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The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

BackgroundThe incidence of atrial fibrillation (AF) shows substantial temporal trends, but the contribution of birth cohort effects is unknown. These effects refer to the relationship between birth year and the likelihood of developing AF. We aimed to assess trends in cumulative incidence of diagnosed AF across birth cohorts and to disentangle the effects of age, birth cohort and calendar period by using age–period–cohort analyses.MethodsIn a Danish nationwide population-based cohort study, 4.7 million individuals were selected at a given index age (45, 55, 65 and 75 years) free of AF and followed up for diagnosed AF. For each index age, we assessed trends in 10-year cumulative incidence of AF across six 5-year birth cohorts. An age–period–cohort model was estimated using Poisson regression with constrained spline functions collapsing data into 1-year intervals across ages and calendar years.ResultsCumulative incidence of AF diagnosis increased across birth cohorts for all index ages (ptrend<0.001). Compared with the first birth cohort, the diagnosed AF incidence rate ratio in the last birth cohort was 3.0 (95% CI 2.9 to 3.2) for index age 45 years, 2.9 (2.8 to 3.0) for 55 years, 2.8 (2.7 to 2.8) for 65 years and 2.7 (2.6 to 2.7) for 75 years. Age–period–cohort analyses showed substantial birth cohort effects independent of age, with no clear period effect. Compared with individuals born in 1930, the diagnosed AF incidence rate was 0.125 smaller among individuals born in 1885 and was four times larger among individuals born in 1975.ConclusionSubstantial birth cohort effects, independent of age and calendar period, influence trends in diagnosed AF incidence.

Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction (MI) and vice versa. This bidirectional association relies on shared risk factors as well as on several direct and indirect mechanisms, including inflammation, atrial ischaemia, left ventricular remodelling, myocardial oxygen supply–demand mismatch and coronary artery embolism, through which one condition can predispose to the other. Patients with both AF and MI are at greater risk of stroke, heart failure and death than patients with only one of the conditions. In this Review, we describe the bidirectional association between AF and MI. We discuss the pathogenic basis of this bidirectional relationship, describe the risk of adverse outcomes when the two conditions coexist, and review current data and guidelines on the prevention and management of both conditions. We also identify important gaps in the literature and propose directions for future research on the bidirectional association between AF and MI. The Review also features a summary of methodological approaches for the study of bidirectional associations in population-based studies.

ObjectivesTo examine how the lifetime risks of atrial fibrillation and of complications after atrial fibrillation changed over time.DesignDanish, nationwide, population based cohort study.SettingPopulation of Denmark from 1 January 2000 to 31 December 2022.Participants3.5 million individuals (51.7% women and 48.3% men) who did not have atrial fibrillation at 45 years of age or older were followed up until incident atrial fibrillation, migration, death, or end of follow-up, whichever came first. All 362 721 individuals with incident atrial fibrillation (46.4% women and 53.6% men), but with no prevalent complication, were further followed up until incident heart failure, stroke, or myocardial infarction.Main outcome measuresLifetime risk of atrial fibrillation and lifetime risks of complications after atrial fibrillation over two prespecified periods (2000-10 v2011-22).ResultsThe lifetime risk of atrial fibrillation increased from 24.2% in 2000-10 to 30.9% in 2011-22 (difference 6.7% (95% confidence interval 6.5% to 6.8%)). After atrial fibrillation, the most frequent complication was heart failure with a lifetime risk of 42.9% in 2000-10 and 42.1% in 2011-22 (−0.8% (−3.8% to 2.2%)). Individuals with atrial fibrillation lost 14.4 years with no heart failure. The lifetime risks of stroke and of myocardial infarction after atrial fibrillation decreased slightly between the two periods, from 22.4% to 19.9% for stroke (−2.5% (−4.2% to −0.7%)) and from 13.7% to 9.8% for myocardial infarction (−3.9% (−5.3% to −2.4%). No evidence was reported of a differential decrease between men and women.ConclusionLifetime risk of atrial fibrillation increased over two decades of follow-up. In individuals with atrial fibrillation, about two in five developed heart failure and one in five had a stroke over their remaining lifetime after atrial fibrillation diagnosis, with no or only small improvement over time. Stroke risks and heart failure prevention strategies are needed for people with atrial fibrillation.

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This study sought to determine whether the risk of atrial fibrillation AF can be estimated accurately by using routinely ascertained features in the electronic health record (EHR) and whether AF risk is associated with stroke.

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Background:Physician communication of lifetime risk prediction can improve patient understanding of atrial fibrillation (AF) risk and motivate lifestyle changes and preventive measures. Therefore, our objective was to assess how physicians perceive short-term and lifetime risks of atrial fibrillation (AF), using a survey.Methods:We invited American Heart Association (AHA) members to complete an online survey via email from November 2-22, 2021. Respondents were randomized to one of 32 vignettes characterized by AF risk factors (height, weight, current smoking, systolic blood pressure, diastolic blood pressure, use of antihypertensive medication, diabetes, history of heart failure, and history of myocardial infarction). Respondents were further randomized to either estimate the 5-year or lifetime AF risk on a 0-100% scale with 10% intervals (e.g., “10-19%”) or were shown the predicted 5-year or lifetime AF risk value and asked to pick the correct interpretation in a multiple-choice question.Results:Of 11,330 AHA professional members who received the emailed survey, 109 (1%) physicians responded (mean age 51 years, 33% women) (Table). Most respondents estimated the 5-year AF risk correctly (7/9, 78%) but none accurately estimated the lifetime risk (0/18, 0%). Most respondents interpreted the predicted 5-year risk correctly (21/28, 75%) but about half of respondents misinterpreted the lifetime risk (14/25, 56%).Conclusions:In a small sample of physicians, few respondents correctly estimated and interpreted the lifetime risk of AF, suggesting that physicians may not be familiar with this risk format. It may be necessary to study the frequency and manner in which physicians communicate lifetime risk of AF.

Clinical trials and basic science studies without statistically significant results are less likely to be published than studies with statistically significant results. Systematic reviews and meta-analyses that omit unpublished data are at high risk of distorted conclusions. Here, we describe methods to search beyond bibliographical databases to reduce evidence selection bias in systematic reviews. Unpublished studies may be identified by searching conference proceedings. Moreover, clinical trial registries—databases of planned and ongoing trials—and regulatory agency websites such as the European Medicine Agency (EMA) and the United States Food and Drug Administration (FDA) may provide summaries of efficacy and safety data. Primary and secondary outcomes are prespecified in trial registries, thus allowing the assessment of outcome reporting bias by comparison with the trial report. The sources of trial data and documents are still evolving, with ongoing initiatives promoting broader access to clinical study reports and individual patient data. There is currently no established methodology to ensure that the multiple sources of information are incorporated. Nonetheless, systematic reviews must adapt to these improvements and cover the new sources in their search strategies.

Background:Obesity and sedentary lifestyles are known risk factors for atrial fibrillation (AF). Wearable devices such as smartwatches present an opportunity to investigate relations between daily step count and AF risk.Hypothesis:Higher daily step count, as measured by wearable devices, will be associated with a smaller five-year risk of AF, as predicted by CHARGE-AF score.Methods:Participants from the electronic Framingham Heart Study (eFHS) utilized an AppleWatch. Individuals with diagnosed AF were excluded. Daily step count, watch wear time (hours, days), and self-reported physical activity were collected. Individual five-year risk of AF was estimated using The Cohorts for Heart and Aging Research in Genomic Epidemiology AF (CHARGE-AF) score. Relation between daily step counts and five-year predicted AF risk was examined with linear regression adjusted for age, sex, and wear time. Secondary analyses examined effect modification by sex and obesity (body mass index ≥30 kg/m2), as well as relation between self-reported physical activity and predicted 5-year AF risk.Results:We examined 932 eFHS participants (mean age 53±9 years, 61% female) with a median daily step of 7360 (25th-75thpercentile 5841-9060). Most participants (89.2%) had <2.5% CHARGE-AF risk. Every 1000 steps were associated with 0.08% lower CHARGE-AF risk (P<0.001). A stronger association was observed in men and individuals with obesity. In contrast, self-reported physical activity was not associated with CHARGE-AF risk.Conclusion:Higher daily step count was associated with lower predicted 5-year risk of AF, and this relation was stronger in men and participants with obesity. The utility of a wearable daily step counter for risk reduction for AF merits further investigation.

Introduction:Aortic stenosis (AS) is characterized by highly variable progression rates. Differential rates of AS progression have been proposed to explain apparent disparities in the treatment of severe AS. However, the evidence supporting this claim is uncertain.Methods:We conducted a systematic review of MEDLINE and EMBASE from 1989 to 2022 to identify prospective cohort studies of AS hemodynamic progression. We evaluated the pooled patient demographics, AS severity, baseline and mean annual changes in echocardiographic markers, and prognostic factors.Results:We identified 32 prospective cohort studies. Overall, 11,432 patients were followed for 27 +/- 15 months on average. The average age was 67 +/- 8 years. The average percent female was 36 +/- 14%. Race was reported in only 4 (13%) cohorts; the average proportion of white patients was 93.9 +/- 6.1%. The average baseline hemodynamic severity was consistent with aortic sclerosis, mild AS, moderate AS, and severe AS in 3 (9.4%), 8 (25.0%), 19 (59.3%), and 2 (6.3%) studies, respectively. Overall, average baseline and annual changes in echocardiographic values were: peak aortic jet velocity (Vmax) 3.21 +/- 0.61 m/s (0.20 +/- 0.09 m/s/yr); aortic valve area (AVA) 1.23 +/- 0.31 cm2 (-0.09 +/- 0.05 cm2/yr); and mean aortic valve gradient (MG) 26.2 +/- 7.6 mmHg (3.9 +/- 1.6 mmHg/yr). Age, sex, coronary artery disease, hypertension, diabetes, hyperlipidemia, and smoking were not associated with AS progression in >75% cohorts. Baseline Vmax and MG were associated with greater AS progression in 6 cohorts (75%). Baseline aortic valve calcification (AVC) and AVA were consistently associated with greater AS progression in 9 cohorts (100%). One cohort found that women have a greater ΔMG for a given level of AVC. A univariate analysis of race in one cohort showed that African American ethnicity was associated with lower risk of progression from normal aortic valves to incident AS.Conclusion:There is limited representation of women and ethnic minorities in prospective AS progression cohorts. Active recruitment of diverse populations in these cohorts is needed. The available clinical evidence provides limited support for claims of differential progression as the cause of racial disparities in AS treatment.

The purpose of this study was to systematically review the research on volume and outcome relationships in critical care.

Compared with carotid endarterectomy (CEA), carotid angioplasty and stenting (CAS) is associated with a higher risk of procedural stroke or death especially in patients with symptomatic stenosis. However, after the perioperative period, risk is similar with both treatments, suggesting that CAS could be an acceptable option in selected patients.

Social determinants of health, in particular education and income, influence the incidence, management, and outcomes of cardiovascular diseases including atrial fibrillation (AF). Data are limited on the associations of socioeconomic status with lifetime risk of incident AF.

The COVID-19 pandemic and its consequences have been associated with an increase in poor population mental health. We assessed how depressive symptoms changed among U.S. adults over the course of the COVID-19 pandemic and identified the key risk factors for these symptoms.

The continuing significant number of patients who die while on a waiting list for lung transplantation (LTx) has led several countries to modify their lung allocation rules in recent years. France has implemented high-emergency allocation rules to allow patients at imminent risk of death to undergo priority transplantation within several days. The aim of this study was to report on the early (2-year) experience of high-emergency LTx (HELTx) in France.

Carotid angioplasty and stenting (CAS) may be more often associated with residual or recurrent stenosis than carotid endarterectomy (CEA). We compared the rates of restenosis in patients treated with CAS or CEA in the EVA-3S trial.

The purposes of this study were to assess the relationships between anatomic and technical factors and the 30-day risk of stroke or death after carotid angioplasty and stenting in the Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial and to perform a systematic review of the literature.

The development of biomarkers able to predict the occurrence of nosocomial infection could help manage preventive strategies, especially in medical patients whose degree of acquired immunosuppression may be variable. We hypothesized that the NO fraction present in the airways (upper and lower) of critically ill patients under mechanical ventilation could constitute such a biomarker. We conducted an observational proof-of-concept study in a medical intensive care unit of a teaching hospital. Forty-five patients (26 men; 72 25th-75th percentiles years 56-82; Simplified Acute Physiology Score II, 63 50-81, 14 infected) under mechanical ventilation (>3 days) underwent on day 1 and day 3 of their stay nasal and exhaled (partitioned in bronchial and alveolar sources) bedside NO measurements, determination of urine NO end products and plasma cytokine (IL-6, IL-10) concentrations, and Sequential Organ Failure Assessment score calculation. Nosocomial infection incidence was recorded during the 15 subsequent days. Fifteen patients (33%) acquired a nosocomial infection (16 infections, 15 ventilator-associated pneumonia and 1 bacteremia). Nasal NO was the only marker significantly different between patients with and without subsequent infection (day 1, 52 ppb 20-142 vs. 134 84-203, P= 0.038; day 3, 98 ppb 22-140 vs. 225 89-288, P= 0.006, respectively). Nasal NO fraction 148 ppb or less at day 3 had an 80% sensitivity, a 70% specificity, and an odds ratio of 2.7 (95% confidence interval, 1.9-3.8) to predict acquisition of nosocomial infection. Nonsurvivors had a higher IL-6 concentration on day 3 (P= 0.014), whereas their nasal NO fractions were not significantly different. Nasal NO seems to be a relatively sensitive and specific biomarker of subsequent nosocomial infection acquisition (at least for ventilator-associated pneumonia), which warrants confirmation in a multicenter trial.

Carotid angioplasty and stenting (CAS) has not been shown to be as safe as carotid endarterectomy (CEA) with regard to the risks of periprocedural complications, but beyond the perioperative period, the risks are comparable, suggesting that CAS may be an acceptable option in selected patients. However, risk factors for perioperative stroke and death have not been clearly established. We aimed to estimate the 30-day absolute risks of stroke or death after CAS and investigate sources of heterogeneity.

Introduction:Prior studies demonstrate correlation between atrial fibrillation (AF) polygenic risk score (PRS) and ischemic stroke, especially cardioembolic (CE) stroke, suggesting shared genetic components. In this study, we hypothesized that an AF PRS can discriminate CE from non-CE strokes.Methods:We evaluated AF and stroke risk in 26,145 individuals of European descent from the NINDS Stroke Genetics Network (SiGN) with study-adjudicated TOAST subtypes. AF genetic risk was estimated using two newly derived PRS (LDpred-funct and sBayesR) and two previously validated PRS (pruning and thresholding and LDpred). A clinical risk score (CRS) was derived within separate individuals in UK Biobank utilizing components of the Cohorts for Aging and Genomic Research in Epidemiology (CHARGE-AF) model available in SiGN. We regressed each AF PRS on AF status and separately CE stroke in logistic regression models adjusted for CRS, imputation group, and the first 10 principal components. We calculated discrimination of AF and CE stroke, and compared across models using 2000-iteration bootstrapping and pairwise Z-testing. We also assessed category-free reclassification of CE stroke risk with the addition of PRS to a) CRS, and b) a modified CHA2DS2-VASc score including all available score components.Results:Each AF PRS was significantly associated with AF and CE stroke after adjustment for the CRS. Addition of any AF PRS significantly improved model discrimination as compared to the CRS alone, and LDpred discriminated both AF and CE better than other PRSs (Figure; P<0.005). Adding LDpred PRS to CRS resulted in appropriate reclassification of CE stroke risk compared to the CRS or the modified CHA2DS2-VASc score alone (Figure).Conclusions:Addition of AF polygenic risk to clinical risk factors improves discrimination of CE from non-CE strokes, as well as reclassification of stroke subtype. AF polygenic risk may be a useful biomarker for identifying AF-related strokes.