Publications

The current manuscript is the Executive Summary of the second update to the original Practical Guide, published in 2013. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF), and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to co-ordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are (i) eligibility for NOACs; (ii) practical start-up and follow-up scheme for patients on NOACs; (iii) ensuring adherence to prescribed oral anticoagulant intake; (iv) switching between anticoagulant regimens; (v) pharmacokinetics and drug-drug interactions of NOACs; (vi) NOACs in patients with chronic kidney or advanced liver disease; (vii) how to measure the anticoagulant effect of NOACs; (viii) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (ix) how to deal with dosing errors; (x) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (xi) management of bleeding under NOAC therapy; (xii) patients undergoing a planned invasive procedure, surgery or ablation; (xiii) patients requiring an urgent surgical intervention; (xiv) patients with AF and coronary artery disease; (xv) avoiding confusion with NOAC dosing across indications; (xvi) cardioversion in a NOAC-treated patient; (xvii) AF patients presenting with acute stroke while on NOACs; (xviii) NOACs in special situations; (xix) anticoagulation in AF patients with a malignancy; and (xx) optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA web site (www.NOACforAF.eu).

Left atrial catheter ablation is an efficacious option for restoring sinus rhythm and is most likely to provide benefit to those in whom durable sinus rhythm can be expected, and whose life expectancy is not significantly reduced by other pathologies or advanced age. A pace-and-ablate approach, particularly with physiological pacing, may provide more benefit to those with low chance of maintaining sinus rhythm. Both invasive options generally outperform pharmacotherapy, although it is important to individualize the approach for each patient through shared decision-making.

Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide. The presence of AF is associated with increased risk of systemic thromboembolism, but with the uptake of oral anticoagulant (OAC) and implementation of a holistic and integrated care management, this risk is substantially reduced. The diagnosis of AF requires a 30-s-long electrocardiographic (ECG) trace, irrespective of the presence of symptoms, which may represent the main indication for an ECG tracing. However, almost half patients are asymptomatic at the time of incidental AF diagnosis, with similar risk of stroke of those with clinical AF. This has led to a crucial role of screening for AF, to increase the diagnosis of population at risk of clinical events. The aim of this review is to give a comprehensive overview about the epidemiology of asymptomatic AF, the different screening technologies, the yield of diagnosis in asymptomatic population, and the benefit derived from screening in terms of reduction of clinical adverse events, such as stroke, cardiovascular, and all-cause death. We aim to underline the importance of implementing AF screening programmes and reporting about the debate between scientific societies' clinical guidelines recommendations and the concerns expressed by the regulatory authorities, which still do not recommend population-wide screening. This review summarizes data on the ongoing trials specifically designed to investigate the benefit of screening in terms of risk of adverse events which will further elucidate the importance of screening in reducing risk of outcomes and influence and inform clinical practice in the next future.

A ML approach demonstrated high performance in identifying MAFLD patients with prevalent CVD based on the easy-to-obtain patient parameters.

In very elderly Japanese patients with nonvalvular atrial fibrillation who were not appropriate candidates for standard doses of oral anticoagulants, a once-daily 15-mg dose of edoxaban was superior to placebo in preventing stroke or systemic embolism and did not result in a significantly higher incidence of major bleeding than placebo. (Funded by Daiichi Sankyo; ELDERCARE-AF ClinicalTrials.gov number, NCT02801669.).

<b>Objectives:</b> To investigate the effects of alcohol abstinence in preventing new-onset atrial fibrillation (AF) in patients with type 2 diabetes mellitus (T2DM). <p><b>Research Design and Methods:</b> A total of 1,112,682 patients newly diagnosed with T2DM between 2011–2014, were identified from the Korean National Health Insurance Service database. After excluding a previous history of AF, 175,100 subjects were included. The primary outcome was new-onset AF.</p> <p><b>Results:</b> During a mean follow-up of 4.0 years, AF occurred in 4,174 patients. Heavy alcohol consumption (alcohol intake ≥40 g/day) before a T2DM diagnosis had a higher risk of AF (adjusted hazard ratio [aHR] 1.22, 95% confidence interval [CI] 1.06–1.41) compared to no alcohol consumption. After a T2DM diagnosis, moderate-to-heavy alcohol consumption (alcohol intake ≥20 g/day) who abstained from alcohol had a lower risk of AF (aHR 0.81, 95% CI 0.68–0.97) than did constant drinkers. Alcohol abstinence showed consistent trends toward lower incident AF in all subgroups and was statistically significant in men (aHR 0.80, 95% CI 0.67–0.96), those aged >65 years (aHR 0.69, 95% CI 0.52–0.91), those with CHA<sub>2</sub>DS<sub>2</sub>-VASc score <3 points (aHR 0.71, 95% CI 0.59–0.86), non-insulin users (aHR 0.77, 95% CI 0.63–0.94), and body mass index < 25 mg/k<sup>2</sup> (aHR 0.68, 95% CI 0.53–0.88).</p> <p><b>Conclusions</b>: In patients with newly diagnosed T2DM, alcohol abstinence was associated with a low risk of AF development. Lifestyle modifications, such as alcohol abstinence, in patients newly diagnosed with T2DM should be recommended to reduce the risk of AF.</p>

The study demonstrates that the public will engage with AF screening undertaken as part of their daily routines using hand-held devices. Sensors can play a key role in identifying asymptomatic patients in this way, but the technology must be further developed to reduce the quantity of non-diagnostic ECGs.

Abstract Background Early cardiovascular complications may occur in 20-30% of patients following following ischaemic stroke (stroke-heart-syndrome, SHS). The risk of dementia in patients with SHS remains unexplored. We aimed to quantify the risk of incident dementia in patients with SHS. Methods We conducted a retrospective analysis using a global federated health care network (TriNetX). We included patients who were discharged alive post-ischaemic stroke from 2000 to 2022. These individuals were classified into two cohorts based on the incidence of cardiovascular complications within 30 days post-stroke (acute heart failure [HF], acute myocardial infarction [AMI], ventricular fibrillation or flutter [VFF], or Takotsubo disease [TTS]), ie. those with SHS (Group 1) and those with stroke-only (without SHS; Group 2). The primary outcome was the five-year risk of dementia (vascular dementia [F01], dementia in other disease [F02], unspecified dementia [F03], Alzheimer’s disease [G30]). Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression analysis after 1:1 propensity score matching (PSM). Results We identified 70,113 patients with SHS (age 67.3±14.0; 42.2% females) and 1,092,540 patients with stroke-only (age 65.2±14.9, 48.1% females). Prior to PSM, patients with SHS were generally older and had a higher prevalence of cardiovascular treatments compared to those without SHS. Following PSM, 70,111 well-balanced patients were considered in each group, however, patients with SHS had a higher risk of dementia compared to patients with stroke-only (HR 1.25, 95%CI 1.20-1.30). Among the SHS complications, the highest dementia risks were associated with acute HF (HR 1.28, 95%CI 1.21-1.36) and AMI (HR 1.24, 95%CI 1.17-1.30), with no significant associations were found for TTS, and VFF. The increased risk of dementia in patients with SHS compared to patients with stroke-only was independent of oral anticoagulant (OAC) use, sex, and age (> or < 75 years) [Figure 1]. Conclusion Stroke-heart syndrome is associated with increased risk of dementia. Innovative strategies to identify and to prevent SHS complications would improve long-term prognosis in patients with recent stroke.

Introduction: The ABC pathway (A: Avoid stroke; B: Better symptoms; C: Comorbidities and lifestyle management) has been proposed to ensure a holistic or integrated care approach to atrial fibrillation (AF) management. There are scarce data about compliance with this strategy in low- and middle-income countries, where the AF populational burden is likely to increase. Hypothesis: Compliance with ABC pathway (ABC-compliance) in Brazil is low and associated with certain patient characteristics. Methods: We included 700 patients (46% women, 69±15 years) with confirmed AF. Participants were recruited from private and public healthcare units in São Paulo city. We built logistic regression models to analyze if age, sex, race, HAS-BLED scores, or healthcare sector (public or private) were associated with lack of ABC-compliance (Table 1). Results: ‘A’, ‘B’, ‘C’ and ABC-compliance occurred in 42%, 82%, 50%, and 21%, respectively. In multiple models (Table 2), lack of ABC-compliance was associated with female sex and high HAS-BLED scores. Lack of ‘B’ component compliance was associated with non-White race. Treatment in public units was positively associated with a lack of ‘A’ component compliance but this was inversely associated with a lack of ‘C’ component compliance. Age and ABC-compliance were not independently associated. Conclusions: Compliance with ABC pathway in our healthcare setting was low. Female sex and high HAS-BLED scores were markers of poor compliance with this integrated approach. Patients treated in private health units may have higher access to oral anticoagulants, while better comorbidity control in public health units may reflect a less segmented system of care.

The 2020 European Society of Cardiology guidelines endorse the Atrial Fibrillation Better Care (ABC) pathway as a structured approach for the management of atrial fibrillation (AF), addressing three principal elements: 'A' - avoid stroke (with oral anticoagulation), 'B' - patient-focused better symptom management, and 'C' - cardiovascular and comorbidity risk factor reduction and management. This review summarizes the definitions used for the ABC criteria in different studies and the impact of adherence/non-adherence on clinical outcomes, from 12 studies on seven different cohorts. All studies consistently showed statistically significant reductions in the risk of stroke, myocardial infarction, and mortality among those with ABC pathway adherent treatment. The ABC pathway provides a simple decision-making framework to enable consistent equitable care from clinicians in primary and secondary/tertiary care. Further research examining the impact of ABC pathway implementation in prospective cohorts utilizing consistent inclusion criteria and definitions of 'A', 'B', and 'C' adherent care is warranted.

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