Anne H. Hobbelt

Duration of device-detected subclinical atrial fibrillation and occurrence of stroke in ASSERT.

Background ASSERT demonstrated that subclinical atrial fibrillation (SCAF) is common in pacemaker patients without prior AF and is associated with increased risk of ischemic stroke or systemic embolism. SCAF episodes vary in duration and little is known about the incidence of different durations of SCAF, or their prognosis. Methods and results ASSERT followed 2580 patients receiving a pacemaker or ICD, aged >65 years with hypertension, without prior AF. The effect of SCAF duration on subsequent risk of ischemic stroke or embolism was evaluated with time-dependent covariate Cox models. Patients in whom the longest SCAF was ⩽6 min were excluded from the analysis (n=125). Among 2455 patients during mean follow-up of 2.5 years, the longest single episode of SCAF lasted >6 min to 6 h in 462 patients (18.8%), >6–24 h in 169 (6.9%), and >24 h in 262 (10.7%). SCAF duration >24 h was associated with a significant increased risk of subsequent stroke or systemic embolism (adjusted hazard ratio [HR] 3.24, 95% confidence interval [CI] 1.51–6.95, P=0.003). The risk of ischemic stroke or systemic embolism in patients with SCAF between 6 min and 24 h was not significantly different from patients without SCAF. Conclusions SCAF >24 h is associated with an increased risk of ischemic stroke or systemic embolism.

Targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent atrial fibrillation: Results of the RACE 3 trial

Aims Atrial fibrillation (AF) is a progressive disease. Targeted therapy of underlying conditions refers to interventions aiming to modify risk factors in order to prevent AF. We hypothesised that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF. Methods and results We randomized patients with early persistent AF and mild-to-moderate heart failure (HF) to targeted therapy of underlying conditions or conventional therapy. Both groups received causal treatment of AF and HF, and rhythm control therapy. In the intervention group, on top of that, four therapies were started: (i) mineralocorticoid receptor antagonists (MRAs), (ii) statins, (iii) angiotensin converting enzyme inhibitors and/or receptor blockers, and (iv) cardiac rehabilitation including physical activity, dietary restrictions, and counselling. The primary endpoint was sinus rhythm at 1 year during 7 days of Holter monitoring. Of 245 patients, 119 were randomized to targeted and 126 to conventional therapy. The intervention led to a contrast in MRA (101 [85%] vs. 5 [4%] patients, P < 0.001) and statin use (111 [93%] vs. 61 [48%], P < 0.001). Angiotensin converting enzyme inhibitors/angiotensin receptor blockers were not different. Cardiac rehabilitation was completed in 109 (92%) patients. Underlying conditions were more successfully treated in the intervention group. At 1 year, sinus rhythm was present in 89 (75%) patients in the intervention vs. 79 (63%) in the conventional group (odds ratio 1.765, lower limit of 95% confidence interval 1.021, P = 0.042). Conclusions RACE 3 confirms that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF. Trial Registration number Clinicaltrials.gov NCT00877643.

Tailored treatment strategies: a new approach for modern management of atrial fibrillation

Atrial fibrillation (AF) is not benign. Cardiovascular diseases and risk factors differ importantly amongst patients. Careful phenotyping with the aim to start tailored therapy may improve outcome and quality of life. Furthermore, structural remodelling plays an important role in initiation and progression of AF. Therapies that interfere in the remodelling processes are promising because they may modify the atrial substrate. However, success is still limited probably due to variations in the underlying substrate in individual patients. The most favourable effects of lifestyle changes on success of rhythm control have been demonstrated in obese patients with AF. Differences in genotype may also play an important role. Common gene variants have been associated with recurrence of AF after electrical cardioversion, antiarrhythmic drug therapy and catheter ablation. Therefore, both phenotyping and genotyping may become useful for patient selection in the future. Beside the choice of rate or rhythm control, and type of rhythm control, prevention of complications associated with AF may also differ depending on genotype and phenotype. Efficacy of stroke prevention has been well established, but bleeding remains a clinically relevant problem. Risk stratification is still cumbersome, especially in low‐risk patients and in those with a high bleeding risk. The decision whether to start anticoagulation (and if so which type of anticoagulant) or, alternatively, to implant an occlusion device of the left atrial appendage may also be improved by genotyping and phenotyping. In this review, we will summarize new insights into the roles of phenotype and genotype in generating more tailored treatment strategies in patients with AF and discuss several patient‐tailored treatment options.

Prethrombotic State in Young Very Low- Risk Patients With Atrial Fibrillation

Atrial fibrillation (AF) is associated with thromboembolic complications due to alterations in blood flow, vascular endothelium, and hemostasis [(1)][1]. Although we have clinical risk assessment scores for stroke risk to identify very-low-risk patients, these prediction rules may misclassify

Clinical, biomarker, and genetic predictors of specific types of atrial fibrillation in a community-based cohort : Data of the PREVEND study

Aims Atrial fibrillation (AF) may present variously in time, and AF may progress from self‐terminating to non‐self‐terminating AF, and is associated with impaired prognosis. However, predictors of AF types are largely unexplored. We investigate the clinical, biomarker, and genetic predictors of development of specific types of AF in a community‐based cohort. Methods We included 8042 individuals (319 with incident AF) of the PREVEND study. Types of AF were compared, and multivariate multinomial regression analysis determined associations with specific types of AF. Results Mean age was 48.5 ± 12.4 years and 50% were men. The types of incident AF were ascertained based on electrocardiograms; 103(32%) were classified as AF without 2‐year recurrence, 158(50%) as self‐terminating AF, and 58(18%) as non‐self‐terminating AF. With multivariate multinomial logistic regression analysis, advancing age (P< 0.001 for all three types) was associated with all AF types, male sex was associated with AF without 2‐year recurrence and self‐terminating AF (P= 0.031 and P= 0.008, respectively). Increasing body mass index and MR‐proANP were associated with both self‐terminating (P= 0.009 and P< 0.001) and non‐self‐terminating AF (P= 0.003 and P< 0.001). The only predictor associated with solely self‐terminating AF is prescribed anti‐hypertensive treatment (P= 0.019). The following predictors were associated with non‐self‐terminating AF; lower heart rate (P= 0.018), lipid‐lowering treatment prescribed (P= 0.009), and eGFR <60 mL/min/1.73 m2 (P= 0.006). Three known AF‐genetic variants (rs6666258, rs6817105, and rs10821415) were associated with self‐terminating AF. Conclusions We found clinical, biomarker and genetic predictors of specific types of incident AF in a community‐based cohort. The genetic background seems to play a more important role than modifiable risk factors in self‐terminating AF.

Time to implement fitness and reduction of fatness in atrial fibrillation therapy

This editorial refers to ‘Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry’ by M. Proietti et al. , doi:10.1093/europace/euw150. Atrial fibrillation (AF) is not a benign condition and contributes importantly to cardiovascular morbidity and mortality. Until recently, only non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonist OACs have been associated with reduction of mortality,1 but not rhythm control therapy. Regular not-vigorous physical activity and respiratory cardiofitness are protective against cardiovascular diseases and all-cause mortality.2,3 Physical activity, especially vigorous exertion and endurance sports, however, has been associated with an increased risk of AF.4 Yet, there is increasing evidence that moderate physical activity and cardiorespiratory fitness are associated with a reduced risk of AF.5 For example, in obese patients (body mass index ≥27 kg/m2), baseline cardiorespiratory fitness was associated with a higher freedom of AF. Furthermore, an improvement in cardiorespiratory fitness (≥2 metabolic equivalents) during follow-up contributed to a further AF burden reduction in association with weight loss, an improvement of glycaemic and lipid control, a reduction in blood pressure, a decrease of atrial and ventricular sizes, and increase in diastolic function and a reduction of systemic inflammation.5 However, data on the effects of physical activity on outcome in patients with AF are lacking. In the current issue of EP-Europace , Proietti et al. 6 report on the relationship between physical activity and major cardiovascular outcomes in AF patients prospectively enrolled in the EURObservational Research Programme on AF (EORP-AF) Pilot Survey conducted in nine European countries. Their aim was to assess, …