Race or ethnicity and education in cardiac rehabilitation enrollment.

BACKGROUND: Although cardiac rehabilitation (CR) has established benefits for cardiovascular health, it remains significantly underutilized, with substantial differences in participation related to factors such as educational attainment (EA), race, and ethnicity. We studied a geographically and racially diverse cohort of insured individuals in a health claims database to (1) evaluate differences in CR participation by EA and race or ethnicity and (2) assess how EA modifies associations between race or ethnicity and CR participation. METHODS: We conducted a retrospective cohort study of individuals identified in Optum's de-identified Clinformatics® database between 1/1/2016 and 12/31/2019. Eligible individuals included those aged ≥18 years with a hospitalization for an incident CR-qualifying diagnosis. We calculated incidence rates of CR enrollment by EA and race or ethnicity, as well as associations of EA and race or ethnicity with CR enrollment, and evaluated interaction between EA and race or ethnicity with respect to CR participation. RESULTS: We identified 171,297 individuals eligible for CR with a mean ±â€¯SD age of 70.4 ±â€¯11.6 years; 37.4 % were female, and 68.3 % had >high school education. We observed a dose-response association between EA and rate of participation in CR. After adjustment, compared to White individuals, the odds of attending CR was 24 % lower for Asian individuals [95 % confidence interval (CI): 17 %, 30 %], 13 % lower for Black individuals (95 % CI: 9 %, 17 %), and 32 % lower for Hispanic individuals (95 % CI: 28 %, 35 %), all p < 0.0001. However, Black individuals with ≥bachelor's degree had a similar odds of CR enrollment as White individuals with ≥bachelor's degree (odds ratio 1.01, 95 % CI: 0.85, 1.20, p = 0.95). CONCLUSIONS: EA was positively associated with CR enrollment across racial and ethnic groups. Higher EA might partially attenuate racial and ethnic differences in CR participation, but significant disparities persist. Our findings support increased attention to individuals with limited education to improve CR enrollment.

Racial and Ethnic Differences in Cardiac Rehabilitation Participation: Effect Modification by Household Income.

Background Cardiac rehabilitation (CR) is associated with improved cardiovascular outcomes. Racial and ethnic differences in CR have been identified, but whether income may attenuate these disparities remains unknown. We evaluated (1) racial/ethnic differences in CR participation in a contemporary sample of insured US adults, and (2) assessed how household income modifies associations between race or ethnicity and CR participation. Methods and Results We identified 107 199 individuals with a CR-qualifying diagnosis between January 1, 2016 and December 31, 2018 in Optum's de-identified Clinformatics database. We evaluated associations between race or ethnicity and participation in CR, and assessed interaction between race or ethnicity and annual household income. The mean±SD age of all participants was 70.4±11.6 years; 37.4% were female and 76.0% were White race. Overall, 28 443 (26.5%) attended ≥1 CR sessions. After adjustment, compared with White individuals, the probability of attending CR was 31% lower for Asian individuals (95% CI, 27%-36%), 19% lower for Black individuals (95% CI, 16%-22%), and 43% lower for Hispanic individuals (95% CI, 40%-45%), all P<0.0001. The time to CR attendance was also significantly longer for Asian, Black, and Hispanic individuals. Associations between race or ethnicity and attendance at CR differed significantly across household income categories (P interaction=0.0005); however, Asian, Black, and Hispanic individuals were less likely to attend CR at all incomes. Conclusions In a geographically and racially diverse cohort, participation in CR was low overall, and was lowest among Asian, Black, and Hispanic candidates. Household income may impact the link between race or ethnicity and attendance at CR, but substantial racial and ethnic disparities exist across incomes.

Sex differences in atrial fibrillation: patient-reported outcomes and the persistent toll on women.

BACKGROUND: Women have worse patient-reported outcomes in atrial fibrillation (AF) than men, but the reasons remain poorly understood. We investigated how comorbid conditions, treatment, social factors, and their modification by sex would attenuate sex-specific differences in patient-reported outcomes in AF. METHODS: In a cohort with prevalent AF we measured patient-reported outcomes with the Short-Form-12 (SF-12, an 8-domain quality of life measure), and the AF Effect on QualiTy of Life (AFEQT), an instrument specific to AF, both with range 0-100 and higher scores indicating superior outcomes. We examined sex-specific differences in patient-reported outcomes in multivariable-adjusted regression analyses incorporating demographics, comorbid conditions, treatment, social factors, and their sex-based modification. RESULTS: In 339 individuals (age 72±10, 45% women), women (vs. men) reported worse physical functioning on the SF-12 (49.7±39.0 versus 65.0±34.0), social functioning (69.8±31.8 versus 79.7±25.8), and mental health (67.4±20.2 versus 75.0±18.6). These differences were attenuated with adjustment for comorbid conditions and depression. Women had worse composite AFEQT scores (73.8±18.4 versus 78.5±16.6) and symptoms and treatment scores than men with differences remaining significant after multivariable adjustment. There were not significant interactions by sex and the array of covariates when examining differences in patient-reported outcomes between women and men. CONCLUSIONS: We identified sex-specific differences in patient-reported outcomes assessed with general and AF-specific measures. Compared to men, women with AF reported worse overall health-related quality of life, even after consideration of both relevant covariates and their modification by sex. Our research indicates the importance of consideration of sex-based inequities when evaluating patient-reported outcomes in AF.

Area Deprivation Index and Cardiovascular Events: CAN CARDIAC REHABILITATION MITIGATE THE EFFECTS?

INTRODUCTION: Neighborhood socioeconomic status is associated with health outcomes. Cardiac rehabilitation (CR) provides a cost-effective, multidisciplinary approach to improve outcomes in cardiovascular disease. We aimed to evaluate the association of the Area Deprivation Index (ADI), a marker of neighborhood social composition, with risk of recurrent cardiovascular outcomes and assessed the modifying effect of CR. METHODS: We identified patients with a primary diagnosis of (1) myocardial infarction or (2) incident heart failure (HF) admitted to a large-sized regional health center during 2010-2018. We derived the ADI from home addresses and categorized it into quartiles (higher quartiles indicating increased deprivation). We obtained number of CR visits and covariates from the health record. We compared rehospitalization (cardiovascular, acute coronary syndrome [ACS], and HF) and mortality rates across ADI quartiles. RESULTS: We included 6957 patients (age 69.2 ± 13.4 yr, 38% women, 89% White race). After covariate adjustment, the ADI was significantly associated with higher incidence rates (IRs)/100 person-yr of cardiovascular rehospitalization (quartile 1, IR 34.6 [95% CI, 31.2-38.2]; quartile 4, 41.5 [95% CI, 39.1-44.1], P < .001). In addition, the ADI was significantly associated with higher rates of rehospitalization for HF (P < .001), ACS (P < .012), and all-cause mortality (P < .04). These differences in rehospitalization and mortality rates by the ADI were no longer significant in those who attended CR. CONCLUSIONS: We found the increased ADI was adversely associated with rehospitalizations and mortality. However, in individuals with CR, outcomes were significantly improved compared with those with no CR. Our findings suggest that CR participation has the potential to improve outcomes in disadvantaged neighborhoods.

Association of Fine Particulate Matter and Risk of Stroke in Patients With Atrial Fibrillation.

Importance: Air pollution is associated with cardiovascular outcomes. Specifically, fine particulate matter measuring 2.5 µm or less (PM2.5) is associated with thrombosis, stroke, and myocardial infarction. Few studies have examined particulate matter and stroke risk in individuals with atrial fibrillation (AF). Objective: To assess the association of residential-level pollution exposure in 1 year and ischemic stroke in individuals with AF. Design, Setting, and Participants: This cohort study included 31 414 individuals with AF from a large regional health care system in an area with historically high industrial pollution. All participants had valid residential addresses for geocoding and ascertainment of neighborhood-level income and educational level. Participants were studied from January 1, 2007, through September 30, 2015, with prospective follow-up through December 1, 2017. Data analysis was performed from March 14, 2018, to October 9, 2019. Exposures: Exposure to PM2.5 ascertained using geocoding of addresses and fine-scale air pollution exposure surfaces derived from a spatial saturation monitoring campaign and land-use regression modeling. Exposure to PM2.5 was estimated annually across the study period at the residence level. Main Outcomes and Measures: Multivariable-adjusted stroke risk by quartile of residence-level and annual PM2.5 exposure. Results: The cohort included 31 414 individuals (15 813 [50.3%] female; mean [SD] age, 74.4 [13.5] years), with a median follow-up of 3.5 years (interquartile range, 1.6-5.8 years). The mean (SD) annual PM2.5 exposure was 10.6 (0.7) µg/m3. A 1-SD increase in PM2.5 was associated with a greater risk of stroke after both adjustment for demographic and clinical variables (hazard ratio [HR], 1.08; 95% CI, 1.03-1.14) and multivariable adjustment that included neighborhood-level income and educational level (HR, 1.07; 95% CI, 1.00-1.14). The highest quartile of PM2.5 exposure had an increased risk of stroke relative to the first quartile (HR, 1.36; 95% CI, 1.18-1.58). After adjustment for clinical covariates, income, and educational level, risk of stroke remained greater for the highest quartile of exposure relative to the first quartile (HR, 1.21; 95% CI, 1.01-1.45). Conclusions and Relevance: This large cohort study of individuals with AF identified associations between PM2.5 and risk of ischemic stroke. The results suggest an association between fine particulate air pollution and cardiovascular disease and outcomes.

The Atrial Fibrillation Health Literacy Information Technology Trial: Pilot Trial of a Mobile Health App for Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a common arrhythmia that adversely affects health-related quality of life (HRQoL). We conducted a pilot trial of individuals with AF using a smartphone to provide a relational agent as well as rhythm monitoring. We employed our pilot to measure acceptability and adherence and to assess its effectiveness in improving HRQoL and adherence. OBJECTIVE: This study aims to measure acceptability and adherence and to assess its effectiveness to improve HRQoL and adherence. METHODS: Participants were recruited from ambulatory clinics and randomized to a 30-day intervention or usual care. We collected baseline characteristics and conducted baseline and 30-day assessments of HRQoL using the Atrial Fibrillation Effect on Quality of Life (AFEQT) measure and self-reported adherence to anticoagulation. The intervention consisted of a smartphone-based relational agent, which simulates face-to-face counseling and delivered content on AF education, adherence, and symptom monitoring with prompted rhythm monitoring. We compared differences in AFEQT and adherence at 30 days, adjusted for baseline values. We quantified participants' use and acceptability of the intervention. RESULTS: A total of 120 participants were recruited and randomized (59 to control and 61 to intervention) to the pilot trial (mean age 72.1 years, SD 9.10; 62/120, 51.7% women). The control group had a 95% follow-up, and the intervention group had a 93% follow-up. The intervention group demonstrated significantly higher improvement in total AFEQT scores (adjusted mean difference 4.5; 95% CI 0.6-8.3; P=.03) and in daily activity (adjusted mean difference 7.1; 95% CI 1.8-12.4; P=.009) compared with the control between baseline and 30 days. The intervention group showed significantly improved self-reported adherence to anticoagulation therapy at 30 days (intervention 3.5%; control 23.2%; adjusted difference 16.6%; 95% CI 2.8%-30.4%; P<.001). Qualitative assessments of acceptability identified that participants found the relational agent useful, informative, and trustworthy. CONCLUSIONS: Individuals randomized to a 30-day smartphone intervention with a relational agent and rhythm monitoring showed significant improvement in HRQoL and adherence. Participants had favorable acceptability of the intervention with both objective use and qualitative assessments of acceptability.

Comprehensive Curriculum for Internal Medicine Residents on Primary Care of Patients Identifying as Lesbian, Gay, Bisexual, or Transgender.

Introduction: Significant gaps remain in the training of health professionals regarding the care of individuals who identify as lesbian, gay, bisexual, and transgender (LGBT). Although curricula have been developed at the undergraduate medical education level, few materials address the education of graduate medical trainees. The purpose of this curriculum was to develop case-based modules targeting internal medicine residents to address LGBT primary health care. Methods: We designed and implemented a four-module, case-based, interactive curriculum at one university's internal medicine residency program. The modules contained facilitator and learner guides and addressed four main content areas: understanding gender and sexuality; performing a sensitive history and physical examination; health promotion and disease prevention; and mental health, violence, and reproductive health. Knowledge, perceived importance, and confidence were assessed before and after each module to assess curricular effectiveness and acceptability. General medicine faculty delivered these modules. Results: Perceived importance of LGBT topics was high at baseline and remained high after the curricular intervention. Confidence significantly increased in many areas, including being able to provide resources to patients and to institute gender-affirming practices (p < .05). Knowledge improved significantly on almost all topics (p < .0001). Faculty felt the materials gave enough preparation to teach, and residents perceived that the faculty were knowledgeable. Discussion: This resource provides an effective curriculum for training internal medicine residents to better understand and feel confident addressing LGBT primary health care needs. Despite limitations, this is an easily transferable curriculum that can be adapted in a variety of curricular settings.

Association of income and health-related quality of life in atrial fibrillation.

Objective: Health-related quality of life (HRQoL) is a patient-centred benchmark promoted by clinical guidelines in atrial fibrillation (AF). Income is associated with health outcomes, but how income effects HRQoL in AF has limited investigation. Methods: We enrolled a convenience cohort with AF receiving care at a regional healthcare system and assessed demographics, medical history, AF treatment, income, education and health literacy. We defined income as a categorical variable (<$20 000; $20 000-$49 999; $50 000-$99 999; >$100 000). We used two complementary HRQoL measures: (1) the atrial fibrillation effect on quality of life (AFEQT), measuring composite and domain scores (daily activity, symptoms, treatment concerns, treatment satisfaction; range 0-100); (2) the 12-item Short Form Survey (SF-12), measuring general HRQoL with physical and mental health domains (range 0-100). We related income to HRQoL and adjusted for relevant covariates. Results: In 295 individuals with AF (age 71±10, 40% women), we observed significant differences in HRQoL by income. Higher mean composite AFEQT scores were observed for higher income groups: participants with income <$20 000 had the lowest HRQoL (n=35, 68.2±21.4), and those with income >$100 000 had the highest HRQoL (n=64, 81.9±17.0; p=0.04). We also observed a significant difference by income in the AFEQT daily activity domain (p=0.02). Lower income was also associated with lower HRQoL in the mental health composite score of the SF-12 (59.7±21.5, income <$20 000 vs 79.3±16.3, income >$100 000; p<0.01). Conclusion: We determined that income was associated with HRQoL in a cohort with prevalent AF. Given the marked differences, we consider income as essential for understanding patient-centred outcomes in AF.

PCSK9 Inhibitor Use in the Real World: Data From the National Patient-Centered Research Network.

Background PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors effectively lower LDL (low-density lipoprotein) cholesterol and have been shown to reduce cardiovascular outcomes in high-risk patients. We used real-world electronic health record data to characterize use of PCSK9 inhibitors, in addition to standard therapies, according to cardiovascular risk status. Methods and Results Data were obtained from 18 health systems with data marts within the National Patient-Centered Clinical Research Network (PCORnet) using a common data model. Participating sites identified >17.5 million adults, of whom 3.6 million met study criteria. Patients were categorized into 3 groups: (1) dyslipidemia, (2) untreated LDL ≥130 mg/dL, and (3) coronary artery disease or coronary heart disease. Demographics, comorbidities, estimated 10-year atherosclerotic cardiovascular disease risk, and lipid-lowering pharmacotherapies were summarized for each group. Participants' average age was 62 years, 50% were female, and 11% were black. LDL cholesterol ranged from 85 to 151 mg/dL. Among patients in groups 1 and 3, 54% received standard lipid-lowering therapies and a PCSK9 inhibitor was prescribed in <1%. PCSK9 inhibitor prescribing was greatest for patients with coronary artery disease or coronary heart disease and, although prescribing increased during the study period, overall PCSK9 inhibitor prescribing was low. Conclusions We successfully used electronic health record data from 18 PCORnet data marts to identify >3.6 million patients meeting criteria for 3 patient groups. Approximately half of patients had been prescribed lipid-lowering medication, but <1% were prescribed PCSK9 inhibitors. PCSK9 inhibitor prescribing increased over time for patients with coronary artery disease or coronary heart disease but not for those with dyslipidemia.

Improvement in ejection fraction after cryoballoon pulmonary vein isolation for atrial fibrillation in individuals with systolic dysfunction.

BACKGROUND: Cryoballoon pulmonary vein isolation (PVI) is commonly used for rhythm control of atrial fibrillation (AF). Data are limited examining the outcomes of cryoballoon PVI in patients with systolic dysfunction. We evaluate the impact of cryoballoon PVI in patients with systolic dysfunction. METHODS: We evaluated a single-center prospective registry of patients undergoing cryoballoon PVI between 8/2011 and 6/2016. Patients with systolic dysfunction (EF < 55%) between the time of AF diagnosis and their cryoballoon PVI procedure were assessed for AF recurrence at 6 months and 1 year post-procedure, with a 3-month blanking period. RESULTS: Final analysis included 66 patients with systolic dysfunction undergoing cryoballoon PVI. An AF diagnosis for ≥ 1 year prior to PVI was present in 62.1% (n = 41), and 53.0% (n = 35) had systolic dysfunction for ≥ 1 year pre-procedure. The proportion of AF-free patients at 1 year was 51.5%. Of patients with echocardiograms performed at 1 year (n = 43), a greater proportion of individuals without AF recurrence had an improvement in EF of ≥ 10% than in those with AF recurrence (54.2% vs. 25.0%, p = 0.039). Of the patients who had systolic dysfunction at the time of the ablation (EF < 55%), there was a significant increase in EF post-procedure (36.5% pre-procedure vs. 48.3% post-procedure, mean change 11.8%, p < 0.001). CONCLUSION: In patients with systolic dysfunction, cryoballoon PVI provides an acceptable AF recurrence-free rate at 1 year. AF recurrence-free individuals were more likely to have improvement in EF. Further evaluation is needed to determine the potential role of early cryoballoon PVI in patients with a new diagnosis of systolic dysfunction and AF.

Impact of 3D mapping on procedural characteristics and outcomes in cryoballoon pulmonary vein isolation for atrial fibrillation.

PURPOSE: The use of 3D mapping during cryoballoon pulmonary vein isolation (PVI) is optional with added cost but potential benefit in aiding vein identification, reducing fluoroscopy, and post-ablation testing. Data are limited evaluating procedural characteristics and outcomes in patients undergoing cryoballoon PVI with mapping vs. no mapping. In the present study, we compare procedural characteristics and recurrence-free rates in patients undergoing cryoballoon PVI among patients using CARTO®, NavX™, or no mapping system. METHODS: We evaluated a single center registry of patients undergoing cryoballoon PVI from 2013 to 2016, retrospectively. Patients undergoing a redo procedure or additional RF ablation were excluded. Baseline and procedural characteristics were compared among CARTO, NavX, and no mapping groups. Post-PVI patients were assessed for atrial arrhythmia recurrence after a 3-month blanking period. Recurrence was based on typical symptoms or ECG/event monitor evidence of atrial fibrillation (AF). Kaplan-Meier analysis was used to compare arrhythmia-free survival between groups. RESULTS: We included 432 patient procedures, 98 using mapping systems (45 NavX, 53 CARTO), and 334 without. When using the CARTO mapping system compared to NavX or no mapping, there were longer procedure times (168 vs.109 vs.115 min, p < 0.001) and LA dwell times (110 vs.81 vs.87 min, p < 0.001). Additionally, both CARTO and NavX, when compared to no mapping, had longer fluoroscopy times (32 vs.31 vs.26 min, p < 0.001). Overall, total ablation time was increased for patients without mapping systems compared to NavX. There were no significant differences in 1-year recurrence-free rates between CARTO, NavX, and no mapping groups (64.9 vs. 65.0 vs. 64.6%, p = 0.278). CONCLUSION: Use of CARTO is associated with increased procedure and LA dwell times compared to NavX or no mapping. Mapping system use yielded longer fluoroscopy times without an improvement in atrial fibrillation recurrence. Given the additional cost of mapping, the role for routine use in cryoballoon PVI is unclear.

Rationale and design of the Atrial Fibrillation health Literacy Information Technology Trial: (AF-LITT).

BACKGROUND: Atrial Fibrillation (AF) is a common cardiac arrhythmia that is challenging for patients and adversely impacts health-related quality of life (HRQoL). Long-term management of AF requires that patients adhere to complex therapies, understand difficult terminology, navigate subspecialty care, and have continued symptom monitoring with the goal of preventing adverse outcomes. Continued interventions to ameliorate the patient experience of AF are essential. DESIGN: The Atrial Fibrillation health Literacy Information Technology Trial (AF-LITT; NCT03093558) is an investigator-initiated, 2-arm randomized clinical trial (RCT). This RCT is a pilot in order to implement a novel, smartphone-based intervention to address the patient experience of AF. This pilot RCT will compare a combination of the Embodied Conversational Agent (ECA) and the Alive Cor Kardia Mobile heart rhythm monitor to the current standard of care. The study will enroll 180 adults with non-valvular AF who are receiving anticoagulation for stroke prevention and randomize them to receive a 30-day intervention (smartphone-based ECA/Kardia) or standard of care, which will include a symptom and adherence journal. The primary end-points are improvement in HRQoL and self-reported adherence to anticoagulation. The secondary end-points are the acceptability of the intervention to participants, its use by participants, and acceptability to referring physicians. CONCLUSIONS: The AF-LITT pilot aims to evaluate the efficacy of the ECA/Kardia to improve HRQoL and anticoagulant adherence, and to guide its implementation in a larger, multicenter clinical trial. The intervention has potential to improve HRQoL, adherence, and health care utilization in individuals with chronic AF.

Incidence and Predictors of Complications During Cryoballoon Pulmonary Vein Isolation for Atrial Fibrillation.

BACKGROUND: Cryoballoon pulmonary vein isolation (PVI) has emerged as an alternative to radiofrequency PVI for atrial fibrillation (AF). Data are lacking to define the rates and predictors of complications, particularly phrenic nerve injury (PNI). METHODS AND RESULTS: We evaluated a single-center prospective registry of 450 consecutive patients undergoing cryoballoon PVI between 2011 and 2015. Patients were 59±10 years old, 26% were women, 58% had hypertension, their mean CHA2DS2VASc score was 1.7±1.3, 30% had persistent atrial fibrillation, and 92% received a second-generation 28-mm balloon. Predefined major complications were persistent PNI, pericardial effusion, deep vein thrombosis, arteriovenous fistula, atrioesophageal fistula, bleeding requiring transfusion, stroke, and death. PNI was categorized as persistent if it persisted after discharge from the laboratory. Logistic regression was performed to identify predictors of complications and specifically PNI. We identified a major complication in 10 (2.2%) patients. In 49 (10.8%) patients, at least transient PNI was observed; only 5 persisted beyond the procedure (1.1%). All cases of PNI resolved eventually, with the longest time to resolution being 48 days. We also describe 2 cases of PNI manifesting after the index hospitalization. Regression analysis identified 23-mm balloon use (16.3% versus 5.2%, odds ratio 2.94, P=0.011) and increased age (62.8±7.7 versus 58.7±0.12 years, odds ratio 1.058, P=0.014) as independent significant predictors of PNI. There were no significant predictors of major complications. CONCLUSIONS: In a large contemporary cohort, cryoballoon PVI is associated with low procedural risk, including lower rates of PNI than previously reported. Older age and 23-mm balloon use were associated with PNI. Our low rate of PNI may reflect more sensitive detection methods, including compound motor action potential monitoring and forced double-deflation.

Efficacy of Cryoballoon Pulmonary Vein Isolation in Patients With Persistent Atrial Fibrillation.

INTRODUCTION: Cryoballoon PVI has emerged as an alternative to radiofrequency PVI for the treatment of paroxysmal AF. The optimal strategy for patients with persistent AF is unclear as data are limited. METHODS: We analyzed a prospective registry of consecutive patients with persistent AF who underwent Cryoballoon PVI at a single center between 2011 and 2014. Patients were assessed for atrial arrhythmia recurrence after a 3-month blanking period at 6 months, 1 year, and 2 years postprocedure. Recurrence was based on typical symptoms, ECG, or event monitor evidence of AF. Kaplan-Meier analysis was used to estimate arrhythmia-free survival. RESULTS: Final analysis included 69 patients who underwent Cryoballoon PVI with a mean age 59.4 ± 8.1 years, 85.5% male, 53.6% HTN patients, CHA2DS2-VASC score 1.6 ± 1.2, and LA size 4.5 ± 0.6 cm. The single procedure atrial arrhythmia recurrence-free rate at 1-year postprocedure after a 3-month blanking period was 59% and 50% at a mean follow-up of 607 days. Of the recurrence-free group, 17% were taking previously ineffective antiarrhythmic medications. In comparing patients with persistent AF duration <1 year versus >1 year, there was a trend toward greater AF recurrence-free rates in the <1 year group (66% vs. 55%, P = 0.09). CONCLUSION: Cryoballoon PVI appears to be an effective initial strategy in treating persistent AF, with an AF recurrence-free rate of 59% at 1 year.

Some Memories are Odder than Others: Judgments of Episodic Oddity Violate Known Decision Rules.

Current decision models of recognition memory are based almost entirely on one paradigm, single item old/new judgments accompanied by confidence ratings. This task results in receiver operating characteristics (ROCs) that are well fit by both signal-detection and dual-process models. Here we examine an entirely new recognition task, the judgment of episodic oddity, whereby participants select the mnemonically odd members of triplets (e.g., a new item hidden among two studied items). Using the only two known signal-detection rules of oddity judgment derived from the sensory perception literature, the unequal variance signal-detection model predicted that an old item among two new items would be easier to discover than a new item among two old items. In contrast, four separate empirical studies demonstrated the reverse pattern: triplets with two old items were the easiest to resolve. This finding was anticipated by the dual-process approach as the presence of two old items affords the greatest opportunity for recollection. Furthermore, a bootstrap-fed Monte Carlo procedure using two independent datasets demonstrated that the dual-process parameters typically observed during single item recognition correctly predict the current oddity findings, whereas unequal variance signal-detection parameters do not. Episodic oddity judgments represent a case where dual- and single-process predictions qualitatively diverge and the findings demonstrate that novelty is "odder" than familiarity.