Publications

Multimorbidity, frailty, and polypharmacy are associated with worse outcomes in patients with atrial fibrillation (AF), leading to 'clinically complex' patient phenotypes. Possible differences between European and Asian patients regarding these aspects have not been studied. We studied AF patients derived from two large prospective observational AF registries, conducted in Europe and Asia. Multimorbidity and polypharmacy were defined according to the number of comorbidities and drugs at baseline. Frailty was defined according to a 40-items frailty index (FI). Prescription of OAC was assessed at baseline. The primary outcome was the composite of all-cause death and major adverse cardiovascular events. European patients had a higher burden of multimorbidity, frailty, and polypharmacy domains compared with Asians. Asian patients with these domains were less likely to be prescribed OAC than Europeans, especially those who were frail. After adjustments, being frail was associated with lower OAC prescription, with Asians less likely prescribed than Europeans (OR 0.34, 95% CI 0.25-0.45 vs. OR 0.47, 95% CI 0.40-0.55, p_int = 0.037). Adjusted Cox regression found that multimorbidity, frailty, and polypharmacy domains were associated with a higher risk of the composite outcome. On subgroup analysis, frail Asian patients had a higher risk of the composite outcome (p_int = 0.007) than Europeans. Multimorbidity, frailty and polypharmacy have different epidemiological characteristics amongst European and Asian AF patients. Being frail was associated with a higher likelihood of not being prescribed OAC, particularly in Asian patients. The adverse impact of 'clinically complex' patient phenotypes on risks of adverse outcomes was greater in Asian patients than in Europeans.

In most patients with atrial fibrillation (AF), effective stroke prevention necessitates long-term (often lifelong) oral anticoagulant therapy (OAC). However, the effectiveness of OAC therapy in a clinical setting (i.e. outside the controlled environment of randomized clinical trials) is strongly influenced by patients' adherence and persistence with prescribed therapy. However, suboptimal adherence to OAC remains a substantial problem in routine practice-available evidence suggests that patients do not take their OAC one out of every four days, and approximately one in three to four patients is poorly adherent to OAC. In addition, around 15% of high-risk OAC-eligible patients with AF refuse to take OAC for a variety of patient-specific reasons. Poor adherence to OAC therapy is associated with adverse clinical outcomes [such as stroke or systemic embolism, hospitalization, mortality, bleeding (particularly with vitamin K antagonist therapy)] and increased economic costs. In this overview, we summarize important aspects of the adherence to medication concept, including the definition and measurement of adherence, the determinants and prevalence of OAC non-adherence, the clinical importance of achieving and maintaining good adherence, strategies to improve adherence to OAC, and alternative treatment options for effective thromboprophylaxis in patients with AF who are non-adherent to OAC therapy.

About one‑third of the patients showed VDD. The VDD and VDS groups did not differ in terms of CVD occurrence and the difference in glycemic control was insignificant. The patients with VDD were more often treated with SGLT‑2is, which requires further investigation.

Abstract Aims Heart failure (HF) is associated with multiple co-morbidities which independently influence response to treatment as well as outcomes. This retrospective observational study (January 2020-June 2021) analysed the impact of monthly virtual HF multi-specialty multi-disciplinary team (MDT) meetings to address the management of associated comorbidities and thereby upon provision, cost of care and HF outcomes. Methods Patients acted as their own controls, with outcomes compared for equal periods (for each patient) pre versus post-MDT meeting. The MDT comprised of HF cardiologists (primary, secondary, tertiary care), HF specialist nurses (hospital, community), nephrologist, endocrinologist, palliative care specialist, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were 1) all-cause hospitalisations, 2) outpatient clinic attendances, and 3) cost. Results 334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9 ± 4 months. The mean age-adjusted Charlson Co-morbidity Index was 7.6 ± 2.1 and Rockwood Frailty Score was 5.5 ± 1.6. The mean number of clinic attendances prevented was 1.6 ± 0.4. The total cost of funding monthly meetings for the duration of the study was £32400 and the 64 clinic appointments generated cost £9600. The MDT meetings prevented 534 clinic appointments (cost saving £80,100) and reduced all-cause hospitalisations (pre-MDT meeting 1.1±0.4 vs. 0.6±0.1 post-MDT meeting; p<0.001), reduction of 1586 hospital bed-days and cost-savings of £634,400. The total cost-saving to the healthcare system was £672,500. Conclusion The HF multispecialty virtual MDT model provides integration of care across all tiers of healthcare for HF management and a holistic approach addressing associated co-morbidities. This approach can reduce the need for out-patient attendances and all-cause hospitalisations, leading to significant cost-savings. Key questions What is already known about this subject? Heart failure is associated with several co-morbid health conditions (multi-morbidity) which independently influence outcomes as well as response to treatment. What does this study add? This study assesses the impact of multispecialty multi-morbidity input into the management of co-morbidities and thereby the effect upon all-cause outcomes. How might this impact on clinical practice? Results of this study illustrate that multi-speciality management of comorbidities associated with heart failure, may not only improve all-cause outcomes but could also prove to be cost-beneficial.

Abstract Introduction Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) commonly coexist. AF is associated with left atrial (LA) and ventricular (LV) myocardial fibrosis, contributing to diastolic dysfunction in HFpEF. Many profibrotic pathways have been studied in AF and HFpEF, but scarce data are available on the role of circulating microparticles (MPs). Purpose To evaluate association of circulating biomarkers of fibrosis and MPs subsets with Doppler-derived parameters of diastolic function in AF and HFpEF. Methods We studied 274 patients with non-valvular AF and HFpEF (median age 62 years, 37% females). Paroxysmal AF was diagnosed in 150 patients (55%) and non-paroxysmal AF (persistent or permanent) in 124 (45%). Median CHA2DS2-VASc score was 3 in males and 4 in females. Transthoracic echocardiography was performed to assess LV diastolic function, including early mitral inflow velocity (E), E/A velocities ratio (on sinus rhythm), early mitral annular diastolic velocity (E') for LV septal and lateral basal regions, E/E' ratio, LA maximum volume index (LAVi), E-wave velocity deceleration time (DT), flow propagation velocity (Vp). Average values from ten consecutive cardiac cycles were calculated. E/E' ratio was chosen as valid and reproducible index of diastolic function in AF patients for regression analysis. Blood levels of galectin 3, interleukin-1 receptor-like 1 (ST2), transforming growth factor beta 1 (TGF-β1), procollagen type III aminoterminal propeptide (PIIINP), matrix metalloproteinase 9 (MMP-9), tissue inhibitor of matrix metalloproteinase 1 (TIMP-1), angiotensin II and aldosterone level were assayed as surrogate biomarkers of myocardial fibrosis and profibrotic signaling. Using microflow cytometry, numbers of platelet-derived (CD42b+), monocyte-derived (CD14+), endothelial (CD144+), and apoptotic MPs (Annexin V+) were quantified in plasma samples. Linear regression was used to reveal parameters associated with diastolic function assessed as E/E' ratio. Data were normalized with Box-Cox transformation. Results Grade I diastolic dysfunction was found in 149 (54%); 94 (34%), and 31 (11%) patients had grade II and grade III diastolic dysfunction, respectively. On univariate analysis, age (β=0.23, p=0.0001); male gender (β=-0.19, p=0.02); history of hypertension (β=0.15, p=0.02); AF type, i.e. progression from paroxysmal to permanent (β=0.14, p=0.02); AnV+ MPs (β=0.19, p=0.01); angiotensin II (β=0.13, p=0.04); ST2 (β=0.1, p=0.04); and TIMP-1 (β=0.13, p=0.03) were associated with E/E' ratio. Using stepwise multivariate regression, AnV+ MPs (β=0.15, p=0.01) and TIMP-1 (β=0.3, p=0.04) remained significant predictors of E/E' ratio, adjusted for age, gender, hypertension and AF type. Relation of E/E' to TIMP-1 and AnV+ MPs Conclusion Apoptotic (AnV+) MPs and TIMP-1 were independently associated with diastolic dysfunction in AF and HFpEF. These may contribute to the pathophysiology of AF and HFpEF, and complications related to the presence of both. Acknowledgement/Funding ESC Research Grant, EHRA Academic Research Fellowship Programme

<h3></h3> the use of a structured approach by HF specialist nurse using prompt of an ABCDEF mnemonic to guide management of multimorbidity in HFpEF clinics and compare this with standard care (without prompt by a mnemonic). <h3>Methods</h3> This was a retrospective analysis of a prospective cohort study of 75 patients with recent decompensated HFpEF within 30 days, <h3>Results</h3> The mean age was comparable between the 2 cohorts. There was also no significant difference in terms of co-morbidities. 30-day all-cause re-admissions showed a trend towards being lower in the mnemonic cohort Use of a structured mnemonic approach to manage multimorbidity appears to be an easy intervention to apply in HFpEF clinics. <h3>Conflict of Interest</h3> None

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia found in clinical practice. AF rarely exists as a single entity but rather as part of a diverse clinical spectrum of cardiovascular diseases, related to structural and electrical remodeling within the left atrium, leading to AF onset, perpetuation, and progression. Due to the high overall prevalence within the AF population arterial hypertension plays a significant role in the pathogenesis of AF and its complications. Fibroblast proliferation, apoptosis of cardiomyocytes, gap junction remodeling, accumulation of collagen both in atrial and ventricular myocardium all accompany ageing-related structural remodeling with impact on electrical activity. The presence of hypertension also stimulates oxidative stress, systemic inflammation, rennin-angiotensin-aldosterone and sympathetic activation, which further drives the remodeling process in AF. Importantly, both hypertension and AF independently increase the risk of cardiovascular and cerebrovascular events, e.g., stroke and myocardial infarction. Given that both AF and hypertension often present with limited on patient wellbeing, treatment may be delayed resulting in development of complications as the first clinical manifestation of the disease. Antithrombotic prevention in AF combined with strict blood pressure control is of primary importance, since stroke risk and bleeding risk are both greater with underlying hypertension.

In patients with AF, social deprivation is associated with an increased risk of death and adverse cardiac events. The presence of possible unmeasured bias associated with the retrospective design requires confirmation in future prospective studies.

In AF patients, clinical complexity influences OAC treatment management, and increases the risk of poor clinical outcomes. These patients require additional efforts, such as integrated care approach, to improve their management and prognosis.

Abstract Background: Obesity has been linked to atrial fibrillation (AF) burden and severity, and epidemiological studies suggest that AF is more prevalent in whites than Asian. We aimed to investigate whether obesity mediates associations with AF in Europe and Asia using patient-level data comparisons of two cohort studies. Methods: Using Korean National Health Insurance Service’s Health Screening (NHIS-HealS) and U.K. Biobank data, we included 401,206 Korean and 477,926 British aged 40–70 years without previous AF who received check-ups. The incidence and risk of AF were evaluated regarding different body mass index (BMI) values. Results: The obese proportion (BMI³30.0 kg/m 2 , 2.8% vs. 24.3%, P &lt;0.001) was higher in the U.K. than the Korean. In the Korean and U.K. cohort, the age- and sex-adjusted incidence rates of AF were 4.97 and 6.54 per 1,000 person-years among obese individuals. Compared to Koreans, the risk of AF was higher in the British population, with adjusted hazard ratios of 1.41 (Korea, 95% CI, 1.26–1.58) and 1.68 (UK, 95% CI, 1.54–1.82) in obese participants ( P for interaction&lt;0.05). Conclusions: Obesity was associated with AF in both populations. British subjects had a greater incidence of AF related to the high proportion of obese individuals, but the risk of AF was also increased when participants into obese categories.

Background: Elderly adults with atrial fibrillation (AF) are at increased risk of frailty and thromboembolic complications. However, studies on the prevalence of frailty in AF patients and data on the relationship between frailty and the use of anticoagulants are limited. Methods: We conducted a cross-sectional study involving 500 participants. Patients aged 65 years or older were consecutively selected from the Chinese Atrial Fibrillation Registry study. The patient’s frailty status was assessed with use of the Canadian Study of Health and Aging Clinical Frailty Scale. We assessed the prevalence of and factors associated with frailty, and how frailty affects anticoagulant therapy. Results: In 500 elderly adults with AF (age 75.2±6.7 years; 51.6% female), 201 patients (40.2%) were frail. The prevalence of frailty was higher in females (P=0.002) and increased with age and CHA 2 DS 2 -VASc score (P for trend less than 0.001 for both). The factors associated with frailty were a history of heart failure (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.39–4.14), female sex (OR 2.09, 95% CI 1.27–3.43), and advanced age (OR 1.13, 95% CI 1.09–1.17). Frail patients were significantly less likely to have ever been prescribed anticoagulants compared with nonfrail patients (81.7 vs. 54.9%, P&lt;0.001). Conclusions: Frailty is prevalent in elderly adults with AF, especially in females, those of advanced age, and those with heart failure. Frailty status has a significant impact on prescription of anticoagulants for high-risk AF patients.

Patients with AF and history of HF may have greater disease burden at AF diagnosis and increased mortality rates vs. patients without HF. Stroke and major bleeding rates were roughly comparable between groups confirming the long-term safety and effectiveness of dabigatran in patients with HF.

Atrial fibrillation (AF) is associated with increased risk of cognitive impairment and dementia, even with no overt stroke. Hypertension has been a potentially modifiable risk factor for dementia, especially in midlife (<70 years) individuals. We aimed to investigate the associations of blood pressure (BP) and hypertension burden with dementia risk among midlife AF patients. From the Korean National Health Insurance Service database, we enrolled 171 228 incident AF patients aged 50 to 69 years with no prior dementia from 2005 to 2016. During a mean of 6.6 years of follow-up, 9909 patients received a first-time diagnosis of dementia. U-shaped relationships were noted between systolic or diastolic BP and dementia risk: A 10 mm Hg increase or decrease in systolic BP starting from 120 mm Hg was associated with 4.4% (95% CI, 2.7%-6.0%) and 4.6% (95% CI, 0.1%-8.2%) higher dementia risk, respectively. An increase or decrease in diastolic BP starting from 80 mm Hg also increased dementia risk. In subtype analyses, Alzheimer disease increases with BP decrease whereas vascular dementia increases according to BP increase. When BP changes over time were accounted for in time-updated models, BP of 120 to 129/80 to 84 mm Hg was associated with the lowest dementia risk. Increasing hypertension burden (the proportion of days with increased BP during follow-up) was associated with higher dementia risk (hazard ratio, 1.10 per 10% increase [95% CI, 1.08-1.12]). Among midlife AF patients, there were a U-shaped association of BP and a log-linear association of hypertension burden with dementia risk. Minimizing the burden of hypertension in AF patients might help to prevent dementia.

Larger peri-atrial EAT volume, in addition to prior TE and lower CCr, was independently associated with postablation ES regardless of AF recurrence and CHA₂ DS₂ -VASc score. (ClinicalTrials.gov number, NCT03479073).