" in patients with atrial fibrillation: Insights from the Gulf SAFE registry.

Background: The prognostic impact of obesity on patients with atrial fibrillation (AF) remains under-evaluated and controversial. Methods: Patients with AF from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) registry were included, who were recruited from six countries in the Middle East Gulf region and followed for 12 months. A multivariable model was established to investigate the association of obesity with clinical outcomes, including stroke or systemic embolism (SE), bleeding, admission for heart failure (HF) or AF, all-cause mortality, and a composite outcome. Restricted cubic splines were depicted to illustrate the relationship between body mass index (BMI) and outcomes. Sensitivity analysis was also conducted. Results: A total of 1,804 patients with AF and recorded BMI entered the final analysis (mean age 56.2 ± 16.1 years, 47.0% female); 559 (31.0%) were obese (BMI over 30 kg/m2). In multivariable analysis, obesity was associated with reduced risks of stroke/systematic embolism [adjusted odds ratio (aOR) 0.40, 95% confidence interval (CI), 0.18-0.89], bleeding [aOR 0.44, 95%CI, 0.26-0.74], HF admission (aOR 0.61, 95%CI, 0.41-0.90) and the composite outcome (aOR 0.65, 95%CI, 0.50-0.84). As a continuous variable, higher BMI was associated with lower risks for stroke/SE, bleeding, HF admission, all-cause mortality, and the composite outcome as demonstrated by the accumulated incidence of events and restricted cubic splines. This "protective effect" of obesity was more prominent in some subgroups of patients. Conclusion: Among patients with AF, obesity and higher BMI were associated with a more favorable prognosis in the Gulf SAFE registry. The underlying mechanisms for this obesity "paradox" merit further exploration.

Symptom Status, Clinical Subtypes, and Prognosis in Patients With Atrial Fibrillation from the Middle East Region (from the Gulf-SAFE Registry).

Atrial fibrillation (AF) is often asymptomatic. The prognosis of asymptomatic AF is at least similar or worse than symptomatic AF, but there are no such data from Middle East patients with AF. The Gulf-SAFE (Gulf Survey of Atrial Fibrillation Events) registry is a multicenter prospective survey of patients presenting with AF to participate medical institutions in 6 countries in the Gulf region. We investigated the prognostic outcomes of patients with asymptomatic AF in relation to clinical subtypes. A total of 2043 patients with AF were included; 541 were identified as having asymptomatic AF (26.5%) who tended to be older, with higher prevalences of hypertension, heart failure, coronary artery disease, diabetes, stroke, renal dysfunction, chronic obstructive pulmonary disease, and had higher Congestive heart failure, Hypertension, Age ≥75, Stroke (2 points), Congestive heart failure, Hypertension, Age ≥75 (2 points), Diabetes, Stroke (2 points), Vascular disease, Age 65-74, Sex category (CHA2DS2-VASc), and Hypertension, Age ≥65, Stroke, Bleeding history, liable INR, Elderly, Drug or alcohol use (HAS-BLED) scores (all p <0.05). After multivariable adjustment, asymptomatic AF was associated with higher risks of stroke/systematic embolism (SE) (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.10 to 4.34), all-cause mortality (aOR 2.85, 95% CI 1.90 to 4.28), and the composite outcome of stroke/SE, bleeding, and all-cause mortality (aOR 1.74, 95% CI 1.26 to 2.41). Patients with asymptomatic AF had fewer admissions for AF (aOR 0.53, 95% CI 0.32 to 0.83) and heart failure (aOR 0.58, 95% CI 0.38 to 0.86). The increased risk of stroke/SE in asymptomatic AF was more prominent among paroxysmal AF subtype (p for interaction = 0.028). In conclusion, in the Gulf-SAFE registry, patients with asymptomatic AF represent a nonbenign entity with worse outcomes compared with symptomatic AF. In paroxysmal AF, the higher risks of events were more prominent. The absence of "warning signs" and lack of timely admission in asymptomatic AF may be major reasons for the unfavorable prognosis.

Catheter ablation of supraventricular tachycardia in patients with dextrocardia and situs inversus.

BACKGROUND: Dextrocardia with situs inversus is a rare cardiac positional anomaly. Catheter ablation procedures performed in this set of patients have not been sufficiently reported. METHODS: A total of 10 patients with dextrocardia and situs inversus who received catheter ablation for supraventricular tachycardia (SVT) were included from a cohort of over 20 000 cases of catheter ablation for SVT in three centers from 2005 to 2016. All patients underwent electrophysiologic study and catheter ablation of SVT. Ablation targets were selected based on different tachycardia mechanisms with the primary endpoint of noninduction of tachycardia. RESULTS: The average age was 32.4 ± 5.6 years. Congenitally corrected transposition of great arteries (TGA) with situs inversus and D-looping of the ventricles and aorta (congenitally corrected TGA {I,D,D}) was found in four patients, while the other six patients exhibited mirror-image dextrocardia {I,L,L}. The mechanisms of SVT were atrioventricular nodal reentrant tachycardia in four patients, atrioventricular reentrant tachycardia in three, typical atrial flutter in one, intra-atrial reentrant tachycardia in one, and focal atrial tachycardia in one. Immediate procedural success was achieved in 9 out of 10 patients with no procedural complications. During a follow-up period of 6.3 ± 3.5 years on average, all patients remained free from recurrent tachycardia. CONCLUSIONS: For patients with dextrocardia and situs inversus, catheter ablation of SVT is safe and feasible. Differences in catheter maneuver and fluroscopy projection, along with difficulties in distorted anatomy are major obstacles for successful ablation.