Validation of a handheld single-lead ECG algorithm for atrial fibrillation detection after coronary revascularization.

BACKGROUND: Atrial fibrillation (AF) is a rapidly increasing global public health concern entailing a high risk for ischemic stroke that can largely be avoided with anticoagulation therapy. AF is often underdiagnosed and there is a need for a reliable method of detection in individuals with additional risk factors for stroke such as coronary artery disease. We aimed to validate an automatic rhythm interpretation algorithm in thumb ECG in subjects with recent coronary revascularization. METHODS: Thumb ECG, a patient-operated handheld single-lead ECG recording device with an automatic interpretation algorithm, was performed three times daily for a month after coronary revascularization and 2-week periods 3, 12, and 24 months post-procedure. The detection of AF by the automatic algorithm on subject and single-strip ECG level was compared to manual interpretation. RESULTS: 48,308 of 30 s thumb ECG recordings from 255 subjects (mean 212 ± 3.5 recordings per subject) were retrieved from a database (AF 47 subjects/655 recordings; non-AF 208 subjects/47,653 recordings). The algorithm sensitivity at subject level was 100%, specificity 11.2%, positive predictive value (PPV) 20.2%, and negative predictive value (NPV) 100%. At the single-strip ECG level, sensitivity was 87.6%, specificity 94.0%, PPV 16.8%, and NPV 99.8%. The most common reasons for false positive results were technical disturbance and frequent ectopic beats. CONCLUSIONS: The automatic interpretation algorithm in a handheld thumb ECG device can rule out AF in patients recently undergoing coronary revascularization with high accuracy, but manual confirmation is needed to confirm the diagnose of AF because of high false positive rates.

All-cause mortality trends in patients hospitalized for atrial fibrillation in Sweden: Role of age, stroke risk, and education.

Background: The incidence of atrial fibrillation (AF) has long been increasing, and AF is associated with increased mortality. Over time, mortality trends may differ between subgroups depending on their underlying risk patterns and treatments. Aim: To explore all-cause-mortality trends over time in patients hospitalized for incident AF, and the effects of age, stroke risk, and education level. Methods and results: Patients hospitalized for incident AF between January 1995 and December 2003 were selected from Swedish national registries. Based on date of index admission, patients were divided into four cohorts and followed for five years. Age- and sex-matched controls were selected. Kaplan-Meier estimates and Cox regressions with trend analysis were used for statistical evaluation. There were 64,489 patients (mean age 72 ± 10.1 years) and 116,893 controls. There was a significantly decreasing trend in the relative risk of all-cause mortality in AF patients over time, with a trend hazard ratio of 0.94 (95 % confidence interval [CI] 0.92-0.96, p < 0.001) in women and 0.91 (95 % CI 0.89-0.93, p < 0.001) in men. The mortality trends did not differ significantly between AF patients and controls. The mortality risk remained unchanged in women aged 18-64 years, in patients with low stroke risk, and in patients with post-secondary education. Conclusion: The all-cause mortality risk decreased over time in both patients and controls, but subgroup analysis revealed an unchanged mortality trend in women aged 18-64 years, in patients with low stroke risk, and in patients with post-secondary education.

Body Mass Index in Adolescence and Long-Term Risk of Early Incident Atrial Fibrillation and Subsequent Mortality, Heart Failure, and Ischemic Stroke.

Background We sought to determine the role of obesity in adolescent men on development of atrial fibrillation (AF) and subsequent associated clinical outcomes in subjects diagnosed with AF. Methods and Results We conducted a nationwide, register-based, cohort study of 1 704 467 men (mean age, 18.3±0.75 years) enrolled in compulsory military service in Sweden from 1969 through 2005. Height and weight, blood pressure, fitness, muscle strength, intelligence quotient, and medical disorders were recorded at baseline. Records obtained from the National Inpatient Registry and the Cause of Death Register were used to determine incidence and clinical outcomes of AF. During a median follow-up of 32 years (interquartile range, 24-41 years), 36 693 cases (mean age at diagnosis, 52.4±10.6 years) of AF were recorded. The multivariable-adjusted hazard ratio (HR) for AF increased from 1.06 (95% CI, 1.03-1.10) in individuals with body mass index (BMI) of 20.0 to <22.5 kg/m2 to 3.72 (95% CI, 2.44-5.66) among men with BMI of 40.0 to 50.0 kg/m2, compared with those with BMI of 18.5 to <20.0 kg/m2. During a median follow-up of ≈6 years in patients diagnosed with AF, we identified 3767 deaths, 3251 cases of incident heart failure, and 921 cases of ischemic stroke. The multivariable-adjusted HRs for all-cause mortality, incident heart failure, and ischemic stroke in AF-diagnosed men with baseline BMI >30 kg/m2 compared with those with BMI <20 kg/m2 were 2.86 (95% CI, 2.30-3.56), 3.42 (95% CI, 2.50-4.68), and 2.34 (95% CI, 1.52-3.61), respectively. Conclusions Increasing BMI in adolescent men is strongly associated with early AF, and with subsequent worse clinical outcomes in those diagnosed with AF with respect to all-cause mortality, incident heart failure, and ischemic stroke.

The a' velocity by tissue-Doppler echocardiography correlates to invasive mean left atrial pressure in patients with normal ejection fraction.

OBJECTIVES: To evaluate the correlation of a' velocity by tissue-Doppler measurements with invasively measured mean left atrial pressure in patients with normal ejection fraction. DESIGN: In this retrospective study, we evaluated the septal a', lateral a' and average a' velocity by tissue-Doppler echocardiography, in 125 in-hospital patients, 1-12 h before an elective pulmonary vein isolation due to intermittent atrial fibrillation, and compared to invasively measured mean left atrial pressure (LAP) during the invasive procedure. The patients, aged 35-81 years, had to be in sinus rhythm at both examinations, no atrial fibrillation during two procedures, no or mild valve disease and normal ejection fraction (>50%). RESULTS: Invasively measured mean LAP correlated well to septal a' (r = -0.435), lateral a' (r = -0.473) and average a' velocity (r = -0.491). Normal mean LAP (≤12 mmHg) was found in 95 patients and elevated mean LAP (>12 mmHg) in 30 patients. The patients with elevated mean LAP had a lower septal a' velocity (6.5 ± 2.7 vs 8.6 ± 2.3 cm/s; p < .01), lateral a' velocity (5.9 ± 2.3 vs 8.6 ± 2.1 cm/s; p < .01) and average a' velocity (6.2 ± 2.4 vs 8.8 ± 2.1 cm/s; p < .01) compared to patients with normal mean LAP. Septal a', lateral a' and average a' velocity were good predictors of elevated mean LAP with AUC of 0.78, 0.83 and 0.82. Average a' velocity with cut-off < 7.25 cm/s had a sensitivity of 83% and a specificity of 77% to predict elevated mean LAP. CONCLUSION: The a' velocity is a good indicator of mean LAP and might be considered in the evaluation of left ventricle filling pressure in patients with normal ejection fraction.

Gender and age differences in symptoms and health-related quality of life in patients with atrial fibrillation referred for catheter ablation.

BACKGROUND: Primary indication for catheter ablation of atrial fibrillation (AF) is to reduce symptoms and improve health-related quality of life (HRQoL). There are data showing differences between the genders and between younger and older patients. To evaluate this, we studied a large Scandinavian cohort of patients referred for catheter ablation of AF. METHODS: Consecutive patients filled out the ASTA questionnaire, assessing symptoms, HRQoL, and perception of arrhythmia, prior to ablation. Patients were recruited from four Swedish and one Danish tertiary center. RESULTS: A total of 2493 patients (72% men) filled out the ASTA questionnaire. Women experienced eight of the nine ASTA scale symptoms more often than men. Patients <65 years reported four symptoms more often, only tiredness was more frequent in those ≥65 years (P = .007). Women and patients <65 years experienced more often palpitations and regarding close to fainting and this was more common among women, no age differences were seen. Women and men scored differently in 10 of the 13 HRQoL items. Only negative impact on sexual life was more common in men (P < .001). Older patients reported more negative influence in four of the HRQoL items and the younger in one; ability to concentrate. CONCLUSIONS: Women experienced a more pronounced symptom burden and were more negatively affected in all HRQoL concerns, except for the negative impact on sexual life, where men reported more influence of AF. Differences between age groups were less pronounced. Disease-specific patient-reported outcomes measures (PROMs) add important information where gender differences should be considered in the care.

A decade of catheter ablation of cardiac arrhythmias in Sweden: ablation practices and outcomes.

AIMS: Catheter ablation is considered the treatment of choice for many tachyarrhythmias, but convincing 'real-world' data on efficacy and safety are lacking. Using Swedish national registry data, the ablation spectrum, procedural characteristics, as well as ablation efficacy and reported adverse events are reported. METHODS AND RESULTS: Consecutive patients (≥18 years of age) undergoing catheter ablation in Sweden between 01 January 2006 and 31 December 2015 were included in the study. Follow-up (repeat ablation and vital status) was collected through 31 December 2016. A total of 26 642 patients (57 ± 15 years, 62% men), undergoing a total of 34 428 ablation procedures were included in the study. In total, 4034 accessory pathway/Wolff-Parkinson-White syndrome (12%), 7358 AV-nodal re-entrant tachycardia (21%), 1813 atrial tachycardia (5.2%), 5481 typical atrial flutter (16%), 11 916 atrial fibrillation (AF, 35%), 2415 AV-nodal (7.0%), 581 premature ventricular contraction (PVC, 1.7%), and 964 ventricular tachycardia (VT) ablations (2.8%) were performed. Median follow-up time was 4.7 years (interquartile range 2.7-7.0). The spectrum of treated arrhythmias changed over time, with a gradual increase in AF, VT, and PVC ablation (P < 0.001). Decreasing procedural times and utilization of fluoroscopy with time, were seen for all arrhythmia types. The rates of repeat ablation differed between ablation types, with the highest repeat ablation seen in AF (41% within 3 years). The rate of reported adverse events was low (n = 595, 1.7%). Death in the immediate period following ablation was rare (n = 116, 0.34%). CONCLUSION: Catheter ablations have shifted towards more complex procedures over the past decade. Fluoroscopy time has markedly decreased and the efficacy of catheter ablation seems to improve for AF.

Patient-Reported Outcomes in Relation to Continuously Monitored Rhythm Before and During 2 Years After Atrial Fibrillation Ablation Using a Disease-Specific and a Generic Instrument.

BACKGROUND: Atrial fibrillation (AF) ablation improves patient-reported outcomes, irrespective of mode of intermittent rhythm monitoring. We evaluated the use of an AF-specific and a generic patient-reported outcomes instrument during continuous rhythm monitoring 2 years after AF ablation. METHODS AND RESULTS: Fifty-four patients completed the generic 36-Item Short-Form Health Survey and the AF-specific AF6 questionnaires before and 6, 12, and 24 months after AF ablation. All patients underwent continuous ECG monitoring via an implantable loop recorder. The generic patient-reported outcomes scores were compared with those of a Swedish age- and sex-matched population. After ablation, both summary scores reached normative levels at 24 months, while role-physical and vitality remained lower than norms. Responders to ablation (AF burden <0.5%) reached the norms in all individual 36-Item Short-Form Health Survey domains, while nonresponders (AF burden >0.5%) reached norms only in social functioning and mental component summary. All AF6 items and the sum score showed moderate to large improvement in both responders and nonresponders, although responders showed significantly greater improvement in all items except item 1 from before to 24 months after ablation. Higher AF burden was independently associated with poorer physical component summary and AF6 sum score. CONCLUSIONS: The AF-specific AF6 questionnaire was more sensitive to changes related to AF burden than the generic 36-Item Short-Form Health Survey. Patients improved as documented by both instruments, but a higher AF burden after ablation was associated with poorer AF-specific patient-reported outcomes and poorer generic physical but not mental health. Our results support the use of an AF-specific instrument, alone or in combination with a generic instrument, to assess the effect of ablation. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00697359.

Patients without comorbidities at the time of diagnosis of atrial fibrillation: causes of death during long-term follow-up compared to matched controls.

BACKGROUND: Little is known about the long-term, cause-specific mortality risk in patients without comorbidities at the time of diagnosis of atrial fibrillation (AF). METHODS: From a nation-wide registry of patients hospitalized with incident AF between 1995 and 2008 we identified 9 519 patients with a first diagnosed AF and no comorbidities at the time of AF diagnosis. They were matched with 12 468 controls. The follow-up continued until December 2008. Causes of death were classified according to the ICD-10 codes. RESULTS: During follow-up, 11.1% of patients with AF and 8.3% of controls died. Cardiovascular diseases were the most common causes of death and the only diagnoses which showed significantly higher relative risk in patients with AF than controls (HR 2.0, 95% CI 1.8-2.3), and the relative risk was significantly higher in women than in men. Stroke was a more common cause among patients with AF, 13.1% versus 9.7% (HR 2.7, 95% CI 1.8-4.0), while cerebral hemorrhage was more common among controls, 4.7% versus 10.2% (HR 0.9, 95% CI 0.6-1.5). The time from AF diagnosis to death was 6.0 ± 3.1 years. CONCLUSIONS: In patients with incident AF and no known comorbidities at the time of AF diagnosis, only cardiovascular diseases were more often causes of death as compared to controls. Women carried a significantly higher relative risk than men.

Patients with atrial fibrillation and outcomes of cerebral infarction in those with treatment of warfarin versus no warfarin with references to CHA2DS2-VASc score, age and sex - A Swedish nationwide observational study with 48 433 patients.

AIMS: There is controversy in the guidelines as to whether patients with atrial fibrillation and a low risk of stroke should be treated with anticoagulation, especially those with a CHA2DS2-VASc score of 1 point. METHODS: In a retrospective, nationwide cohort study, we used the Swedish National Patient Registry, the National Prescribed Drugs Registry, the Swedish Registry of Education and the Population and Housing Census Registry. 48 433 patients were identified between 1 January 2006 and 31 December 2008 with incident atrial fibrillation who were divided in age categories, sex and a CHA2DS2-VASc score of 0, 1, 2 and ≥3 and they were included in a time-varying analysis of warfarin treatment versus no treatment. The primary end-point was cerebral infarction and stroke, and patients were followed until 31 December 2009. RESULTS: Patients with 1 point from the CHA2DS2-VASc score showed the following adjusted hazard ratios (HR) with a 95% confidence interval: men 65-74 years 0.46 (0.25-0.83), men <65 years 1.11 (0.56-2.23) and women <65 years 2.13 (0.94-4.82), where HR <1 indicates protection with warfarin. In patients <65 years and 2 points, HR in men was 0.35 (0.18-0.69) and in women 1.84 (0.86-3.94) while, in women with at least 3 points, HR was 0.31 (0.16-0.59). In patients 65-74 years and 2 points, HR in men was 0.37 (0.23-0.59) and in women 0.39 (0.21-0.73). Categories including age ≥65 years or ≥3 points showed a statistically significant protection from warfarin. CONCLUSIONS: Our results support that treatment with anticoagulation may be considered in all patients with an incident atrial fibrillation diagnosis and an age of 65 years and older, i.e. also when the CHA2DS2-VASc score is 1.

Assessment of Use vs Discontinuation of Oral Anticoagulation After Pulmonary Vein Isolation in Patients With Atrial Fibrillation.

Importance: Pulmonary vein isolation (PVI) is a recommended treatment for patients with atrial fibrillation, but it is unclear whether it results in a lower risk of stroke. Objectives: To investigate the proportion of patients discontinuing anticoagulation treatment after PVI in association with the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65-74 years, sex category [female]) score, identify factors predicting stroke after PVI, and explore the risk of cardiovascular events after PVI in patients with and without guideline-recommended anticoagulation treatment. Design, Setting, and Participants: A retrospective cohort study was conducted using Swedish national health registries from January 1, 2006, to December 31, 2012, with a mean-follow up of 2.6 years. A total of 1585 patients with atrial fibrillation undergoing PVI from the Swedish Catheter Ablation Register were included, with information about exposure to warfarin in the national quality register Auricula. Data analysis was performed from January 1, 2015, to April 30, 2016. Exposures: Warfarin treatment. Main Outcomes and Measures: Ischemic stroke, intracranial hemorrhage, and death. Results: In this cohort of 1585 patients, 73.0% were male, the mean (SD) age was 59.0 (9.4) years, and the mean (SD) CHA2DS2-VASc score was 1.5 (1.4). Of the 1585 patients, 1175 were followed up for more than 1 year after PVI. Of these, 360 (30.6%) discontinued warfarin treatment during the first year. In patients with a CHA2DS2-VASc score of 2 or more, patients discontinuing warfarin treatment had a higher rate of ischemic stroke (5 events in 312 years at risk [1.6% per year]) compared with those continuing warfarin treatment (4 events in 1192 years at risk [0.3% per year]) (P = .046). Patients with a CHA2DS2-VASc score of 2 or more or those who had previously experienced an ischemic stroke displayed a higher risk of stroke if warfarin treatment was discontinued (hazard ratio, 4.6; 95% CI, 1.2-17.2; P = .02 and hazard ratio, 13.7; 95% CI, 2.0-91.9; P = .007, respectively). Conclusions and Relevance: These findings indicate that discontinuation of warfarin treatment after PVI is not safe in high-risk patients, especially those who have previously experienced an ischemic stroke.

Assessment of Atrial Fibrillation-Specific Symptoms Before and 2 Years After Atrial Fibrillation Ablation: Do Patients and Physicians Differ in Their Perception of Symptom Relief?

OBJECTIVES: The aim of this study was to evaluate patient-reported and physician-assessed atrial fibrillation (AF)-related symptoms after AF ablation. BACKGROUND: Success of AF ablation is usually defined as freedom from AF, although symptom relief is often patients' desire. METHODS: Symptom relief was assessed as perceived by patients using the short, validated, AF-specific symptom questionnaire AF6 and as classified by physicians using the European Heart Rhythm Association (EHRA) classification at baseline and 6, 12, and 24 months after AF ablation. Recurrence of arrhythmia was documented by continuous electrocardiographic monitoring. RESULTS: In total, 54 patients completed the 24-month follow-up. All 6 items on the AF6, AF6 sum score, and EHRA class improved significantly over time. The greatest improvement was seen during the first 6 months after ablation, but AF6 scores showed continued improvement up to 12 months, in contrast to EHRA class. There was a low correlation between AF6 score and EHRA class, but the predictive ability was low. Both AF6 scores and EHRA class were significantly correlated with AF burden at all times after ablation. A change of >9 points in AF6 sum score corresponded to a meaningful reduction in symptom severity. CONCLUSION: Patient-reported and physician-assessed outcomes were both useful in assessing symptom relief after AF ablation, although patient-reported outcomes were more sensitive tools. There was also a discrepancy between patient-reported and physician-assessed outcomes after ablation. Freedom from AF and a low AF burden most often resulted in a reduction of symptoms, but symptom relief also occurred despite little effect on the arrhythmia.

Rhythm Control and Its Relation to Symptoms during the First Two Years after Radiofrequency Ablation for Atrial Fibrillation.

CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov. Unique Identifier: NCT00697359. OBJECTIVES: To evaluate rhythm control up to two years after atrial fibrillation (AF) ablation and its relation to reported symptoms. BACKGROUND: The implantable loop recorder (ILR) continuously records the electrocardiogram (ECG), has an automatic AF detection algorithm, and has a possibility for patients to activate an ECG recording during symptoms. METHODS: Fifty-seven patients (mean age 57 ± 9 years, 60% male, 88% paroxysmal AF) underwent AF ablation following ILR implantation. Device data were downloaded at the ablation and three, six, 12, 18, and 24 months after ablation. RESULTS: Fifty-four patients completed the two-year follow-up. Thirteen (24%) patients had no AF episodes detected by ILR during follow-up. Ten of 41 patients (24%) with AF recurrence were only detected by ILR and AF recurrences were detected earlier by ILR (P < 0.001). The median AF burden in patients with AF recurrence was 5.7% (interquartile range 0.4-14.4) and was even lower in patients with AF only detected by ILR (P = 0.001). Forty-eight % of the patients indicated symptoms via the patient activator but 33% of those recordings were not due to AF. Early AF recurrence (within 3 months) was highly associated with later AF recurrence (P < 0.001). AF burden >0.5% and longest AF episode >6 hours before the ablation were independent predictors of AF recurrence during intermittent but not continuous monitoring. CONCLUSIONS: After AF ablation, the AF burden was low throughout the 24 months follow-up. Nevertheless, symptoms were commonly indicated but one-third of patient-activated recordings did not show AF. Continuous monitoring was superior to intermittent follow-up in detecting AF episodes and assessing the AF burden.

Gender-related differences in risk of cardiovascular morbidity and all-cause mortality in patients hospitalized with incident atrial fibrillation without concomitant diseases: a nationwide cohort study of 9519 patients.

BACKGROUND: Previous studies of patients with "lone" and "idiopathic" atrial fibrillation (AF) have provided conflicting evidence concerning the development, management and prognosis of this condition. METHODS: In this nation-wide, retrospective, cohort study, we studied patients diagnosed with incidental AF recorded in national Swedish registries between 1995 and 2008. Controls were matched for age, sex and calendar year of the diagnosis of AF in patients. All subjects were free of any in-hospital diagnosis from 1987 and until patients were diagnosed with AF and also free of any diagnosis within one year from the time of inclusion. Follow-up continued until 2009. We identified 9519 patients (31% women) and 12,468 matched controls. RESULTS: Relative risks (RR) versus controls for stroke or transient ischemic attack (TIA) in women were 19.6, 4.4, 3.4 and 2.5 in the age categories <55, 55-64, 65-74 and 75-85, years respectively. Corresponding figures for men were 3.4, 2.5, 1.7 and 1.9. RR for heart failure were 6.6, 6.6, 6.3 and 3.8 in women and 7.8, 4.6, 4.9 and 2.9 in men. All RR were statistically significant with p < 0.01. RR for myocardial infarction and all-cause mortality were statistically significantly increased only in the two oldest age categories in women and 65-74 years in men. CONCLUSIONS: Patients with AF and no co-morbidities at inclusion had at least a doubled risk of stroke or TIA and a tripled risk of heart failure, through all age categories, as compared to controls. Women were at higher RR of stroke or TIA than men.

Predictors of hospitalization for heart failure and of all-cause mortality after atrioventricular nodal ablation and right ventricular pacing for atrial fibrillation.

AIMS: Atrioventricular junction ablation (AVJA) is a highly effective treatment in patients with therapy refractory atrial fibrillation (AF) but renders the patient pacemaker dependent. We aimed to analyse the long-term incidence of hospitalization for heart failure (HF) and all-cause mortality in patients who underwent AVJA because of AF and to determine predictors for HF and mortality. METHODS AND RESULTS: We retrospectively enrolled 162 consecutive patients, mean age 67 ± 9 years, 48% women, who underwent AVJA because of symptomatic AF refractory to pharmacological treatment (n = 117) or unsuccessful repeated pulmonary vein isolation (n = 45). Hospitalization for HF occurred in 32 (20%) patients and 35 (22%) patients died, representing a cumulative incidence for hospitalization for HF and mortality over the first 2 years after AVJA of 9.1 and 5.2%, respectively. Hospitalization for HF occurred to the same extent in patients who failed pharmacological treatment as in patients with repeated pulmonary vein isolation (PVI), although the mortality was slightly higher in the former group. QRS prolongation ≥120 ms and left atrial diameter were independent predictors of hospitalization for HF, while hypertension and previous HF were independent predictors of death. CONCLUSION: The long-term hospitalization rate for HF and all-cause mortality was low, which implies that long-term ventricular pacing was not harmful in this patient population, including patients with unsuccessful repeated PVI.

Sinus bradycardia and sinus pauses immediately after electrical cardioversion of persistent atrial fibrillation--what do they mean?

BACKGROUND: To determine the role of sinus bradyarrhythmia (SB) immediately after electrical cardioversion of persistent atrial fibrillation (AF) on the short-term recurrence rate and long-term pacemaker need and all-cause mortality. METHODS: SB defined as sinus bradycardia (sinus rate <40 bpm for ≥2 consecutive cycles) and/or sinus pauses (>2 s), were recorded during 5 minutes immediately after successful DC cardioversion in 140 consecutive patients with persistent AF. RESULTS: SB was observed during the first minute of SR in 31 patients (22%). Sinus bradycardia was present in 27 patients, sinus pauses in 16 (>3 s in 10) patients, and both in 12 patients. Compared to patients without SB, the mean heart rate during the first minute after cardioversion was lower, 57 ± 13 versus 63 ± 11 bpm; P < 0.05, while the mean heart rates during the subsequent 4 minutes were not statistically significantly different. The AF recurrence rates were not significantly different at 1 week (45% vs. 40%), or at 3 months (68% vs. 53%) in patients with or without SB. After a mean follow-up of 86 ± 6 months the pacemaker implantation rate was 10% versus 11% (NS) and an all-cause mortality of 26 versus 18% (NS). CONCLUSIONS: SB immediately after electrical cardioversion of persistent AF had no significant impact on the 3-month AF recurrence rate, the long-term need for pacemaker or all-cause mortality.

All-cause mortality in 272,186 patients hospitalized with incident atrial fibrillation 1995-2008: a Swedish nationwide long-term case-control study.

AIMS: To evaluate long-term all-cause risk of mortality in women and men hospitalized for the first time with atrial fibrillation (AF) compared with matched controls. METHODS AND RESULTS: A total of 272 186 patients (44% women) ≤ 85 years at the time of hospitalization with incidental AF 1995-2008 and 544 344 matched controls free of in-hospital diagnosis of AF were identified. Patients were followed via record linkage of the Swedish National Patient Registry and the Cause of Death Registry. Using Cox regression models, the long-term relative all-cause mortality risk, adjusted for concomitant diseases, in women vs. controls was 2.15, 1.72, and 1.44 (P < 0.001) in the age categories ≤ 65, 65-74, and 75-85 years, respectively. The corresponding figures for men were 1.76, 1.36, and 1.24 (P < 0.001). Among concomitant diseases, neoplasm, chronic renal failure, and chronic obstructive pulmonary disease contributed most to the increased all-cause mortality vs. controls. In patients with AF as the primary diagnosis, the relative risk of mortality was 1.63, 1.46, and 1.28 (P < 0.001) in women and 1.45, 1.17, and 1.10 (P < 0.001) in men. CONCLUSION: Atrial fibrillation was an independent risk factor of all-cause mortality in patients with incident AF. The concomitant diseases that contributed most were found outside the thromboembolic risk scores. The highest relative risk of mortality was seen in women and in the youngest patients compared with controls, and the differences between genders in each age category were statistically significant.

Vectorcardiography shows cardiac memory and repolarization heterogeneity after ablation of accessory pathways not apparent on ECG.

BACKGROUND: Pacing induced cardiac memory is an established phenomenon, but following successful WPW ablation, cardiac memory was present on ECG in variable proportions of patients depending on accessory pathway (AP) location. We hypothesized that vectorcardiography (VCG), which is more sensitive than ECG, would show cardiac memory after WPW ablation independent of AP location. METHODS: Thirty-six patients were followed after successful AP ablation, 11 with overt posteroseptal (PS), 13 with overt left-sided (LS) and 12 with concealed APs (controls). VCGs were recorded the day before and after the procedure, ≥ once/week for 6-8 weeks and after ≥ 3 months. T vector and T-vector loop parameters were analyzed and compared. RESULTS: After ablation of overt APs, there was a correlation between the directions of the preexcited maximum QRS-vector and the post-ablation maximum T-vector, confirming the presence of cardiac memory. Ablation of overt APs was followed by cardiac memory apparent in different directions. Thus, ablation of PS APs was followed by most pronounced changes in T-vector elevation and LS APs with significant changes only in T-vector azimuth. Cardiac memory disappeared within a month in > 80% of cases. Furthermore, T-vector loop morphology changes suggested a period of repolarization heterogeneity immediately after ablation of overt APs. CONCLUSIONS: According to VCG analysis cardiac memory was present after ablation of overt APs independent of location as consistently as after ventricular pacing, and disappeared within a similar time frame during normal ventricular activation. In addition, signs of transient repolarization heterogeneity were observed after ablation of overt APs.

Effect of new versus known versus no atrial fibrillation on 30-day and 10-year mortality in patients with acute coronary syndrome.

Coronary artery disease promotes the development of atrial fibrillation (AF). The aim of this study was to determine short- and long-term mortality in patients with acute coronary syndromes (ACS) and AF, depending on the AF presentation. A total of 2,335 consecutive patients with ACS were included. AF was classified as known persistent or permanent AF, known paroxysmal AF, new AF at admission, and new AF during hospitalization for ACS. Four hundred forty-two patients had any AF: 54 with known persistent or permanent AF, 150 with known paroxysmal AF, 54 with new AF at admission, and 184 with new AF during hospitalization. Statistically significant differences among subgroups related to previous heart failure (p <0.0001), stroke (p = 0.04), myocardial infarction (p <0.0001), angina pectoris (p <0.0001), hypercholesterolemia (p = 0.007), coronary artery bypass grafting (p <0.0001), and percutaneous coronary intervention (p = 0.03) were observed. Thirty-day mortality differed among the subgroups (p = 0.02) and was lowest in patients with known paroxysmal AF (7.3%). Ten-year mortality ranged from 53% to 78% among the subgroups. There were 5 predictors of long-term mortality across the subgroups: age (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.04 to 1.09, p <0.0001), previous myocardial infarction (HR 1.4, 95% CI 1.0 to 1.8, p = 0.04), heart failure (HR 1.8, 95% CI 1.3 to 2.4, p = 0.0002), diabetes (HR 1.7, 95% CI 1.2 to 2.2, p = 0.0005), and smoking (HR 1.7, 95% CI 1.2 to 2.3, p = 0.001). In conclusion, patient characteristics and 30-day mortality differed significantly among the subgroups, but long-term mortality did not. Any AF associated with ACS almost doubled the long-term mortality risk. AF in patients with ACS should therefore be regarded as an important risk factor irrespective of its presentation.