Publications

In patients with ischemic stroke or TIA, increasing BGPVS burden is associated with more severe cerebral small vessel disease and higher ischemic stroke risk. Neither BGPVS nor CSOPVS were independently associated with future ICH.

The novel treatment strategies mentioned above have shown great potential, however, large randomized controlled trials are still lacking. The biggest challenge is translating the results seen in preclinical trials into clinical trials. We recommend a multi-disciplinary team approach with cardiologists, geneticist, pharmacologists, bioengineers, researchers, regulators, and patients to improve heart failure outcomes. Future management can involve telemedicine, remote monitoring, and artificial intelligence to optimize patient care.

In atrial fibrillation patients, contemporary clinical risk scores are associated with an increased risk of all-cause death. Use of these scores for death prediction in atrial fibrillation patients could be considered as part of holistic clinical assessment. The CHA₂DS₂-VASc score had consistently high negative predictive value during follow-up and the highest probability of being the best performing clinical score.

AF patients who are on warfarin therapy at sepsis diagnosis experienced an increase in bleeding rates within the 3 months following sepsis. Warfarin use was associated with lower mortality, despite virtually comparable thromboembolic event rates.

Objective To evaluate the effectiveness and safety of rivaroxaban in real-world practice compared with dabigatran (R vs. D) or with warfarin (R vs. W) for stroke prevention in atrial fibrillation (AF). Methods and Results 17 studies were included after a thorough search in PubMed for studies reporting comparative effectiveness and safety of R vs. D(3), R vs. W (11) or both conditions (3)for stroke prevention in AF. Overall, the risks of ischaemic stroke (IS)/systematic thromboembolism (TE) with rivaroxaban were similar compared with dabigatran (Figure 1) IS/TE: (HR:1.02,95% CI: 0.91–1.13, I2=70.2%, n=5), but were significantly reduced when compared to warfarin. IS/TE:(0.75,0.64–0.85, I2=45.1%, n=9). Major bleeding risk was significantly higher with rivaroxaban than dabigatran (Figure 2) (1.38, 1.27–1.49, I2=26.1%, n=5), but similar to warfarin (0.99, 0.91–1.07, I2=0.0%, n=6). Rivaroxaban was associated with increased all-cause mortality and gastrointestinal bleeding (GIB), but similar risk of acute myocardial infarction (AMI) and intracranial bleeding (ICB) compared with dabigatran. When compared with warfarin, rivaroxaban was associated with similar risk of any bleeding, mortality and AMI, but a higher risk of GIB and lower risk of ICB. Conclusions In this systematic review and meta-analysis, rivaroxaban was as effective as dabigatran, but was more effective than warfarin for the prevention of IS/TE in AF patients. Major bleeding risk was significantly higher with rivaroxaban than dabigatran, as was all-cause mortality and GIB. Rivaroxaban was comparable to warfarin for major bleeding, with an increased risk in GIB and decreased risk of ICB. Abstract 45 Figure 1 Rivaroxaban compared with Dabigatran in risk of IS/TE in AF patients. IS, ischemic stroke, TE, thromboembolism. LD,low-dose; HD,high-dose; BD,both-dose. AF, atrial fibrillation Abstract 45 Figure 2 Rivaroxaban compared with Dabigatran in risk of major bleeding in AF patients. AF, atrial fibrillation. ECH, extracranial hemorrhage.

Abstract Aims The 4S-AF scheme [Stroke risk, Symptom severity, Severity of atrial fibrillation (AF) burden, Substrate severity] has recently been described as a novel approach to in-depth characterization of AF. We aim to determine if the 4S-AF scheme would be useful for AF characterization and provides prognostic information in real-world AF patients. Methods and results The Spanish and French cohorts of the EORP-AF Long-Term General Registry were included. The baseline 4S-AF scheme was calculated and related to the primary management strategy (rhythm or rate control). Follow-up was performed at 1-year with all-cause mortality and the composite of ischaemic stroke/transient ischaemic attack/systemic embolism, major bleeding, and all-cause death, as primary endpoints. A total of 1479 patients [36.9% females, median age 72 interquartile range (IQR 64–80) years] were included. The median 4S-AF scheme score was 5 (IQR 4–7). The 4S-AF scheme, as continuous and as categorical, was associated with the management strategy decided for the patient (both P < 0.001). The predictive performances of the 4S-AF scheme for the actual management strategy were appropriate in its continuous [c-index 0.77, 95% confidence interval (CI) 0.75–0.80] and categorical (c-index 0.75, 95% CI 0.72–0.78) forms. Cox regression analyses showed that ‘red category’ classified patients in the 4S-AF scheme had a higher risk of all-cause death (aHR 1.75, 95% CI 1.02–2.99) and composite outcomes (aHR 1.60, 95% CI 1.05–2.44). Conclusion Characterization of AF by using the 4S-AF scheme may aid in identifying AF patients that would be managed by rhythm or rate control and could also help in identifying high-risk AF patients for worse clinical outcomes in a ‘real-world’ setting.

Introduction: For heart failure (HF) with iron deficiency (ID), the benefits of intravenous iron might differ according to kidney function. Methods: IRONMAN was a randomised, open-label trial of intravenous ferric derisomaltose (FDI) versus usual care (UC) in patients with HF, left ventricular ejection fraction ≤45%, and ID (transferrin saturation <20% and/or ferritin <100 µg/L). The primary composite endpoint of recurrent hospitalisation for HF and cardiovascular (CV) death was lower in those assigned to FDI. Analysis according to baseline estimated glomerular filtration rate (eGFR) is now reported, with outcomes assessed in 3 categories of eGFR. Results: Of 1,137 patients randomised, eGFR was <45 mL/min/1.73 m2 for 435 (38%), 45–59 mL/min/1.73 m2 for 295 (26%), and ≥60 mL/min/1.73 m2 for 407 (36%). Patients with eGFR <45 mL/min/1.73 m2 were older and had more severe HF and more events. For the primary outcome, the primary endpoint rates per 100 patient-years for FDI versus UC across eGFR categories were 164 and 213 (rate ratio [RR]: 0.77 [95% CI: 0.57, 1.03]), 84 and 105 (RR: 0.79 [95% CI: 0.51, 1.22]), 88 and 93 (RR: 0.98 [95% CI: 0.62, 1.54]), respectively, but no statistically significant interaction between eGFR category and treatment effect was observed (p<sub>interaction</sub> = 0.67). When eGFR was <45 mL/min/1.73 m2, FDI was associated with more favourable effects on Minnesota Living with Heart Failure score at 4 months (p < 0.001; p<sub>interaction</sub> = 0.01 by eGFR class) and trends to greater reductions in first hospitalisation for HF or CV death (hazard ratio [HR]: 0.76 [95% CI: 0.58, 0.99]; p<sub>interaction</sub> = 0.53) and first hospitalisation for myocardial infarction, stroke or HF, or CV death (HR: 0.71 [95% CI: 0.55, 0.92]; p<sub>interaction</sub> = 0.29), although tests for interaction by eGFR class were not significant. Conclusion: For patients with HF and ID, those with eGFR <45 mL/min/1.73 m2 are more symptomatic, have worse outcomes, and might receive greater benefit from FDI. Analysis of other randomised trials, ideally an individual patient data meta-analysis, are required to confirm these findings.

The increasing ageing of the general population has led to a significant burden of multimorbidity in the general population, requiring significant changes to healthcare and management, as well as clinical approaches. Hence, increasing attention to the progressively increasing burden of multimorbidity and the need for more integrated care management in patients with chronic long-term conditions.1,2 Even in the most common heart rhythm disorder, atrial fibrillation (AF), the presence of multimorbidity has proven to significantly influence clinical management and prognosis.3,4 The burden of multimorbidity in AF patients, similar to the overall general population, requires new strategies to manage patients and reduce the risk of adverse outcomes. This holistic or integrated care approach has been proposed and framed as the ‘Atrial fibrillation Better Care’ (ABC) pathway5 and is based on three main pillars: (i) ‘A’: avoid stroke by anticoagulation management; (ii) ‘B’: better symptom control by patient-centred symptom-directed decisions on rate or rhythm control strategies; (iii) ‘C’: cardiovascular and non-cardiovascular risk factors and comorbidities, as well as lifestyle changes. Adherence to the ABC pathway has been shown to improve clinical outcomes, including the reduction in mortality, stroke, major bleeding, and hospitalizations.6 Given the growing evidence-base, the ABC pathway has been recommended in AF clinical management guidelines from Europe and Asia-Pacific.7,8

Abstract Background Atrial fibrillation (AF) is the commonest abnormal heart rhythm with significant related morbidity and mortality. There is increasing evidence that abnormalities of the cardiac autonomic nervous system (ANS) are involved in the pathogenesis of AF. Exploring the ANS is possible through heart rate variability (HRV) evaluation. Purpose To investigate whether HRV is more abnormal in patients with permanent AF compared to paroxysmal AF. Design In a cross-sectional comparison, we studied two patient groups: permanent AF (n=30) and paroxysmal AF (n=31). Time-domain, frequency-domain and non-linear measures of HRV were determined using eMotion Faros ECG sensor. Participant's breathing was controlled with a metronome set at 12 breaths per minute. Data was analysed using SPSS software. Results Time-domain and non-linear indices of HRV were significant higher in permanent AF group compared to paroxysmal AF (table 1). Permanent AF was the only independent predictor of HRV on multivariable analysis in this cohort of patients (p=0.006) Conclusions First study investigating autonomic function in patients with permanent AF and paroxysmal AF. HRV indices were significantly higher in permanent AF compared to paroxysmal AF which may suggest pronounced cardiac autonomic influence in the pathophysiology of permanent AF. Funding Acknowledgement Type of funding sources: None.