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The use of triple antithrombotic therapy (TAT) consisting of an oral anticoagulant (OAC), aspirin, and a P2Y12 inhibitor in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and / or undergoing percutaneous coronary intervention (PCI) is associated with a high risk of bleeding. Recently, several randomized clinical trials tested the hypothesis as to whether dual antithrombotic therapy (DAT) regimens (consisting of an OAC and a single antiplatelet drug) may be safer in terms of bleeding events as compared with TAT. They also investigated the role of non-vitamin K antagonist oral anticoagulants (NOACs) as a part of DAT and TAT. The purpose of this review is to provide an overview of available evidence regarding the safety and efficacy of DAT compared with TAT regimens, international guidelines recommendations, knowledge gaps, and unmet needs in the management of patients with AF and ACS and / or undergoing PCI.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of death, stroke, and heart failure. Prevalence and incidence of AF are rising due to better overall medical treatment, longer survival, and increasing incidence of cardiometabolic and lifestyle risk factors. Treatment of AF and AF‑related complications significantly increases healthcare costs. In addition, the use of conventional rhythm control strategies (including, antiarrhythmic drugs and catheter ablation) is associated with limited efficacy for sinus rhythm maintenance and serious adverse effects. Aggressive cardiometabolic risk factor management may prevent incident as well as recurrent AF, improve overall health, and reduce mortality. Therefore, modifiable risk factor management became one of the 3 treatment pillars in AF management along with anticoagulation as well as conventional rate and rhythm control strategies. The second part of this review systematically discusses the association between AF and potentially modifiable risk factors for AF, such as obesity, obstructive sleep apnea, alcohol consumption, and dyslipidemia. We also provide practical guidelines for the risk factor management with respect to primary and secondary prevention of AF.

Background: An incidental lesion of the parasympathetic ganglia during circumferential pulmonary vein isolation (CPVI) may affect heart rate variability (HRV). Aims: We studied the pattern of changes in HRV parameters and the relationship between the 1‑year HRV change following CPVI and the recurrence of atrial fibrillation (AF). Methods: A total of 100 consecutive patients undergoing CPVI for paroxysmal AF were enrolled (mean [SD] age, 56 [11.2] years; 61 men). We measured HRV on the day before and after CPVI, and then at 1 month as well as 3, 6, and 12 months after CPVI using 24‑hour Holter monitoring. Results: During the median follow‑up of 33 months, 38 patients experienced the late recurrence of AF (LRAF). Compared with the pre‑CPVI values, HRV was significantly attenuated on day 1 after CPVI in all patients. However, at 3 to 6 months after CPVI, all HRV parameters remained significantly decreased in LRAF‑free patients but not in those with LRAF. The multivariate Cox analysis showed that early AF recurrence within the blanking period (hazard ratio [HR], 4.87; 95% CI, 2.44–9.69; P < 0.001) and a change in the standard deviation of normal‑to‑normal intervals (SDNN) observed 3 months after ablation (HR, 0.99; 95% CI, 0.98–1; P = 0.01) were associated with LRAF. The cumulative LRAF freedom after CPVI was greater in patients with an SDNN reduction of more than 25 ms reported 3 months after ablation than in those with a reduction of 25 ms or lower (log‑rank P = 0.004). Conclusions: Sustained parasympathetic denervation during 12 months after CPVI was a marker of successful CPVI, whereas a 3‑month post‑CPVI SDNN reduction of 25 ms or lower predicted LRAF.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased risk of death, stroke, and heart failure. Prevalence and incidence of AF are rising due to better overall medical treatment, longer survival, and increasing incidence of cardiometabolic and lifestyle risk factors. Treatment of AF and AF‑related complications significantly increases healthcare costs. In addition, the use of conventional rhythm control strategies (including, antiarrhythmic drugs and catheter ablation) is associated with limited efficacy for sinus rhythm maintenance and serious adverse effects. Aggressive cardiometabolic risk factor management may prevent incident as well as recurrent AF, improve overall health, and reduce mortality. Therefore, modifiable risk factor management became one of the 3 treatment pillars in AF management along with anticoagulation as well as conventional rate and rhythm control strategies. The second part of this review systematically discusses the association between AF and potentially modifiable risk factors for AF, such as obesity, obstructive sleep apnea, alcohol consumption, and dyslipidemia. We also provide practical guidelines for the risk factor management with respect to primary and secondary prevention of AF.

Background: Subcutaneous implantable cardioverter-defibrillator (S-ICD) may be an alternative to transvenous ICD (TV-ICD). Aim: We sought to evaluate factors determining the choice of S-ICD vs. TV-ICD in Polish patients in comparison to other European countries. Methods: All consecutive patients who underwent TV-ICD or S-ICD implantation in centres participating in the European Heart Rhythm Association prospective snapshot survey were included. Results: During an eight-week study period, 429 patients were recruited, including 136 (31.7%) ICD patients from Poland (eight with S-ICD). In comparison to other European centres, the proportion of S-ICD implantations in Poland was lower (7% vs. 26%, p < 0.001), whereas the ratio of cardiac resynchronisation therapy defibrillator implantations was higher (43% vs. 26%; p < 0.001). Subjects receiving S-ICD in Poland were more often over 75 years old (25% vs. 0%, p < 0.001), in New York Heart Association class II (87.5% vs. 29.4%, p = 0.001), with chronic kidney disease (37.5% vs. 5.9%, p = 0.003), and with lower left ventricular ejection fraction (32% [14%–50%] vs. 50% [25%–60%], p = 0.04), compared to other European countries. Additionally, in comparison to subjects from other European centres, Polish patients were significantly more often implanted with S-ICD due to prior infection (37.5% vs. 1.5%, p < 0.001) and a lack of venous access (25% vs. 0%, p < 0.001), whereas the largest subset of patients in other European countries were implanted with S-ICD because of young age (50% vs. 25%, p = NS). Conclusions: The main reasons leading to S-ICD implantations in Polish patients differ from the indications adopted in other European countries. In Poland, patients referred for TV-ICD or S-ICD implantation had more advanced heart failure and more comorbidities in comparison to subjects from other European countries. S-ICD is still underused in Polish patients.