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 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\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

Determination of the default curve for the unfolding procedure in the measurement of threshold neutron excitation functions

In this study, we have improved the technique for measuring the neutron activation cross-section using wide energy neutron beams (NAXSUN). We propose a method for the determination of the default function for the unfolding procedure, which is an important and critical part for extracting reaction cross-sections from this type of measurements. The new method was tested on the measurement of the excitation function from the threshold energy up to 5.6 MeV for the 113In(n,n')113mIn and 115In(n,n')115mIn reactions.JRC.D.4-Standards for Nuclear Safety, Security and Safeguard

A Novel Global MPPT Algorithm for distributed MPPT Systems

International audienc

Single-stage Low Cost Grid Connected Inverter in Photovoltaic Energy Applications

International audienceDue to the rising fuel costs and growingworldwide demand for electricity, renewable energy sourcesbecome a necessity rather than a luxury. This paperpresents an original control strategy for a buck-boost basedconverter used as a low cost inverter in a photovoltaic (PV)system. The main objective of the inverter is to harvestmaximum power from the PV module and to inject it intothe grid. The design of the converter is detailed and,together with the control method, a macro-model for theinverter is proposed. The macro-model is developed in orderto have shorter simulation times and test various maximumpower point tracking (MPPT) algorithms. Simulations andexperimental results validate the proposed PV system

Neutron-induced fission cross section of 242Pu from 15 MeV to 20 MeV

Accurate nuclear-data needs in the fast-neutron-energy region have been recently addressed for the development of next generation nuclear power plants (GEN-IV) by the OECD Nuclear Energy Agency (NEA). This sensitivity study has shown that of particular interest is the 242Pu(n,f) cross section for fast reactor systems. Measurements have been performed with quasi-monoenergetic neutrons in the energy range from 15 MeV to 20 MeV produced by the Van de Graaff accelerator of the JRC-Geel. A twin Frischgrid ionization chamber has been used in a back-to-back configuration as fission fragment detector. The 242Pu(n,f) cross section has been normalized to 238U(n,f) cross section data. The results were compared with existing literature data and show acceptable agreement within 5%.JRC.G.2-Standards for Nuclear Safety, Security and Safeguard

The cross section functions for neutron induced reactions with Rhenium in the energy range 13.0–19.5 MeV

The technique for measuring neutron activation cross-sections using wide energy neutron beams (NAXSUN) was recently developed at JRC-Geel. This method is based on the detection of the gamma activity induced by the activation of the samples in different but overlapping neutron fields and following an unfolding procedure. In the present work, measurements of the cross-section functions by the NAXSUN technique for the (n,a), (n,2n), (n,p) and (n,3n) reactions on rhenium isotopes 185Re and 187Re were performed. The results are the first experimental data for the mentioned reaction cross-sections in the energy range 13.0-19.5 MeV. The obtained data are of interest for possible applications of Re in nuclear technology and medicine.JRC.G.2-Standards for Nuclear Safety, Security and Safeguard

The cross-sections for the 187Re(n,p)187W and 185Re(n,3n)183Re reactions in the energy range between 13.08 MeV and 19.50 MeV

Using the NAXSUN technique developed at the JRC-Geel, the cross section functions for neutron induced reactions 187Re(n,p)187W and 185Re(n,3n)183Re have been measured in the energy range between 13.08 MeV and 19.5 MeV. These data are the first experimentally obtained values for those nuclear reactions in this neutron energy range. Obtained results have been compared with existing evaluated data from ENDF/B-VII 0, JEFF 3.3, JEFF 3.2, BROND 3.1, JEF - 2.2, JENDL, ROSFO ND-2010. The TALYS 1.9 and EMPIRE 3.2.3 calculations were performed using different available models and calculations using several semi-empirical existing formulas. A comparison between theoretical model calculations and experimental results was made.JRC.G.2-Standards for Nuclear Safety, Security and Safeguard

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

Background: Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent. Objectives: We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients. Methods: A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined. Results: Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55–0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty. Conclusions: In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones