Is it high time to leave the chronic disease care of rural older people to village doctors in China: Insights from a population-based atrial fibrillation screening study.

OBJECTIVE: No study has systematically investigated the quality of long-term care delivered to the rural older people with chronic diseases, such as atrial fibrillation (AF) in China. This study aims to provide contemporary data on the prevalence and awareness of AF among the older population in rural China and to evaluate healthcare knowledge and delivery by village doctors. DESIGN: A cross-sectional study. SETTING: Rural villages in Daqiao and Xiaoji towns of Jiangsu Province, China. PARTICIPANTS: Rural population aged ≥65 years. OUTCOME MEASURES: AF was identified using 12-lead electrocardiography in the first-step (government-led health examination) and single-lead electrocardiography in the second-step (in-house AF screening). Questionnaire surveys were designed for the AF patients and their village doctors. RESULTS: Among 31,342 permanent residents, 12,630 (40.3 %) declined, 7,956 (25.3 %) participated in the first-step and 10,756 (34.3 %) in the second-step. The overall AF detection rate was 4.3 % (810/18,712). Of the 810 AF patients (mean age 76.1±5.9 years; 51.4 % female), 51.5 % were illiterate, only 2.6 % could use smartphone applications, and 8.1 % lived with their children. Common risk factors were older age, men, hypertension, diabetes, prior stroke, vascular disease, and congestive heart failure. Among the 402 patients with known AF, 367 were at high risk of stroke and 10.9 % (40/367) were anticoagulated. Only 17.6 % patients with known hypertension had blood pressure level <140/90 mmHg, and 6.0 % with known diabetes had a fasting blood glucose level ≤6.1 mmol/L. Only 7.3 % (9/122) village doctors reported having the knowledge of integrated care AF management. CONCLUSIONS: This study identified AF in 4.3 %, but AF management was suboptimal in rural China. The current village doctor-dominant rural healthcare system is far from delivering standardized AF management for older patients in rural China. There is an urgent need to empower the village doctors in optimising the care of AF patients.

A Simple Score to Predict New-Onset Atrial Fibrillation After Ablation of Typical Atrial Flutter.

BACKGROUND: New-onset atrial fibrillation (NeAF) is common after cavotricuspid isthmus-dependent counterclockwise atrial flutter (CCW-AFL) ablation. This study aimed to investigate a simple predictive model of NeAF after CCW-AFL ablation. METHODS: From January 2013, to December 2017, consecutive patients receiving CCW-AFL ablation were enrolled from 3 centres. Clinical, echocardiographic, and electrocardiographic data were collected and followed. Patients from 2 centres and another centre were assigned into the derivation and validation cohorts, respectively. In the derivation cohort, logistic regression was performed to evaluate the ability of parameters to discriminate those with and without NeAF. A score system was developed and then validated. RESULTS: Two hundred seventy-one patients (mean 59.7 ± 13.6 age; 205 male) were analyzed. During follow-up (73.0 ± 6.5 months), 107 patients (39.5%) had NeAF; 190 and 81 patients were detected in the derivation and validation cohorts, respectively. Hypertension, age ≥ 70 years, left atrial diameter ≥ 42 mm, P-wave duration ≥ 120 ms and the negative component of flutter wave in lead II ≥ 120 ms were selected as the final parameters. A weighted score was used to develop the HAD-AF score ranging from 0 to 9. In the derivation cohort, area under the receiver operating characteristic curve (AUC) was 0.938 (95% confidence interval [CI], 0.902-0.974), superior to those of currently used CHA2DS2-VASC (0.679, 95% CI, 0.600-0.757) and HATCH scores (0.651, 95% CI, 0.571-0.730) (P < 0.001). Performance maintained in the validation cohort. CONCLUSIONS: Six years after CCW-AFL ablation, 39.5% of patients developed NeAF. HAD-AF score can reliably identify patients likely to develop NeAF after CCW-AFL ablation.

Empirical superior vena cava isolation improves outcomes of radiofrequency re-ablation in pulmonary vein isolation non-responders: A 2-center retrospective study in China.

Background: Pulmonary vein isolation (PVI) is the standard ablation strategy for treating atrial fibrillation (AF). However, the optimal strategy of a repeat procedure for PVI non-responders remains unclear. Objective: This study aims to investigate the incidence of PVI non-responders in patients undergoing a repeat procedure, as well as the predictors for the recurrence of repeat ablation. Methods: A total of 276 consecutive patients who underwent repeat ablation from August 2016 to July 2019 in two centers were screened. A total of 64 (22%) patients with durable PVI were enrolled. Techniques such as low voltage zone modification, linear ablation, non-PV trigger ablation, and empirical superior vena cava (SVC) isolation were conducted. Results: After the 20.0 ± 9.9 month follow-up, 42 (65.6%) patients were free from atrial arrhythmias. A significant difference was reported between the recurrent and non-recurrent groups in non-paroxysmal AF (50 vs. 23.8%, p = 0.038), diabetes mellitus (27.3 vs. 4.8%, p = 0.02), and empirical superior vena cava (SVC) isolation (28.6 vs. 60.5%, p = 0.019). Multivariate regression analysis demonstrated that empirical SVC isolation was an independent predictor of freedom from recurrence (95% CI: 1.64-32.8, p = 0.009). Kaplan-Meier curve demonstrates significant difference in recurrence between empirical and non-empirical SVC isolation groups (HR: 0.338; 95% CI: 0.131-0.873; p = 0.025). Conclusion: About 22% of patients in repeat procedures were PVI non-responders. Non-paroxysmal AF and diabetes mellitus were associated with recurrence post-re-ablation. Empirical SVC isolation could potentially improve the outcome of repeat procedures in PVI non-responders.

Vaspin Attenuates Atrial Abnormalities by Promoting ULK1/FUNDC1-Mediated Mitophagy.

The worldwide incidence and prevalence of atrial fibrillation (AF) are increasing, making it a life-threatening condition due to the higher numbers of people suffering from obesity. Vaspin, an adipokine derived from epicardial adipose tissue, has been reported to reduce inflammation, inhibit apoptosis, and induce autophagy; however, its role in the pathogenesis of AF is not known. In this study, we investigated the role of vaspin in patients with AF and explored the molecular mechanisms using atrial myocytes in vitro. Our data showed that vaspin levels were significantly reduced in the plasma of patients with AF. Lower plasma levels of vaspin were also associated with a higher risk of AF in patients with obesity. Vaspin treatment in vitro alleviated cardiomyocyte injury, atrial fibrosis, atrial myocyte apoptosis, and mitochondrial injury in atrial myocytes following Ang-II stress. Moreover, our results demonstrated that vaspin protected against Ang-II-induced atrial myocyte dysfunction by inducing mitophagy. We also observed that vaspin treatment enhanced the phosphorylation of Fun14 domain-containing protein 1 (FUNDC1) at Ser17 by unc-51 like autophagy activating kinase 1 (ULK1), resulting in the induction of mitophagy. These positive effects of vaspin were reversed by ULK1 silencing in Ang-II-stimulated HL-1 cells. Our study is the first to propose that vaspin plays a vital role in AF pathogenesis via ULK1/FUNDC1-regulated mitophagy and could be a novel therapeutic target for AF.

ECG Predictors for New-Onset Atrial Fibrillation Within a Year After Radiofrequency Ablation of Counterclockwise-Rotating Atrial Flutter.

Background: New-onset atrial fibrillation (AF) after ablation of typical atrial flutter (AFL) is not rare. This study aimed to investigate the predictive value of electrocardiographic parameters on new-onset AF post-typical AFL ablation. Methods: A total of 158 consecutive patients (79.1% males, mean age 57.8 ± 14.3 years) with typical AFL were enrolled between January 2012 and August 2017 in this single-center study. Patients with a history of AF before ablation were excluded. ECGs during sinus rhythm (SR) and AFL were collected. The duration of the negative component of flutter wave in lead II (DFNII), proportion of the DFNII of the total circle length of AFL (DFNII%), amplitude of the negative component of flutter wave in lead II (AFNII), duration (DPNV1), and amplitude (APNV1) of negative component of the P wave in lead V1, and P wave duration in lead II (DPII) during sinus rhythm were measured. Results: During a median follow-up of 26.9 ± 11.8 months, 22 cases (13.9%) developed new-onset AF. DFNII was significantly longer in patients with new-onset AF compared to patients without AF (114.7 ± 29.6 ms vs. 82.7 ± 12.8 ms, p < 0.0001). AFNII was significantly lower (0.118 ± 0.034 mV vs. 0.168 ± 0.051 mV, p < 0.0001), DPII (144.21 ± 23.77 ms vs. 111.46 ± 14.19 ms, p < 0.0001), and DPNV1 was significantly longer (81.07 ± 16.87 ms vs. 59.86 ± 14.42 ms, p < 0.0001) in patients with new-onset AF. In the multivariate analysis, DFNII [odds ratio (OR), 1.428; 95% CI, 1.039-1.962; p = 0.028] and DPII (OR, 1.429; 95% CI, 1.046-1.953; p = 0.025) were found to be independently associated with new-onset AF after typical AFL ablation. Conclusion: Parameters representing left atrial activation time under both the SR and AFL were independently associated with new-onset AF post-typical AFL ablation and may be useful in risk prediction, which needs to be confirmed by further prospective studies.

Nonatrial Fibrillation Patients With Complete P Wave Disappearance: An Overlooked Population With High Stroke Risk.

BACKGROUND AND PURPOSE: Complete P wave disappearance (CPWD) in patients without atrial fibrillation is an uncommon clinical phenomenon. We aimed to study the relationship between CPWD and thromboembolism. METHODS: Between July 2007 and December 2018, consecutive patients with CPWD on surface ECG and 24-hour Holter recording were recruited into the study from 4 centers in China. All recruited patients underwent transesophageal echocardiography or cardiac computed tomography to screen for atrial thrombus. Atrial electrical activity and scar were assessed by electrophysiological study (EPS) and 3-dimensional electroanatomic mapping. Cardiac structure and function were assessed by multimodality cardiac imaging. RESULTS: Twenty-three consecutive patients (8 male; mean age 48.5±14.7 years) with CPWD were included. Only 3 patients demonstrated complete atrial electrical silence with atrial noncapture. Thirteen patients who had invasive atrial endocardial mapping demonstrated extensive scar. Pulse-wave mitral inflow Doppler demonstrated absent and dampened A waves in 18 and 5 patients, respectively. Pulse-wave tricuspid inflow Doppler showed absent and dampened A waves in 19 and 4 patients, respectively. Upon recruitment, 8 patients had previous stroke and 3 patients had atrial thrombus. Warfarin was prescribed to all patients. During median follow-up of 42.0 months, 2 patients developed massive ischemic stroke due to warfarin discontinuation. CONCLUSIONS: Our study suggested that CPWD reflects extensive atrial electrical silence and significantly impaired atrial mechanical function. It was strongly associated with thromboembolism and the clinical triad of CPWD-atrial paralysis-stroke was proposed. Anticoagulation should be recommended in such patients.

Clinical Outcomes of Revascularization Strategies for Patients With MVD/LMCA Disease: A Systematic Review and Network Meta-Analysis.

Hybrid coronary revascularization (HCR), a new minimally invasive procedure for patients requiring revascularization for multivessel coronary lesions, combines coronary artery bypass grafting (CABG) for left anterior descending (LAD) lesions and percutaneous coronary intervention (PCI) for non-LAD coronary lesions. However, available data related to outcomes comparing the 3 revascularization therapies is limited to small studies.We conducted a search in MEDLINE, EMBASE, and the Cochrane Library of Controlled Trials up to December 31, 2014, without language restriction. A total of 16 randomized trials (n=4858 patients) comparing HCR versus PCI or off-pump CABG (OPCAB) were included in this meta-analysis. The primary outcomes were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, myocardial infarction (MI), cerebrovascular events (CVE), and target vessel revascularization (TVR). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using random-effect and fixed-effect models. Ranking probabilities were used to calculate a summary numerical value: the surface under the cumulative ranking (SUCRA) curve.No significant differences were seen between the HCR and PCI in short term (in hospital and 30 days) with regard to MACCE (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.00-2.35), all-cause death (OR = 2.09, 95% CI 0.34-7.66), MI (OR = 1.02, 95% CI 0.19-2.95), CVE (OR = 4.45, 95% CI 0.39-19.16), and TVR (OR = 6.99, 95% CI 0.17-39.39). However, OPCAB had lower MACCE than HCR (OR = 0.19, 95% CI 0.00-0.95). In midterm (1 year and 3 year), in comparison with HCR, PCI had higher all-cause death (OR = 5.66, 95% CI 0.00-13.88) and CVE (OR = 4.40, 95% CI 0.01-5.68), and lower MI (OR = 0.51, 95% CI 0.00-2.86), TVR (OR = 0.53, 95% CI 0.05-2.26), and thus the MACCE (OR = 0.51, 95% CI 0.00-2.35). Off-pump CABG presented a better outcome than HCR with significant lower MACCE (OR = 0.17, 95% CI 0.01-0.68). Surface under the cumulative ranking probabilities showed that HCR may be the superior strategy for MVD and LMCA disease when regarded to MACCE (SUCRA = 0.84), MI (SUCRA = 0.76) in short term, and regarded to MACCE (SUCRA = 0.99), MI (SUCRA = 0.94), and CVE (SUCRA = 0.92) in midterm.Hybrid coronary revascularization seemed to be a feasible and acceptable option for treatment of LMCA disease and MVD. More powerful evidences are required to precisely evaluate risks and benefits of the 3 therapies for patients who have different clinical characteristics.