Impact of Sleep Apnea on Nocturnal Parasympathetic Activity in Atrial Fibrillation Patients After Catheter Ablation　- Implications for Heart Rate Variability Analysis.

BACKGROUND: The impact of sleep apnea (SA) on heart rate variability (HRV) in atrial fibrillation (AF) patients has not been investigated. METHODS AND RESULTS: Of 94 patients who underwent AF ablation between January 2021 and September 2022, 76 patients who had a nocturnal Holter electrocardiography and polysomnography conducted simultaneously were included in the analysis. A 15-min duration of HRV, as determined by an electrocardiogram during apnea and non-apnea time, were compared between patients with and without AF recurrence at 12 months' postoperatively. Patients had a mean age of 63.4±11.6 years, 14 were female, and 20 had AF recurrence at 12 months' follow-up. The root mean square of the difference between consecutive normal-to-normal intervals (RMSSD, ms) an indicator of a parasympathetic nervous system, was more highly increased in patients with AF recurrence than those without, during both apnea and non-apnea time (apnea time: 16.7±4.5 vs. 13.5±3.3, P=0.03; non-apnea time: 20.9±9.5 vs. 15.5±5.9, P<0.01). However, RMSSD during an apneic state was decreased more than that in a non-apneic state in both groups of patients with and without AF recurrence (AF recurrence group: 16.7±4.5 vs. 20.9±9.5, P<0.01; non-AF recurrence group; 13.5±3.3 vs. 15.5±5.9, P=0.03). Consequently, the effect of AF recurrence on parasympathetic activity was offset by SA. Similar trends were observed for other parasympathetic activity indices; high frequency (HF), logarithm of HF (lnHF) and the percentage of normal-to-normal intervals >50 ms (pNN50). CONCLUSIONS: Without considering the influence of SA, the results of nocturnal HRV analysis might be misinterpreted. Caution should be taken when using nocturnal HRV as a predictor of AF recurrence.

Comparison of maximum-sized visually guided laser balloon and cryoballoon ablation.

Balloon ablation therapy has recently been used for atrial fibrillation (AF) ablation. Laser balloons possess the property in which the balloon size can be changed. Standard laser balloon ablation (Standard LBA) was followed by additional ablation using a maximally extended balloon (Extended LBA) and its lesion characteristics were compared to cryoballoon ablation (CBA), another balloon technology. From June 2020 to July 2021, patients with paroxysmal AF who underwent an initial pulmonary vein (PV) isolation were enrolled. Sixty-five patients with paroxysmal AF were included, 32 in the LBA and 33 in the CBA group. To measure the isolated surface area after the ablation procedures, left atrial voltage mapping was performed after Standard LBA, Extended LBA, and CBA. The baseline patient characteristics did not differ between LBA and CBA. Extended LBA could successfully increase the isolated area more than Standard LBA for all four PVs. Compared to CBA, the isolated area of both superior PVs was significantly greater with Extended LBA (left superior PV: 8.5 ± 2.1 vs 7.3 ± 2.4, p = 0.04, right superior PV: 11.4 ± 3.7 vs 8.7 ± 2.7, p < 0.01), and thus the non-isolated posterior wall (PW) was smaller (8.5 ± 3.4 vs 12.4 ± 3.3, p < 0.01). Nevertheless, changes in the cardiac injury markers were significantly lower with LBA than CBA. There was no significant correlation between the cardiac injury level and isolated area in both groups. In conclusion, Extended LBA exhibited a significantly greater isolation of both superior PVs and resulted in a smaller non-isolated PW, but the cardiac injury markers were significantly suppressed as compared to CBA.

Effects of Longitudinal Changes in Lifestyle-Related Risk Factors on the Incidence of Major Adverse Cardiac and Cerebrovascular Disease in Young Adults.

Metabolic syndrome (MetS) is one focus of healthcare system reform in Japan. We examined the effects of changes in individual risk factors over time on the incidence of major adverse cardio-cerebrovascular events (MACCE) in adults under the age of 50 years. Study participants under the age of 50 with neither hypertension nor hyperglycemia at baseline were analyzed. We used a parametric proportional hazard model to determine the effect of changes in abdominal circumference, blood pressure, serum lipids, and blood glucose on the incidence of MACCE.A total of 6,125 women and 6,403 men were subject to the analyses. The incidence rate of MACCE per 1,000 person-years was 1.17 for women and 2.42 for men. In men under the age of 50, an increase in abdominal circumference was associated with an increase in MACCE incidence (hazard ratio per 1 cm increase: 1.10; 95% confidence interval [CI], 1.04-1.17), whereas no statistically significant association was observed in women. Compared with Visit 1, if the abdominal circumference increased by 4 cm at Visit 3, the hazard ratio for developing MACCE was approximately 1.5 (hazard ratio 1.48; 95% CI, 1.18-1.86). In men under the age of 50, increases in abdominal circumference and systolic blood pressure were associated with an increased risk of developing MACCE, regardless of the degree of obesity at baseline. Therefore, encouraging young adults to improve their health before developing MetS may reduce the risk of MACCE.

Relationship Between Body Mass Index and Incidence of Atrial Fibrillation in Young Japanese Men　- The Nishimura Health Survey.

BACKGROUND: The associations between body mass index (BMI) and incidence of atrial fibrillation (AF) in young men are scarce, especially in Asian countries, given the differences in BMI between Asians and Western populations.Methods and Results:This study analyzed 17,865 middle-aged Japanese men without AF from a cohort of employees undergoing annual health examinations. AF incidence was evaluated during a follow-up period (median 4.0 years, interquartile range 2.0-7.1 years). Among young men aged 30-49 years, AF incidence was 0.64/1,000 person-years, whereas it was 2.54/1,000 and 7.60/1,000 person-years among men aged 50-59 and ≥60 years, respectively. Multivariable Cox regression analysis among young men revealed age (hazard ratio [HR] 3.28 by 10-years' increase, 95% confidence interval [CI] 1.72-6.25, P<0.001), BMI (BMI-quadratic, HR 1.01, 95% CI 1.00-1.01, P<0.001, BMI-linear, HR 0.95, 95% CI 0.86-1.05, P=0.33), and electrocardiogram (ECG) abnormalities, such as PQ prolongation, supraventricular beat, and p wave abnormality (HR 8.79, 95% CI 3.05-25.32, P<0.001), were significantly associated with AF incidence. There was a reverse J-shaped association between BMI and AF incidence in young men, whereby the presence of ECG abnormality inversely influenced the BMI-incident AF relationship. A linear association between BMI and AF incidence in men aged 50-59 and ≥60 years was present. CONCLUSIONS: AF incidence displays a reverse J-shaped relationship with BMI in young men, but a linear association in men aged ≥50 years. The paradoxical relationship seen in young men only may reflect atrial electrical or structural abnormalities.

Importance of Preoperative Computed Tomography Assessment of the Membranous Septal Anatomy in Patients Undergoing Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve.

BACKGROUND: Cardiac conduction disturbance (CD) is the most frequent complication following transcatheter aortic valve replacement (TAVR). This study examined whether the anatomy of the membranous septum (MS) could provide useful information about the risk of CD following TAVR with a balloon-expandable valve (BEV).Methods and Results:Among 132 consecutive patients, 106 (mean age, 85.6±5.1 years; 75 females) were included in the study. Using preoperative CT and angiography, MS length and implantation depth (ID) were assessed. The MS length minus the prosthesis ID was calculated (∆MSID). Correlation between CD, defined as new-onset left-bundle branch block (LBBB) or the need for permanent pacemaker (PPM) within 1 week after the procedure, and MS length were evaluated. A total of 19 patients (18%) developed CD following TAVR. MS length was significantly shorter in these patients than in those without CD (5.3±1.3 vs. 6.6±1.4; P<0.001), and was the important predictor of CD (odds ratio [OR]: 0.43, 95% confidence interval [CI]: 0.27-0.69, P<0.001). When considering the pre- and postprocedural parameters, the ∆MSID was smaller in patients with CD (-1.7±1.5 vs. 0.8±1.9, P<0.001), and emerged as the important predictor of CD (OR: 0.47, 95% CI: 0.33-0.69, P<0.001). CONCLUSIONS: Short MS is associated with an increased risk of CD after TAVR with BEV.

Proximal Occlusion in the Right Coronary Artery Involving the Atrial Branch as a Strong Predictor of New-Onset Atrial Fibrillation in Acute Myocardial Infarction.

Although atrial ischemic damage is an atrial fibrillation (AF) risk factor, the impact of atrial branches' occlusion on AF development after acute myocardial infarction (AMI) is unclear. Therefore, this study's purpose was to identify predictors of new-onset AF with regard to atrial branches' occlusion. We retrospectively analyzed the AMI database at our single center. Consecutive patients with AMI from June 2011 to May 2017 were enrolled. Exclusion criteria were prior AF before AMI, hemodialysis, and follow-up of < 30 days. The study enrolled 204 consecutive patients (follow-up, 543 ± 469 days; age, 66 ± 12 years; male sex, 77%). All patients underwent primary percutaneous coronary intervention. Thirty-six patients (18%) had new-onset AF in the hospital after AMI. The Killip classification ≥ 3 (41% versus 7%, P < 0.001), ejection fraction ≤ 35% (19% versus 5%, P = 0.014), ischemic occlusion of atrial branches (58% versus 28%, P < 0.001), and ischemic occlusion of atrial branches originating from the right coronary artery (52% versus 18%, P < 0.001) were more frequent in patients with new-onset AF. Multivariable logistic regression analysis showed that Killip classification ≥ 3 (odds ratio, 6.97; 95% confidence interval [CI], 2.77-17.52; P < 0.001), and ischemic occlusion of the atrial branch of the right coronary artery (odds ratio, 4.35; 95% confidence interval, 1.91-9.93; P < 0.001) were independent predictors of new-onset AF. Altogether, proximal occlusion in the right coronary artery involving the atrial branch is a strong predictor of new-onset AF after AMI.

Silent Cerebral Infarction in East Asian vs. Non-Asian Atrial Fibrillation Patients　- Meta-Analysis.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia in the ageing population in East Asia. Silent cerebral infarction (SCI) is defined as cerebral infarction in the absence of corresponding clinical symptoms, and is a highly prevalent and morbid condition in AF. SCI is increasingly being recognized as a risk factor for future stroke, which can lead to cognitive decline or dementia. The latter is an increasingly common health problem in East Asia.Methods and Results:We conducted a meta-analysis to compare the association of AF and SCI between East Asian and non-Asian patients. AF was associated with SCI in patients with no symptomatic stroke history (relative risk [RR], 2.24; 95% CI: 1.26-3.99, I2=83%; P=0.006) although the prevalence varied widely between studies (P for heterogeneity<0.001). In non-Asian patients, the prevalence of SCI in AF is higher than that in controls (RR, 1.85; 95% CI: 1.65-2.08, I2=17%; P<0.001). There was no significant racial difference between Asian and non-Asian studies (P=0.53). CONCLUSIONS: In East Asia, AF was significantly associated with SCI and no racial difference was seen between East Asian and non-Asian patients. The present findings offer clinicians new insights into the association between AF and SCI.

Usefulness of ultra-high resolution mapping for detecting epicardial atrial activation during mitral isthmus ablation.

We describe a patient with perimitral atrial flutter (PMF) following the atrial fibrillation ablation and the linear ablation at the mitral isthmus (MI). From both the activation and the voltage maps using ultra-high resolution mapping, we detected the epicardial connection through the coronary sinus (CS) within the entire reentrant circuit. Point ablation within the CS, not additional linear MI ablation from the endocardium terminates PMF, with a bidirectional block across the low voltage area at the MI.

Body Mass Index and Adverse Outcomes in Elderly Patients With Atrial Fibrillation: The AMADEUS Trial.

BACKGROUND AND PURPOSE: Obesity has been associated with increased cardiovascular risk in atrial fibrillation, but little is known in elderly patients with atrial fibrillation. METHODS: Post hoc analysis of data from the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. RESULTS: We studied 1588 elderly patients, who were categorized as normal body mass index (BMI, 18.5-25 kg/m(2); n=515 [32.4%]), overweight (BMI, 25-30 kg/m(2); n=711 [44.8%]), and obese (BMI≥30 kg/m(2); n=362 [22.8%]). There was a significant reduction in the composite outcome of cardiovascular death and stroke/systemic embolism with increasing BMI category, being 5.0%, 3.2%, and 1.5% per 100 patient-years, respectively (P for trend=0.01). Cox proportional hazards analysis found obesity to be associated with a lower risk of the primary composite outcome (hazard ratio, 0.29; 95% confidence interval, 0.11-0.77; P=0.01). In the warfarin arm (n=814), multivariate logistic regression analysis demonstrated that obesity was independently related to higher odds of time in therapeutic range ≥60% (odds ratio, 1.84; 95% confidence interval, 1.21-2.80; P=0.004). CONCLUSION: Obesity was associated with a lower stroke and mortality rate in elderly anticoagulated atrial fibrillation patients. Obesity was related to good quality anticoagulation control.

Female Sex, Time in Therapeutic Range, and Clinical Outcomes in Atrial Fibrillation Patients Taking Warfarin.

BACKGROUND AND PURPOSE: Female patients have higher risk for stroke than male patients in nonanticoagulated atrial fibrillation patients, but limited data are available on sex differences in stroke and bleeding outcomes among patients with anticoagulated atrial fibrillation on warfarin, especially in relation to quality of anticoagulation control, as reflected by the time in therapeutic range (TTR). METHODS: We investigated adverse outcomes in females (n=791) and males (n=1501) among 2292 patients with atrial fibrillation taking warfarin arm in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. RESULTS: The combined end point of cardiovascular death and stroke/systemic embolism (SSE) was similar in females versus males. There was no sex differences in either cardiovascular death or SSE. Compared with males, females had a lower risk of major bleeding (hazard ratio, 0.39; 95% confidence interval, 0.18-0.87; P=0.02). No differences were seen in mortality and stroke outcomes between females and males either in the prespecified age subgroups or in relation to TTR categories. TTR was negatively correlated with any clinically relevant bleeding in both females (r=-0.86; P=0.03) and males (r=-0.94; P=0.005). On Cox regression, TTR (but not female sex) emerged as an independent predictor for combined cardiovascular death/SSE and clinically relevant bleeding events. CONCLUSION: Anticoagulated female patients with atrial fibrillation had a similar rate of cardiovascular death and SSE, but a lower risk of major bleeding, compared with males. TTR (but not female sex) was an independent predictor for combined cardiovascular death and SSE and clinically relevant bleeding events.

Relationship of Age With Stroke and Death in Anticoagulated Patients With Nonvalvular Atrial Fibrillation: AMADEUS Trial.

BACKGROUND AND PURPOSE: The prevalence of atrial fibrillation increases with age, but age-specific data on the incidence of stroke and death in anticoagulated patients with atrial fibrillation are more limited, particularly with regard to comparisons of relative risks of clinical outcomes between the different age strata in relation to quality of anticoagulation control among warfarin users. METHODS: We investigated the incidence of adverse outcomes between tertiles of age groups (age, <67 [n=722]; age, 67-74 [n=747]; and age, ≥75 [n=824]) in 2293 patients with atrial fibrillation participating in warfarin arm in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. The average time in therapeutic range was calculated as a measure of anticoagulation control and related to clinical outcomes. RESULTS: Absolute rates for stroke/systemic embolism (SSE), cardiovascular death, or any clinically relevant bleeding increased with increasing age strata. The combined end point of cardiovascular death and SSE was the highest in the top tertile (adjusted hazard ratio, 2.63; 95% confidence interval, 1.23-5.63) compared with the middle and lowest tertiles (P for trend=0.01). For bleeding, there was no significant difference in relative risks between the age strata (P for trend=0.55 in the warfarin group and in the warfarin group with time in therapeutic range≥60%, P for trend=0.60). The quality of anticoagulation control (time in therapeutic range) significantly correlated with any clinically relevant bleeding (r=-0.91; P<0.001) and cardiovascular death/SSE rates (r=-0.76; P=0.01). CONCLUSIONS: Elderly patients with atrial fibrillation have higher absolute risks of cardiovascular death, SSE, and bleeding, but relative risks of clinically relevant bleeding are not significantly different with increasing age strata. A significant inverse relationship between time in therapeutic range and bleeding and cardiovascular death/SSE emphasizes the importance of good quality anticoagulation control.

Residual Risk of Stroke and Death in Anticoagulated Patients According to the Type of Atrial Fibrillation: AMADEUS Trial.

BACKGROUND AND PURPOSE: Atrial fibrillation (AF) and heart failure frequently coexist and are associated with increased morbidity and mortality. We investigated the prognosis of anticoagulated patients with permanent AF and nonpermanent AF according to preexisting heart failure in the AMADEUS (Evaluating the Use of SR34006 Compared to Warfarin or Acenocoumarol in Patients With Atrial Fibrillation) trial. METHODS: The primary outcome was a composite of cardiovascular death and stroke or systemic embolism, analyzed using a Cox proportional hazards model, adjusted for baseline age, sex, diabetes mellitus, hypertension, creatinine, and previous cardiovascular diseases. The median follow-up was 11.6 months (interquartile range, 6.2-15.2). RESULTS: Nonpermanent AF was present in 2072 patients (46% of cohort), of which 339 (16%) had preexisting heart failure. A total of 2484 patients had permanent AF (54% of cohort), with a higher burden of heart failure including 730 patients (29%; P<0.001). Overall, death because of cardiovascular causes occurred in 57 patients and 45 had stroke or systemic embolism (1.4/100 person-years for each). Overall, the adjusted incidence of the composite outcome was higher in patients with permanent AF than in patients with nonpermanent AF. In multivariate analysis, permanency of AF, creatinine, prior cerebrovascular events, and previous coronary disease were independently associated with the primary outcome. The hazard ratio for permanent versus nonpermanent AF was 1.68 (95% confidence interval, 1.08-2.55; P=0.02). The presence of heart failure increased the risk of adverse outcomes in a similar way in both permanent and nonpermanent AF (interaction P value=0.76). CONCLUSIONS: The risk of cardiovascular death, stroke, or systemic embolism is higher in anticoagulated patients with permanent AF than in those with nonpermanent AF, regardless of preexisting heart failure.

Comparative efficacy and safety of the non-vitamin K antagonist oral anticoagulants for patients with nonvalvular atrial fibrillation.

The non-vitamin K antagonist oral anticoagulants (NOACs), such as the thrombin inhibitor (dabigatran) and the direct factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), have been shown to be at least as efficacious and safe as conventional oral anticoagulants, such as the vitamin K antagonists (VKAs) (e.g., warfarin), for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). Each NOAC has various advantages and specific features, and therefore decisions regarding appropriate stroke prevention require individual assessment of stroke and bleeding risk on anticoagulation with VKA therapy and NOACs when starting on any of these drugs. This review briefly describes the results of the four NOACs clinical randomized trials and discusses how they might impact clinical practice and choice of anticoagulants in atrial fibrillation patients. Moreover, this review discusses the differences of the proposed management of antithrombotic therapy in several international guidelines and pragmatic issues of NOACs for stroke prophylaxis.

Efficacy and safety of non-vitamin K antagonist oral anticoagulants vs. warfarin in Japanese patients with atrial fibrillation ­ meta-analysis.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOAC) have been developed as alternatives to warfarin. Until recently, the latter was the standard oral anticoagulant for patients with non-valvular atrial fibrillation (NVAF). The efficacy and safety of NOAC in Japanese patients with NVAF has been investigated in small trials or subgroups from global randomized control trials (RCT). METHODS AND RESULTS: We conducted a systematic review and meta-analysis of RCT, to compare the efficacy and safety of NOAC to those of warfarin in Japanese patients with NVAF. Published research was systematically searched for RCT that compared NOAC to warfarin in Japanese patients with NVAF. Random-effects models were used to pool efficacy and safety data across RCT. Three studies, involving 1,940 patients, were identified. Patients randomized to NOAC had a decreased risk for stroke and systemic thromboembolism (relative risk [RR], 0.45; 95% CI: 0.24-0.85), with a non-significant trend for lower major bleeding (RR, 0.66; 95% CI: 0.29-1.47), intracranial bleeding (RR, 0.46; 95% CI: 0.18-1.16) and gastrointestinal bleeding (RR, 0.52; 95% CI: 0.25-1.08). CONCLUSIONS: NOAC are more efficacious than warfarin for the prevention of stroke and systemic embolism in Japanese patients with NVAF. The present findings offer clinicians a more comprehensive picture of NOAC as a therapeutic option to reduce the risk of stroke in Japanese NVAF patients.

Progression to the persistent form in asymptomatic paroxysmal atrial fibrillation.

BACKGROUND: This study investigated the progression of paroxysmal atrial fibrillation (AF) to the persistent form in Japanese asymptomatic AF patients. METHODS AND RESULTS: Data were derived from a single hospital-based cohort in the Shinken Database 2004-2012 (n=19,994), in which 1,176 patients were diagnosed as having paroxysmal AF. AF progression occurred in 115 patients (6.0%/year) during the mean follow-up period (1,213±905 days). Although patients who were asymptomatic at the initial visit (n=468) had a low-risk profile compared with symptomatic patients, they had greater AF progression at follow-up (unadjusted hazard ratio, 1.611; 95% CI: 1.087-2.389; P=0.018). Absence of symptoms, male sex, and cardiomyopathy were independent predictors for AF progression in the multivariate model. It was noted that asymptomatic patients were less likely to undergo pulmonary vein isolation (PVI). In addition, the interaction term between asymptomatic AF and absence of PVI could be another independent predictor for AF progression. Prognosis was similar between asymptomatic and symptomatic patients with AF. CONCLUSIONS: Irrespective of low-risk profile, patients with asymptomatic paroxysmal AF had greater progression of AF compared with symptomatic patients. This paradoxical result appeared to be the result of less intensive clinical management, including invasive rhythm control.

Pitfalls and tips for lumenless lead extraction inserted deep within the ventricular septum.

Key Clinical Message: This case highlights the pitfalls and provides tips for the extraction of deeply implanted lumenless leads, and encourages careful lead selection in the current era of widespread left bundle branch area pacing. Abstract: The extraction of cardiovascular implantable electronic device leads is sometimes complicated. We describe a case with difficult but successful extraction of SelectSecure, a lumenless permanent pacemaker lead, implanted deep in the ventricular septum, highlighting its pitfalls and tips in the current era of left bundle branch area pacing.

Sex Differences in the Relationship Between Schizophrenia and the Development of Cardiovascular Disease.

BACKGROUND: There are few data on sex differences in the association between schizophrenia and the development of cardiovascular disease (CVD). We sought to clarify the relationship of schizophrenia with the risk of developing CVDs and to explore the potential modification effect of sex differences. METHODS AND RESULTS: We conducted a retrospective analysis using the JMDC Claims Database between 2005 and 2022. The study population included 4 124 508 individuals aged 18 to 75 years without a history of CVD or renal replacement therapy. The primary end point is defined as a composite end point that includes myocardial infarction, angina pectoris, stroke, heart failure, atrial fibrillation, and pulmonary thromboembolism. During a mean follow-up of 1288±1001 days, we observed 182 158 composite end points. We found a significant relationship of schizophrenia with a greater risk of developing composite CVD events in both men and women, with a stronger association observed in women. The hazard ratio for the composite end point was 1.63 (95% CI, 1.52-1.74) in women and 1.42 (95% CI, 1.33-1.52) in men after multivariable adjustment (P for interaction=0.0049). This sex-specific difference in the association between schizophrenia and incident CVD was consistent for angina pectoris, heart failure, and atrial fibrillation. CONCLUSIONS: Our analysis using a large-scale epidemiologic cohort demonstrated that the association between schizophrenia and subsequent CVD events was more pronounced in women than in men, suggesting the clinical importance of addressing schizophrenia and tailoring the CVD prevention strategy based on sex-specific factors.

Sex Differences in the Association Between Depression and Incident Cardiovascular Disease.

Background: Depression is a known risk factor for cardiovascular disease (CVD), but the potential sex differences in this association remain unclear. Objectives: The aim of this study was to investigate the association between depression and subsequent CVD events, and to explore potential sex differences. Methods: The authors conducted a retrospective analysis using the JMDC Claims Database between 2005 and 2022. The study population included 4,125,720 individuals aged 18 to 75 years without a history of cardiovascular disease or renal failure and missing data at baseline. Participants were followed up for a mean of 1,288 days to assess the association between depression and subsequent CVD events, such as myocardial infarction, angina pectoris, stroke, heart failure, and atrial fibrillation. Results: Our analysis revealed a significant association between depression and subsequent composite CVD events in both men and women, with a stronger association observed in women. The HR for the composite endpoint was 1.64 (95% CI: 1.59-1.70) in women and 1.39 (95% CI: 1.35-1.42) in men after multivariable adjustment (P for interaction <0.001). Furthermore, the individual components of the composite endpoint were also associated with depression in both men and women, each of which was also observed to be more strongly associated in women. Conclusions: Our study provides evidence of a significant association between depression and subsequent CVD events in both men and women, with a more pronounced association observed in women. These findings highlight the importance of addressing depression and tailoring prevention and management strategies according to sex-specific factors.

Survey of physicians' and patients' understanding, perceptions, and attitudes toward depressive state in atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia among older people and has a significant impact on quality of life. However, it is not always perceived as a serious mental health risk. This study investigated the understanding, perceptions, and attitudes toward the risk of depressive state associated with older patients with AF. METHODS: We conducted a quantitative survey in April-June 2021 among patients with AF aged ≥65 years (n = 156), and physicians or cardiologists attending at least 10 older patients with AF annually (n = 158). RESULTS: In total, 45% of patients considered AF a cause of a depressive state. In contrast, 16% of physicians reported that they considered AF a cause of a depressive state. Fifty-two percent of the patients had experienced a depressive state. Of these, 98% expressed that a depressive state lowered their quality of life. Two of the three patients reported that they would consult their physicians if they felt depressed. By contrast, 30% of physicians responded that even if they perceived their patients as depressed, they prescribe anti-anxiety medication but do not refer the patient to psychiatrists. Of the physicians, 50% stated that they did not regard the association of AF and depressive state as serious, although both physicians and patients understood that negative anxiety, such as fear of AF attacks, strokes, or heart failure, was the most important contributor to a depressive state. CONCLUSION: Establishing mental healthcare involving physicians together with psychiatrists is necessary to improve the mental and physical health outcomes for older patients with AF. Geriatr Gerontol Int 2023; 23: 543-548.

Prediction model for the new onset of atrial fibrillation combining features of 24-hour Holter electrocardiogram with 12-lead electrocardiogram.

Background: Several factors that predict new-onset atrial fibrillation (AF) have been investigated using the 24-hour Holter electrocardiogram (ECG) and 12-lead ECG; however, these have been based on each test independently. The aim of this study was to combine findings from the two tests to create a comprehensive, easy-to-use score and to examine its validity. Methods and Results: A total of 502 patients underwent 24-hour Holter ECG and 12-lead ECG were followed up for 6.2 ± 3.5 years, and 66 patients developed new-onset AF. Multivariate Cox regression analyses revealed that total number of supraventricular extrasystoles (SVEs) ≥ 100 beats/day and SVE's longest run ≥ 3 beats on 24-hour Holter ECG and PR interval ≥ 185 ms, amplitude ratio of P wave (aVR/V1) < 1.0 and amplitude of RV5 + SV1 ≥ 2.2 mV on 12-lead ECG were significant independent predictors for developing AF (all p < 0.01). Using these cut-off points, the PAAFS (acronym for risk factors) score was constructed by adding one point for each parameter if the patient met each of the criteria. The area under the curve (AUC) of the PAAFS score was 0.80, compared to the AUCs of 24-hour Holter ECG-only factors (0.73) and 12-lead ECG-only factors (0.72), indicating an improvement in score. The annual incidence of AF for each PAAFS score were 0.0%, 0.2%, 0.7%, 1.9%, 5.6%, and 11.1%/year for scores 0 to 5, respectively. Conclusion: The PAAFS score, which combines findings from 24-hour Holter ECG and 12-lead ECG, was superior to 24-hour Holter ECG and 12-lead ECG alone in predictive accuracy for new-onset AF.