Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p <.001. Over 24 months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients : a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients’ clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward’s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients’ prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27–3.62; HR 3.42, 95%CI 2.72–4.31; HR 2.79, 95%CI 2.32–3.35), and Cluster 1 (HR 1.88, 95%CI 1.48–2.38; HR 2.50, 95%CI 1.98–3.15; HR 2.09, 95%CI 1.74–2.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P <.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

General anaesthesia during radiofrequency ablation of atrial fibrillation is associated with improved procedural characteristics but with similar long-term outcomes: a single center study

Abstract Funding Acknowledgements Type of funding sources: None. Introduction General anaesthesia (GA) or conscious sedation can be used during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) based on physician’s and patient’s preference. Increasing number of centers include GA in their institutional protocols for RFCA of AF.  Purpose The current study aims to compare real-world data on procedural characteristics, complication rate and procedural outcomes in patients undergoing RFCA of AF under GA or sedation at a single center. Methods A total of 167 patients (116 males, age 57.53 ± 9.78 years) with paroxysmal or persistent AF undergoing RFCA were studied retrospectively. Patients underwent RFCA under GA (108 patients, Group 1) provided by the anaesthesia team at our institution or under conscious sedation (59 patients, Group 2) guided by the operator using bolus doses of midazolam and fentanyl. We compared procedural time, fluoroscopy time, dose-area product (DAP), number of lesions and cumulative RF time between the two groups. We also analysed the complication rates and the long-term outcome in the two groups. Results are presented as mean ± SD or median (25th – 75th percentile). Results   Groups 1 and 2 were comparable in terms of baseline clinical characteristics. Group 1 patients demonstrated significantly shorter procedural time as compared to Group 2: 149.52 ± 41.31 min vs. 208.23 ± 77.10 min, P &amp;lt; 0.0005. Fluoroscopy time was also shorter in Group 1 24 (20-31.75) min compared to 36 (22.5-46.5) min in Group 2, P &amp;lt; 0.0001. This corresponded to lower radiation dose expressed by DAP which was also significantly lower in Group 1 patients: 3230 (1660-6793.2) cGy/cm2 vs. 13880 (4215-21324) cGy/cm2 for Group 2, P &amp;lt; 0.0001. Administration of GA during the procedure was associated with lower number of RF applications: 52.49 ± 19.36 in Group 1 vs. 68.33 ± 30.74 in Group 2, P = 0.0001. This corresponded with the lower cumulative RF time noted in the patients from Group 1: 2499.2 ± 824.17 sec vs. 3220 ± 1357.26 sec in Group 2, P &amp;lt; 0.0001. Procedural complications occurred in 5 patients from Group 1 (4.6%) and in 8 patients (13.6%) in Group 2, P = 0.066. There was a single case of atrioesophageal fistula in a patient from Group 1. After a median follow-up of 20 (8-41) months 75% of the patients from both Group 1 and Group 2 were arrhythmia-free following 1.5 ± 0.68 procedures (P = 1.0).  Conclusion Performing RFCA of AF under GA is associated with shorter procedural time, lower radiation dose and with the need for less energy application. This does not result in significantly lower complication rates. Long-term procedural outcomes do not seem to be affected by the use of GA. </jats:sec

Age and impaired left atrial performance are associated with increased atrial fibrosis in patients with paroxysmal and persistent atrial fibrillation

Abstract Background Atrial performance assessed by strain imaging is used as a surrogate for left atrial (LA) structural remodelling. Presence of low voltage zones (LVZs) detected by three-dimensional electroanatomical mapping in patients with atrial fibrillation (AF) denotes more expressed extrapulmonary substrate potentially leading to worse outcomes following pulmonary vein isolation (PVI) for the treatment of AF. Purpose The current study aims to investigate the association between strain imaging parameters from echocardiography and the presence and extent of LVZs derived from LA electroanatomical mapping in patients undergoing AF ablation. Methods Seventy-eight patients (58 males, 74%) aged 59±9.48 years undergoing PVI for paroxysmal (35 patients, 49%) or persistent AF were prospectively studied. Preprocedural echocardiography included LA strain imaging assessing global LA strain (LAS) and regional strain of the basolateral region (RSLB). During the procedure, LA electroanatomical mapping during paced atrial rhythm was performed in all patients obtaining a LA voltage map. All LA maps were analysed offline using a custom-made software calculating the zone of low bipolar voltage &amp;lt;0.5 mV (LVZ&amp;lt;0.5mV) and the total LA endocardial area excluding pulmonary veins antra. LVZ&amp;lt;0.5mv was expressed as an absolute value and as percentage of the whole LA area. Results Patients aged more than 65 years (N=21, 27%) demonstrated a larger area of LVZ&amp;lt;0.5mV: 25.5±17.8 cm2 vs. 9.4±10.6 cm2 in those younger than 65 years, P=0.001. This corresponded to a higher proportion of the LA area demonstrating LVZ&amp;lt;0.5mV in patients older than 65 years: 22.6±14.6% vs. 8.9±11.8% in those younger than 65 years, P&amp;lt;0.0001. Twenty-nine of 78 patients (37.1%) had preprocedural LAS&amp;lt;20% and 23 (29.5%) demonstrated RSLB of &amp;lt;21%. Patients with LAS &amp;lt;20% had a higher total LVZ&amp;lt;0.5mV: 20.3±16.6 cm2 vs. 9.8±12.1 cm2 in patients with LAS≥20% at baseline, P=0.004. This equaled to 17.7±15.6% vs. 9.5±11.9% of total LA area, respectively (P=0.011). Patients with RSLB&amp;lt;21% also demonstrated larger areas of LVZ&amp;lt;0.5mV in the LA: 21.6±17.9 cm2 vs. 10.39±11.83 cm2 in the patients with RSLB ≥21%, P=0.012. Expressed as a proportion of the whole LA area the difference remained significant: 18.8±17.1% vs. 9.9±11.6%, respectively P=0.01. Conclusion Older age and impaired LA performance assessed by LA strain imaging are associated with larger areas of LVZ&amp;lt;0.5mV possibly reflecting more expressed LA fibrotic changes in patients with paroxysmal and persistent AF. These findings might serve in the preprocedural selection of the patients undergoing catheter ablation of AF. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Bulgarian Society of Cardiology </jats:sec

Atrial fibrillation history impact on catheter ablation outcome. Findings from the ESC-EHRA Atrial Fibrillation Ablation Long-Term Registry

Background Atrial fibrillation (AF) promotes atrial remodeling that in turn promotes AF perpetuation. The aim of our study is to investigate the impact of AF history length on 1-year outcome of AF catheter ablation in a cohort of patients enrolled in the Atrial Fibrillation Ablation Registry. Methods We described the real-life clinical epidemiology, therapeutic strategies, and the short- and mid-term outcomes of 1948 patients (71.9% with paroxysmal AF) undergoing AF ablation procedures, stratified according to AF history duration (= 2 years). Results The mean AF history duration was 46.2 +/- 57.4 months, 592 patients had an AF history duration = 2 years (mean 75.5 +/- 63.5 months) (P = 2 years (34.0%) (P = 0.037). AF history duration >= 2 years, overall ablation procedure duration, hypertension, and chronic kidney disease were all predictors of recurrences after the blanking period. Conclusions In this multicenter registry, performing catheter ablation in patients with an AF history >= 2 years was associated with higher rates of AF recurrences at 1 year. Since cumulative time in AF in not necessarily equivalent to AF history, its role remains to be clarified.Cardiolog

Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry

Aims: The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process. Methods and results: Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60-25.9], (Sb) (aHR 1.21, 95% CI: 1.08-1.35), and (Su) (aHR 1.27, 95% CI: 1.14-1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45-2.06) and (Sy) (aHR 1.29, 95% CI: 1.00-1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55-0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16-1.56). Conclusion: Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry.

Background Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p = 90 ml/min/1.73 m(2)). Conclusion A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Clinical utility and prognostic implications of the novel 4S-AF scheme to characterize and evaluate patients with atrial fibrillation: a report from ESC-EHRA EORP-AF Long-Term General Registry

Aims: The 4S-AF classification scheme comprises of four domains: stroke risk (St), symptoms (Sy), severity of atrial fibrillation (AF) burden (Sb), and substrate (Su). We sought to examine the implementation of the 4S-AF scheme in the EORP-AF General Long-Term Registry and compare outcomes in AF patients according to the 4S-AF-led decision-making process. Methods and results: Atrial fibrillation patients from 250 centres across 27 European countries were included. A 4S-AF score was calculated as the sum of each domain with a maximum score of 9. Of 6321 patients, 8.4% had low (St), 47.5% EHRA I (Sy), 40.5% newly diagnosed or paroxysmal AF (Sb), and 5.1% no cardiovascular risk factors or left atrial enlargement (Su). Median follow-up was 24 months. Using multivariable Cox regression analysis, independent predictors of all-cause mortality were (St) [adjusted hazard ratio (aHR) 8.21, 95% confidence interval (CI): 2.60-25.9], (Sb) (aHR 1.21, 95% CI: 1.08-1.35), and (Su) (aHR 1.27, 95% CI: 1.14-1.41). For CV mortality and any thromboembolic event, only (Su) (aHR 1.73, 95% CI: 1.45-2.06) and (Sy) (aHR 1.29, 95% CI: 1.00-1.66) were statistically significant, respectively. None of the domains were independently linked to ischaemic stroke or major bleeding. Higher 4S-AF score was related to a significant increase in all-cause mortality, CV mortality, any thromboembolic event, and ischaemic stroke but not major bleeding. Treatment of all 4S-AF domains was associated with an independent decrease in all-cause mortality (aHR 0.71, 95% CI: 0.55-0.92). For each 4S-AF domain left untreated, the risk of all-cause mortality increased substantially (aHR 1.35, 95% CI: 1.16-1.56). Conclusion: Implementation of the novel 4S-AF scheme is feasible, and treatment decisions based on this scheme improve mortality rates in AF